What is the best course of treatment for a 40-year-old teacher with a history of panic attacks in their 20s, who experiences anxiety and irritability, particularly while driving, and uses weed (cannabis) to cope with social anxiety, but avoids it due to paranoia, and consumes high amounts of energy drinks (e.g. Red Bull), and has a high-stress lifestyle with overstimulation from work and family?

Treatment Approach for Panic Disorder with Cannabis Use and High Stimulant Intake

This patient requires immediate cessation of cannabis and energy drinks, initiation of an SSRI (sertraline 25-50mg daily or escitalopram 10mg daily), and referral for cognitive behavioral therapy—cannabis use is likely exacerbating panic attacks rather than helping anxiety, and high caffeine intake from energy drinks is a direct panic trigger that must be eliminated. 1, 2, 3

Immediate Interventions Required

Substance Modification (Critical First Step)

• Discontinue all cannabis use immediately as chronic cannabis dependence can cause panic attacks even after cessation, and current intermittent use perpetuates anxiety symptoms rather than alleviating them 3
• Cannabis-induced panic disorder should be strongly considered in patients presenting with panic attacks following periods of cannabis use, particularly when symptoms include palpitations, dyspnea, paresthesias, and diaphoresis 3
• Eliminate all energy drink consumption (Red Bull) as high caffeine intake is a well-established trigger for panic attacks and anxiety symptoms 2, 4
• The patient's pattern of using cannabis "only when around people" but experiencing paranoia indicates maladaptive coping that reinforces avoidance behavior rather than treating underlying social anxiety 5

Pharmacotherapy Initiation

• Start sertraline 25-50mg daily OR escitalopram 10mg daily as first-line SSRI treatment for panic disorder 1, 2, 6
• Sertraline and escitalopram are preferred due to favorable safety profiles, low drug interaction potential, and established efficacy in panic disorder 7, 1
• Initial adverse effects may include transient anxiety or agitation in the first 1-2 weeks, which typically resolve with continued use 1
• Avoid benzodiazepines for long-term management due to risk of dependence, tolerance, and potential for paradoxical agitation; reserve only for short-term bridging if panic attacks are severely disabling during SSRI initiation 2, 6, 4

Psychotherapy (Essential Component)

Cognitive Behavioral Therapy

• Refer for individual CBT specifically designed for panic disorder, consisting of approximately 12-14 sessions over 3-4 months 7, 8
• CBT should include: psychoeducation about panic disorder, cognitive restructuring of catastrophic thoughts, interoceptive exposure to feared bodily sensations, and relapse prevention strategies 7
• Individual therapy is superior to group therapy for panic and social anxiety disorders in terms of clinical effectiveness 7, 5
• Combination of SSRI plus CBT provides superior efficacy compared to medication monotherapy and may offer more durable long-term benefits 9, 8, 4

Addressing Comorbid Social Anxiety

Diagnostic Clarification

• The patient's anxiety "when around people" and paranoia with cannabis use suggests comorbid social anxiety disorder requiring formal assessment 5
• Use Mini-SPIN screening tool (cutoff ≥6 points has 89% sensitivity and 90% specificity) to confirm social anxiety diagnosis 5
• Both panic disorder and social anxiety respond to the same first-line SSRIs (sertraline, escitalopram) and CBT approaches 7, 5

Treatment Implications

• Do not write work excuse letters or provide accommodations that reinforce avoidance, as this perpetuates the core maintaining factor in anxiety disorders 5
• SSRIs at therapeutic doses (sertraline up to 200mg daily, escitalopram 10-20mg daily) effectively treat both panic disorder and social anxiety disorder simultaneously 7, 5

Lifestyle and Environmental Modifications

Stress Management

• Address occupational overstimulation through structured breaks, boundary-setting with work demands, and development of decompression routines between work and home 4
• Implement regular exercise, which may have beneficial effects on anxiety symptoms 2
• Establish consistent sleep hygiene practices, as sleep disruption exacerbates anxiety and panic symptoms 4

Treatment Monitoring and Duration

Assessment Timeline

• Evaluate treatment response at 4 weeks and 8 weeks using standardized measures (GAD-7, panic disorder severity scale) 1, 2
• Monitor for symptom relief, medication side effects, adherence to cannabis/caffeine cessation, and functional improvement in driving and work settings 1

Medication Adjustment Strategy

• If symptoms are stable or worsening after 8 weeks despite good adherence, consider: switching to different SSRI, increasing to maximum therapeutic dose, or switching to SNRI (venlafaxine 75-225mg daily) 1, 9
• Venlafaxine (SNRI) is an appropriate alternative if SSRIs prove ineffective or poorly tolerated 7, 9

Long-Term Treatment Duration

• Continue pharmacotherapy for minimum 12-24 months after symptom remission for first episode of panic disorder 1, 8
• For recurrent panic disorder (which this patient has, given history in his 20s), longer-term or indefinite treatment may be necessary 1, 8
• Never discontinue SSRIs abruptly—taper gradually over 10-14 days minimum to avoid discontinuation syndrome (dizziness, paresthesias, anxiety, irritability) 1

Critical Pitfalls to Avoid

• Do not prescribe benzodiazepines for long-term management as they cause dependence, cognitive impairment, and higher mortality risk 2, 6
• Do not allow continued cannabis use under the misconception it helps anxiety—it is likely a primary contributor to panic attacks 3
• Do not ignore the caffeine/energy drink contribution—this is a modifiable trigger that must be eliminated 2, 4
• Do not provide work accommodations that enable avoidance behavior—this reinforces anxiety rather than treating it 5
• Do not start treatment without addressing substance use first—cannabis and high caffeine intake will undermine pharmacotherapy effectiveness 3, 4