What is the recommended treatment for panic disorder?

Treatment of Panic Disorder

For panic disorder, the recommended first-line treatment is a combination of Cognitive Behavioral Therapy (CBT) and a Selective Serotonin Reuptake Inhibitor (SSRI) or Serotonin-Norepinephrine Reuptake Inhibitor (SNRI). 1

Pharmacological Treatment

First-Line Medications

• SSRIs and SNRIs are the first-line pharmacological treatments for panic disorder due to their efficacy and favorable side effect profiles 1
  • Paroxetine has FDA approval specifically for panic disorder 2
  • Start with lower doses than used for depression and titrate slowly to minimize initial anxiety/agitation
  • Treatment should continue for at least 6-12 months after symptom remission 1

Second-Line Medications

• Benzodiazepines like clonazepam may be used:
  • For short-term treatment during SSRI/SNRI initiation
  • In treatment-resistant cases
  • When rapid symptom control is needed
  • Clonazepam has demonstrated efficacy in reducing panic attacks (at doses of 1-4 mg/day) 3
  • Important caution: Only use benzodiazepines when the patient does not have a history of dependency, as they carry risks of tolerance and dependence 4

Psychotherapy Approach

• Cognitive Behavioral Therapy (CBT) specifically developed for panic disorder is highly effective 1
  • Individual therapy is preferred over group therapy
  • Key components include:
    • Education about panic and anxiety
    • Cognitive restructuring to address catastrophic misinterpretations
    • Interoceptive exposure to physical sensations
    • In vivo exposure to feared situations
  • Even brief forms of CBT can be effective 5

Combined Treatment Approach

• Combined CBT and medication is the most successful treatment strategy for panic disorder 4
  • Start both treatments simultaneously for moderate to severe cases 1
  • For mild cases with minimal functional impairment, CBT alone may be sufficient initially 1
  • If a patient declines face-to-face CBT, self-help with support based on CBT principles can be offered 1

Treatment Algorithm

1. Assess severity and functional impairment

   • Mild: Consider CBT alone initially
   • Moderate to severe: Start combined CBT and SSRI/SNRI

2. Medication selection

   • First-line: SSRI (e.g., paroxetine) or SNRI
   • Consider benzodiazepines only for short-term use during SSRI/SNRI initiation or in treatment-resistant cases

3. Treatment monitoring

   • Assess response after 4-6 weeks of medication 1
   • If inadequate response:
     • Optimize medication dose
     • Intensify CBT
     • Consider switching to another SSRI/SNRI
     • Consider augmentation strategies

4. Maintenance phase

   • Continue effective medication for at least 6-12 months after symptom remission 1
   • Taper gradually when discontinuing to avoid withdrawal symptoms

Special Considerations

• Comorbidities are common (depression, other anxiety disorders, substance use) and may require additional targeted interventions 1
• Pregnancy/lactation: SSRIs may be used with caution when benefits outweigh risks 1
• Elderly patients: Start on lower doses and titrate more slowly 1
• Treatment resistance should prompt:
  • Reevaluation of diagnosis
  • Assessment of medication adherence
  • Consideration of alternative or augmentation strategies 1

Common Pitfalls to Avoid

• Premature discontinuation of medication (continue for 6-12 months after remission)
• Rapid benzodiazepine discontinuation (taper slowly to avoid withdrawal)
• Overlooking comorbid conditions that may complicate treatment
• Inadequate dosing of medications (start low but ensure adequate therapeutic dose)
• Failure to combine pharmacotherapy with CBT when indicated
• Not addressing anticipatory anxiety and phobic avoidance that often accompany panic attacks

By following this evidence-based approach, most patients with panic disorder can achieve significant improvement in symptoms and quality of life.