What is the best course of treatment for a 25-year-old patient with a history of 'school phobia', family history of depression, and recent episodes of tachycardia, shortness of breath, and shakiness, who has had normal cardiac testing and lab work, including a normal thyroid-stimulating hormone (TSH) level, and a Patient Health Questionnaire-9 (PHQ-9) score of 6, indicating mild depression?

Panic Disorder with Cognitive-Behavioral Therapy and SSRI Pharmacotherapy

This patient requires treatment for panic disorder with a combination of cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitor (SSRI) pharmacotherapy, such as sertraline, as first-line management. 1

Clinical Diagnosis

The presentation is classic for panic disorder:

• Recurrent, unexpected panic attacks with characteristic symptoms: palpitations, perceived arrhythmia ("skipping beats"), dyspnea, diaphoresis, tremulousness, and intense fear of dying or having a heart attack 2
• Duration of 10-15 minutes is typical for panic attacks 2
• Nocturnal panic attacks (waking from sleep) occur in panic disorder and often increase patient distress 2
• Anticipatory anxiety and avoidance behavior affecting work and social functioning are hallmarks of panic disorder 2
• Medical workup appropriately ruled out cardiac and thyroid pathology (normal EKGs, angiogram, TSH 2.2 mIU/L) 2

The PHQ-9 score of 6 indicates minimal depressive symptoms, not meeting criteria for major depression 3. The history of "school phobia" suggests childhood anxiety disorder, which increases risk for adult panic disorder 2.

Treatment Algorithm

Step 1: Confirm Diagnosis and Rule Out Remaining Medical Causes

While cardiac and thyroid causes have been excluded, ensure no other organic contributors remain 4:

• Substance use: Caffeine, stimulants, or withdrawal states can mimic panic attacks 2
• Medication review: Beta-agonists (albuterol), decongestants, or other sympathomimetic agents 2
• Anemia, dehydration, or electrolyte disturbances have been ruled out by normal labs 2

Step 2: Initiate Combined Pharmacotherapy and Psychotherapy

First-line treatment combines SSRI medication with cognitive-behavioral therapy 2:

• SSRI pharmacotherapy: Sertraline is FDA-approved for panic disorder and should be initiated 1

  • Starting dose: 25 mg daily for one week, then increase to 50 mg daily 1
  • Therapeutic range: 50-200 mg daily 1
  • Full therapeutic effect may take 4-6 weeks 1

• Cognitive-behavioral therapy: Should be delivered by appropriately trained mental health professionals 2

  • CBT specifically targets panic symptoms, catastrophic thinking, and avoidance behaviors 2
  • Exposure therapy addresses situational avoidance (work, social engagements) 2

Step 3: Safety Monitoring and Patient Education

Critical safety considerations with SSRI initiation 1:

• Monitor for increased anxiety, agitation, or suicidal ideation, particularly in the first few weeks of treatment or with dose changes 1
• Young adults (age 18-24) have increased risk of treatment-emergent suicidal thoughts (5 additional cases per 1000 patients treated) 1
• Schedule close follow-up: Weekly for the first month, then every 2-4 weeks during dose titration 1
• Educate about serotonin syndrome risk: Avoid concurrent use of triptans, tramadol, St. John's Wort, or other serotonergic agents 1

Step 4: Address Functional Impairment

Immediate workplace and social functioning support 2:

• Provide work accommodation documentation if needed for panic attacks occurring at work 2
• Psychoeducation: Explain that panic attacks, while terrifying, are not medically dangerous and will not cause heart attacks 2
• Encourage gradual re-engagement with avoided social situations as treatment progresses 2

Step 5: Consider Psychiatric Referral

Refer to psychiatry or psychology for 3, 4:

• Specialized CBT for panic disorder with exposure-based interventions 2, 3
• Medication management if primary care provider is uncomfortable managing SSRIs 3
• Complex cases: If patient has comorbid conditions or doesn't respond to initial treatment 3

Common Pitfalls to Avoid

Do not use benzodiazepines as first-line treatment despite their rapid anxiolytic effect, as they carry dependence risk and don't address underlying pathophysiology 2. Reserve benzodiazepines only for severe, acute episodes while awaiting SSRI therapeutic effect, and taper quickly 2.

Do not dismiss the traumatic childhood experience (finding father's body after suicide at age 12) as this may contribute to anxiety vulnerability and should be addressed in psychotherapy 2.

Do not abruptly discontinue SSRI if started, as this causes withdrawal symptoms including anxiety, irritability, dizziness, and "electric shock-like sensations" 1. Taper gradually if discontinuation is needed 1.

Do not overlook the family history of depression (father's suicide, mother's depression with hospitalizations), which increases this patient's risk for mood disorders and requires ongoing monitoring 3, 4.

Prognosis and Follow-Up

Panic disorder is highly treatable with combined CBT and SSRI therapy showing superior outcomes to either modality alone 2. The patient's good insight ("I want my life back"), stable social support system, and absence of substance abuse are favorable prognostic factors 2. Regular monitoring for treatment response, medication adherence, and emergence of depressive symptoms is essential 3, 4.