What is the diagnosis and treatment for panic disorder?

Diagnosis and Treatment of Panic Disorder

The most effective approach for panic disorder is a combination of cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs), with paroxetine being the most strongly supported medication for reducing panic attacks and associated symptoms. 1, 2

Diagnosis

Diagnostic Criteria

• Panic disorder is characterized by recurrent unexpected panic attacks, defined as discrete periods of intense fear with rapid onset (peaking within 10 minutes) accompanied by at least 4 of the following symptoms 1:

  • Palpitations, pounding heart, accelerated heart rate
  • Sweating
  • Trembling or shaking
  • Shortness of breath or smothering
  • Feeling of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Dizziness, unsteadiness, lightheadedness
  • Derealization or depersonalization
  • Fear of losing control
  • Fear of dying
  • Paresthesias (numbness/tingling)
  • Chills or hot flushes

• Diagnosis requires both recurrent unexpected panic attacks and at least one month of persistent concern about having additional attacks, worry about implications of attacks, or significant behavioral changes related to the attacks 1

Assessment Tools

• Structured diagnostic interviews are recommended to confirm diagnosis according to DSM-5 criteria 3
• The 7-item Generalized Anxiety Disorder scale (GAD-7) can be used as an initial screening tool, with scores ≥10 indicating moderate to severe anxiety symptoms requiring further evaluation 4
• Assess for risk of self-harm or harm to others, which would necessitate emergency evaluation 4

Differential Diagnosis

• Medical conditions that can mimic panic symptoms must be ruled out 3, including:

  • Hyperthyroidism
  • Cardiac arrhythmias or valvular disease
  • Asthma
  • Hypoglycemia
  • Pheochromocytoma
  • Caffeine intoxication 4

• Assess for comorbid conditions that commonly occur with panic disorder 5:

  • Major depressive disorder
  • Other anxiety disorders (social anxiety, generalized anxiety)
  • Substance use disorders
  • Agoraphobia 1, 5

Treatment

First-Line Treatments

Pharmacotherapy

• SSRIs are first-line pharmacological treatment for panic disorder 2, 6:
  • Paroxetine is FDA-approved for panic disorder at doses of 10-60 mg/day (start at 10 mg/day and titrate up) 1
  • Fluoxetine is effective at 10-60 mg/day (start at 10 mg/day for one week, then increase to 20 mg/day) 7, 2
  • Treatment should be continued for at least 9-12 months after symptom remission to prevent relapse 3, 8

Psychotherapy

• Cognitive behavioral therapy (CBT) is the most effective psychotherapeutic approach for panic disorder 3, 9
• Key components of effective CBT include:
  • Psychoeducation about panic and anxiety
  • Diaphragmatic breathing techniques
  • Cognitive restructuring of catastrophic thoughts
  • Interoceptive exposure to feared bodily sensations
  • In vivo exposure to feared situations 3, 2

Second-Line and Adjunctive Treatments

Alternative Medications

• Benzodiazepines can be effective for acute symptom management but carry risk of dependence 3, 10:

  • Clonazepam (0.5-4 mg/day) has demonstrated efficacy in reducing panic attacks 10, 6
  • Should not be used as sole first-line treatment due to dependence risk 3
  • May be considered for short-term use during SSRI initiation period 2

• Serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine can be effective alternatives to SSRIs 2, 6

• Tricyclic antidepressants (TCAs) are effective but have more side effects than SSRIs 6, 8

Adjunctive Approaches

• Structured physical activity can reduce panic symptoms 8
• Relaxation training may be used as an adjunctive treatment 3

Treatment Algorithm

1. Initial Treatment:

   • Begin with either an SSRI (preferably paroxetine) or CBT, or both concurrently for more severe cases 1, 2
   • For severe, disabling symptoms, consider short-term benzodiazepine use while waiting for SSRI effect 10, 2

2. Monitoring and Adjustment:

   • Assess response after 4-6 weeks of medication treatment 1
   • If partial response, increase SSRI dose within recommended range 1, 7
   • If minimal/no response to initial SSRI, switch to another SSRI or an SNRI 2, 6

3. Maintenance:

   • Continue effective medication for at least 9-12 months after symptom remission 3, 8
   • Consider gradual taper after this period, monitoring closely for relapse 7

Special Considerations

Cultural Factors

• Cultural adaptations to CBT may be necessary for certain populations 3:
  • Incorporating mindfulness techniques for Asian Americans
  • Addressing culturally specific manifestations of panic for Hispanic/Latino patients
  • Emphasizing in vivo exposure for African Americans

Common Pitfalls to Avoid

• Failing to differentiate panic disorder from medical conditions with similar presentations 3
• Stopping medication treatment too early (before 9-12 months after recovery) 3, 8
• Using benzodiazepines as sole first-line treatment due to risk of dependence 3, 9
• Overlooking cultural factors that may influence symptom presentation and treatment response 3