What is the best approach to manage anxiety and prevent future panic attacks in a patient with PTSD, depression, ADHD, and anxiety, on lamictal 100mg and klonopin 0.5mg as needed, with a history of trying various medications and recent restaurant anxiety after a panic attack?

Management of Panic Disorder with Social Anxiety in Complex Psychiatric Comorbidity

This patient requires cognitive-behavioral therapy (CBT) with exposure-based techniques as the primary intervention, combined with an SSRI trial (specifically escitalopram or paroxetine) given the treatment-resistant nature and specific fear of panic attacks in social situations. 1

Immediate Treatment Strategy

Psychotherapy as Primary Intervention

CBT with exposure therapy should be initiated immediately as it addresses both the panic disorder and anticipatory anxiety about future attacks. 1, 2

• Individual CBT is strongly preferred over group therapy for social anxiety presentations, particularly when the patient fears drawing attention to themselves 1, 3
• The therapy must include imaginal exposure (repeated recounting of the panic attack experience) and in vivo exposure (gradual confrontation with restaurant settings and similar feared situations) 1
• Between 40-87% of patients no longer meet criteria for panic disorder after 9-15 sessions of exposure therapy, compared to less than 5% with no intervention 1
• Exposure therapy has the strongest evidence base across the widest range of populations and directly targets the core fear maintaining this patient's avoidance 1

Pharmacotherapy Optimization

Given the extensive medication trial history, an SSRI that has not been tried should be initiated, specifically escitalopram or paroxetine, as these have FDA indication for both panic disorder and social anxiety disorder. 1, 4

• SSRIs are first-line pharmacotherapy with GRADE 2C recommendation for social anxiety disorder 1
• Paroxetine and sertraline have FDA indication specifically for panic disorder, with 53-85% of patients classified as treatment responders 1
• The current Klonopin 0.5mg as-needed regimen is appropriate for short-term use but should not be escalated - benzodiazepines are useful for rapid onset anti-anxiety effects during the first few days but are not first-choice for medium/long-term treatment due to tolerance and dependence 5, 4
• Lamictal 100mg should be continued as it may provide benefit for PTSD symptoms and mood stabilization, with preliminary evidence suggesting effectiveness for reexperiencing and avoidance/numbing symptoms 6

Alternative Pharmacologic Option

If SSRIs continue to fail, venlafaxine (SNRI) is the next evidence-based alternative with nearly identical efficacy to SSRIs (NNT 4.94 vs 4.70). 3

• Venlafaxine has demonstrated effectiveness specifically for panic disorder and social anxiety disorder 5
• Do not use propranolol - it has been explicitly deprecated by Canadian guidelines based on negative evidence for social anxiety disorder, and this patient has already failed a trial 3

Addressing the Specific Fear Pattern

This patient's "restaurant anxiety" represents anticipatory anxiety about panic attacks (fear of fear), which is the core maintaining factor in panic disorder. 2, 5

• The treatment must specifically target the catastrophic misinterpretation of panic sensations and the belief that having a panic attack in public would be unbearable 2
• Cognitive restructuring should challenge thoughts about: (1) the likelihood of another panic attack, (2) the consequences of others noticing anxiety symptoms, and (3) the ability to cope if panic occurs 1
• Graduated exposure hierarchy should start with less anxiety-provoking situations (e.g., quiet café during off-hours) and progress to more challenging scenarios (busy restaurants during peak times) 1, 2

Critical Monitoring Requirements

• Schedule weekly visits during the first 4 weeks of any new SSRI or dose adjustment to monitor for treatment-emergent suicidal ideation, particularly given the PTSD and depression comorbidity 7, 3
• Assess for akathisia (restlessness) if starting or increasing SSRIs, as this can increase suicidality risk 7
• Evaluate treatment response at 4 and 8 weeks using standardized anxiety rating scales 3
• Monitor for serotonin syndrome given the combination of lamotrigine and SSRI 3

Common Pitfalls to Avoid

Do not increase benzodiazepine frequency or dose - while Klonopin provides immediate relief, regular use will prevent the patient from learning that panic sensations are tolerable and will pass without medication, which is essential for CBT success 4, 5

• Avoid combining multiple sedating agents (benzodiazepines with other CNS depressants) due to additive cognitive impairment 3
• Never discontinue lamotrigine or any SSRI abruptly - taper gradually over at least 10-14 days to avoid discontinuation syndrome 3
• Do not escalate SSRI doses too quickly - allow 1-2 weeks between increases to assess tolerability 3
• Recognize that approximately 60% of untreated social anxiety cases persist for several years, emphasizing the importance of active intervention 1, 7

Integration with Existing Conditions

The treatment plan must account for PTSD, depression, and ADHD comorbidity, which increases functional impairment and worsens outcomes. 1

• Interventions should be transdiagnostic, targeting overlapping processes like rumination and avoidance that maintain both anxiety and depression 1
• CBT elements can be adapted quickly (5-minute exercises) and practiced at home, making them compatible with ADHD-related attention difficulties 1
• The combination of CBT and SSRI shows better outcomes than either treatment alone for comorbid anxiety and depression 7