What is the best course of treatment for a 46-year-old male driver experiencing panic attacks, anxiety, and stress due to workplace harassment and grievances, who is having trouble sleeping, and is experiencing impaired cognitive function, with access to an employee assistance program (EAP) through a relative's company?

Treatment Approach for Work-Related Panic Attacks and Anxiety

This patient requires immediate initiation of an SSRI (sertraline 50mg daily) combined with short-term benzodiazepine support (clonazepam 0.25mg twice daily for 2-3 weeks only) while simultaneously arranging cognitive behavioral therapy through the employee assistance program. 1, 2, 3, 4

Immediate Management (Today's Visit)

Acute Symptom Control

• Start sertraline 50mg once daily (morning or evening) as first-line pharmacotherapy for panic disorder 3, 5
• Add clonazepam 0.25mg twice daily for 2-3 weeks maximum to provide rapid symptom relief while waiting for SSRI onset of action 4, 6
  • This short-term benzodiazepine bridge is appropriate given his severe functional impairment (cannot sleep, cannot function, memory affected) 6
  • Critical caveat: Benzodiazepines must be time-limited (2-3 weeks) and discontinued as SSRI takes effect to avoid dependency 7
  • Plan taper schedule now: after 2-3 weeks, decrease by 0.125mg every 3 days 4

Rule Out Medical Emergencies

• While panic is likely given the clear workplace stressor and symptom pattern (acute onset, racing thoughts, sleep disruption, cognitive impairment), briefly assess for cardiac risk factors given his age (46 years) 1
• Ask specifically about: chest pain quality, pain with palpation/movement, multiple pain sites—these features argue against cardiac causes 1

Psychological First Aid (Teach Today)

Immediate Coping Strategies

• Teach diaphragmatic breathing technique: slow deep breaths through nose, hold briefly, exhale slowly through pursed lips to interrupt catastrophic thinking 1
• Provide sensory grounding techniques for use when he feels panic building:
  • Notice environmental details (colors, textures, sounds in the truck cab) 1
  • Cognitive distractions (counting backwards from 100 by 7s, naming state capitals) 1
  • Physical grounding (flicking rubber band on wrist, holding ice cube) 1

Written Action Plan

• Create a written panic attack management plan that he keeps in his truck 1
• Include early warning signs he's identified: racing thoughts about the supervisor, sense of dread before work, physical tension 1
• List specific steps: pull over safely, implement breathing technique, use grounding exercises, remind himself symptoms peak in 10 minutes 1

Employee Assistance Program Referral (Arrange This Week)

CBT Structure and Goals

• Request 12-20 sessions of individual face-to-face CBT over 3-4 months through the EAP 2
  • Individual therapy is superior to group therapy for both clinical outcomes and cost-effectiveness 2
  • Each session should be 60-90 minutes 2

Essential CBT Components the Therapist Should Provide

• Cognitive restructuring to address catastrophic thinking about the supervisor's actions and job security 2
• Graduated exposure to work-related anxiety triggers (starting with thinking about work, then driving to work, then interacting with supervisor) 2
• Homework assignments between sessions—this is the strongest predictor of both short and long-term success 2
• Challenge specific distortions: catastrophizing ("I'll definitely lose my job"), overgeneralization ("this supervisor ruins everything"), all-or-nothing thinking ("I'm either perfect or fired") 2

What NOT to Do in Therapy

• Avoid psychological debriefing where he's asked to repeatedly ventilate emotions and relive the workplace trauma—this can worsen outcomes 1

Medication Management Timeline

Week 1-3

• Continue sertraline 50mg daily 3
• Continue clonazepam 0.25mg twice daily 4
• Monitor for SSRI side effects (nausea, initial anxiety increase, sexual dysfunction) 5
• Common pitfall: Patients often discontinue SSRIs in first 2 weeks due to initial activation—warn him this is temporary 5

Week 3-4

• Begin clonazepam taper: decrease by 0.125mg every 3 days until discontinued 4
• Assess sertraline response 3

Week 4-8

• If inadequate response at 50mg, increase sertraline by 50mg increments weekly up to maximum 200mg daily 3
  • Do not increase more frequently than weekly given 24-hour half-life 3
• Higher doses are typically needed for anxiety disorders compared to depression 5

Month 3-4

• Reassess with standardized measure (GAD-7 scale) 2
• If still inadequate response despite 200mg sertraline and ongoing CBT, consider switching to different SSRI (escitalopram) or SNRI (venlafaxine extended-release) 8, 5

Long-Term Maintenance

Duration of Treatment

• Continue sertraline for minimum 12-24 months after symptom remission 9, 7
• Given the chronic workplace stressor (ongoing supervisor conflict, final warning status), he may require indefinite treatment 9
• Do not discontinue prematurely—panic disorder is chronic and rarely resolves without sustained treatment 9

Monitoring for Complications

• Screen for depression at each visit—depression commonly co-occurs with panic disorder and can develop secondary to chronic workplace stress 1
• Untreated depression can significantly worsen outcomes and quality of life 1

Addressing the Workplace Stressor

Practical Recommendations

• The union representation is appropriate—encourage him to fully engage with this process 8
• Consider whether workplace accommodations are needed (e.g., modified schedule during acute treatment phase) 8
• Anxiety management at work: practice grounding techniques during breaks, use breathing exercises before supervisor interactions 8

Sleep Hygiene

• Address insomnia directly as it perpetuates anxiety and cognitive impairment 8
• Sleep hygiene education: consistent sleep schedule, avoid caffeine after noon, no screens 1 hour before bed, reserve bed for sleep only 8
• If insomnia persists despite sertraline, consider adding trazodone 50-100mg at bedtime rather than continuing benzodiazepines 7

Follow-Up Schedule

• Week 2: Phone check-in for medication tolerance and clonazepam taper plan
• Week 4: In-person visit to assess response, adjust sertraline dose, confirm clonazepam discontinued
• Week 8: In-person visit to optimize sertraline dose
• Month 3: In-person visit with GAD-7 scoring to objectively measure progress 2
• Monthly thereafter until stable, then every 3 months 7