Panic Disorder

Panic disorder definition

recurrent, unexpected panic attacks followed by at least 1 month of 1 or more of the following --> concern about having another panic attack, anticipatory anxiety or fear, significant behavioral change related to panic attack

How long must a patient experience symptoms before panic disorder is diagnosed?

1 month

Panic disorder frequently co-occurs with what fear?

agoraphobia

DSM-5 Panic Attack Criteria

Abrupt surge of intense fear peaking within 10 min.

At least four of these symptoms:

1. Sweating

2. Trembling or shaking.

3. Unsteady (dizziness/faint)

4. Derealization/depersonalization

5. Excessive HR (palpitations)

6. Nausea

7. Tingling/numbness

8. Shortness of breath

9. Fear of losing control or "going crazy."

10. Fear of dying

11. choking sensation

12. chest pain/discomfort

13. Chills/heat sensation

Describe panic disorder treatment "response."

- decrease in panic attack severity

- decrease in panic attack frequency

- reduction in anticipatory fear

- improved functioning

Describe panic disorder treatment "remission"

- no panic attacks

- no avoidance behaviors

- no anticipatory anxiety

- no fear of leaving the home/going outside

What is the first line treatment for panic disorder?

CBT + SSRI or SNRI

What SSRIs are first line for panic disorder (6)

1. fluoxetine

2. paroxetine

3. sertraline

4. citalopram

5. escitalopram

6. fluvoxamine

What SNRI is first line for panic disorder (1)?

venlafaxine

If first line therapy does not work for panic disorder, what is the next step?

try another first line agent

What are the second line agents for the treatment of panic disorder (3)?

1. TCAs (clomipramine and imipramine)

2. Mirtazapine

3. Benzos (alprazolam, clonazepam, diazepam and lorazepam)

When would it be appropriate to use benzos to treat panic disorder?

benzos may be used initially while waiting on response to SSRI (or to combat SSRI initial anxiety sxs)

How long is it appropriate to use benzos for the treatment of panic disorder?

8 weeks (4 weeks of treatment + 4 week taper)

Which benzo has the highest potential for abuse?

diazepam

List the adjunct pharmacotherapy options for panic disorder (4)

1. SGAs

2. Anticonvulsants (divalproex)

3. hydroxyzine

4. beta blockers (pindolol)

How often should medications used to treat panic disorder be titrated?

every 1-2 weeks over 4-6 weeks

Once target dose is reached, how long does it take to see improvement in panic disorder symptoms?

4-8 weeks

How long is considered an adequate trial for pharmacotherapy in treating panic disorder?

4-12 weeks

How often should you follow up with patients being treated for panic disorder?

Every 2 weeks for the first 6 weeks then monthly

How long should pharmacotherapy be continued after response/remission of panic disorder?

at least 12 months