What therapy is recommended for a patient experiencing panic attacks and interpersonal conflicts?

Cognitive Behavioral Therapy is the First-Line Treatment for Panic Attacks with Interpersonal Conflict

Individual Cognitive Behavioral Therapy (CBT) is the recommended first-line treatment for this patient experiencing panic attacks and interpersonal conflicts, with SSRIs such as sertraline as an adjunctive option if needed. 1

Assessment of Presenting Issues

The patient is experiencing:

• Panic attacks triggered by stress about responsibilities
• Interpersonal conflicts with family members
• Feelings of being underappreciated despite significant responsibilities
• Anxiety about daily tasks and obligations

Treatment Recommendations

First-Line Treatment: Cognitive Behavioral Therapy

1. Individual CBT Structure:

   • Recommended format: 14 sessions over 4 months, each lasting 60-90 minutes 1
   • Key components should include:
     • Education about panic attacks and anxiety
     • Behavioral goal setting
     • Cognitive restructuring to address negative thought patterns
     • Exposure techniques to reduce panic sensitivity

2. CBT Specific Techniques for Panic:

   • Interoceptive exposure (controlled exposure to physical sensations that trigger panic)
   • Cognitive restructuring to address catastrophic misinterpretations of bodily sensations
   • Breathing retraining and relaxation techniques
   • Gradual exposure to avoided situations 2, 3

3. CBT for Interpersonal Conflicts:

   • Communication skills training
   • Assertiveness training to help express needs appropriately
   • Cognitive restructuring of thoughts related to family interactions
   • Problem-solving strategies for managing conflicts

Pharmacotherapy Options (If Needed)

If CBT alone is insufficient after 4-6 weeks or if symptoms are severe:

1. First-line medication: SSRIs such as sertraline

   • Starting dose: 25-50 mg daily
   • Target dose: up to 200 mg daily 1, 4
   • Effective for both panic disorder and associated anxiety

2. Alternative medication: Fluoxetine

   • Starting dose: 10 mg daily for panic disorder
   • Increase to 20 mg after one week
   • Maximum dose: 60 mg daily 5

Monitoring and Follow-Up

• Assess response to CBT at 4 and 8 weeks using standardized tools like the Hospital Anxiety and Depression Scale (HADS) 1
• If medication is prescribed, monitor for side effects, particularly during the first few weeks
• Schedule regular follow-up sessions to assess progress and adjust treatment as needed

Lifestyle Modifications

• Implement regular exercise regimen
• Practice sleep hygiene techniques
• Teach stress management strategies:
  • Deep breathing exercises
  • Progressive muscle relaxation
  • Mindfulness meditation 1

Treatment Duration and Expectations

• CBT for panic disorder has shown effectiveness with 85% of patients becoming panic-free post-treatment 6
• Brief cognitive therapy approaches can be effective with as few as 6.5 hours of therapist time 7
• If medication is initiated, continue for at least 12-24 months after achieving remission 1

Caution About Media Consumption

• Limit exposure to anxiety-provoking media content
• Be cautious about seeking mental health advice from non-professional sources, which may inadvertently increase anxiety 8

Self-Help Strategies

• Self-help resources based on CBT principles can supplement formal therapy
• Structured journaling to identify panic triggers and thought patterns
• Development of a personalized coping plan for managing panic attacks

CBT has demonstrated superior efficacy compared to other treatments for panic disorder, with improvements maintained at follow-up assessments 6, 2. The combination of CBT techniques to address both panic symptoms and interpersonal skills will provide this patient with comprehensive tools to manage their current challenges.