What is the treatment for a teenager experiencing panic attacks and social anxiety disorder, with symptoms including inability to focus on schoolwork and frequent meltdowns in a high school setting?

Treatment for Adolescent with Panic Attacks and Social Anxiety Disorder

Combination treatment with cognitive-behavioral therapy (CBT) plus an SSRI (specifically sertraline) should be offered as first-line treatment for this teenager, as this approach demonstrates superior efficacy compared to either treatment alone for adolescents with social anxiety and panic disorder. 1

First-Line Treatment Approach

Combination Therapy (Preferred)

• CBT combined with sertraline is the recommended initial treatment for adolescents aged 6-18 years with social anxiety and panic disorder, showing moderate strength of evidence for improved anxiety symptoms, global function, treatment response, and disorder remission compared to monotherapy 1
• The Child-Adolescent Anxiety Multimodal Study (CAMS) demonstrated that combination treatment was significantly superior to either CBT alone or medication alone in initial treatment response, which strongly predicted long-term outcomes 1
• While long-term follow-up showed that the initial superiority of combination treatment diminished over time, the critical factor is achieving a strong initial response—which combination therapy delivers best 1

Monotherapy Options (If Combination Not Feasible)

• If combination therapy cannot be implemented, either CBT alone or an SSRI alone can be offered, though with lower expected efficacy 1
• CBT as monotherapy has established efficacy and should be prioritized if the patient or family refuses medication 1, 2
• SSRI monotherapy (sertraline preferred) is appropriate if CBT is unavailable or if the patient cannot engage in therapy due to severity of symptoms 1

Specific Medication Recommendations

SSRI Selection and Dosing

• Sertraline is the first-choice SSRI for adolescents with social anxiety and panic disorder, with FDA approval and extensive evidence base 3
• Starting dose for adolescents (ages 13-17): 50 mg once daily (morning or evening), which can be increased in 50 mg increments at intervals of at least 1 week based on response 3
• Maximum dose: 200 mg/day, though most adolescents respond to lower doses (mean effective dose approximately 70-102 mg/day) 1, 3
• Parental oversight of medication administration is paramount in this age group 1

Alternative SSRI Options

• If sertraline is not tolerated, other SSRIs (fluoxetine, escitalopram, citalopram) can be considered as they also have evidence for anxiety disorders 1
• SNRIs (venlafaxine, duloxetine) represent second-line pharmacological options if SSRIs are ineffective or not tolerated 1

Cognitive-Behavioral Therapy Specifications

CBT Components for This Patient

• Exposure-based interventions targeting social and performance situations that trigger panic attacks 1, 4
• Cognitive restructuring to address catastrophic thinking about panic symptoms and social evaluation 4, 2
• Interoceptive exposure for panic symptoms (controlled exposure to physical sensations of panic) 4
• Social skills training and behavioral experiments in feared social situations 2

Treatment Structure

• Typical course: 12-18 weekly sessions of 50 minutes each 1
• Can be delivered individually or in group format for social anxiety components 2
• Parent involvement is beneficial, particularly if parents themselves have anxiety 1

Critical Monitoring Requirements

Safety Monitoring (Essential)

• Monitor closely for suicidal ideation and behavior, especially in the first weeks after starting or increasing SSRI dose, as adolescents have increased risk 1, 3
• Assess for behavioral activation/agitation, which can occur early in SSRI treatment 1
• Use standardized symptom rating scales to systematically track treatment response 1
• Monitor for common SSRI side effects: gastrointestinal symptoms, sleep disturbance, fatigue/somnolence 1

Treatment Response Assessment

• Evaluate response at 4-6 weeks; if inadequate response, consider dose increase or treatment intensification 1
• Full therapeutic effect may take 8-12 weeks 3
• If no response after adequate trial (8-12 weeks at therapeutic dose), consider switching medications or augmenting treatment 1

School Accommodation Considerations

Immediate Interventions

• Coordinate with school to implement accommodations for panic attacks (safe space, ability to leave class briefly) 1
• Consider 504 plan or IEP modifications to address functional impairments in schoolwork and social situations 1
• Gradual exposure hierarchy for school attendance and participation, integrated with CBT treatment 1, 4

Treatment Duration and Maintenance

Acute Phase

• Continue combination treatment for at least 4-6 months after achieving symptom remission 3
• Both panic disorder and social anxiety disorder typically require several months of sustained treatment beyond initial response 3

Long-Term Management

• Maintenance treatment for 12 months or longer is recommended after symptom remission to prevent relapse 3
• Periodic reassessment (every 3-6 months) to determine ongoing need for treatment 3
• If discontinuing SSRI, taper slowly over several weeks to avoid discontinuation syndrome 3
• CBT skills provide longer-term maintenance of gains even after treatment ends 4, 2

Common Pitfalls to Avoid

• Do not use benzodiazepines as first-line treatment in adolescents despite their rapid anxiolytic effect, due to risks of dependence, cognitive impairment, and lack of evidence for long-term efficacy 1, 5
• Do not delay treatment waiting for "the perfect intervention"—early effective treatment predicts better long-term outcomes 1
• Do not abruptly discontinue SSRIs, particularly sertraline, as this causes discontinuation syndrome 3
• Do not treat in isolation—coordinate care between mental health provider, primary care, and school 1
• Do not ignore parental anxiety, which can inadvertently reinforce avoidance behaviors; consider parental treatment if indicated 1