Panic Disorder

Panic Disorder

- anxiety characterized by intermittent "attacks" of intense fear & discomfort

- 50% of pts will develop agoraphobia

Clinical Presentation

- depersonalization

- derealization

- fear of: losing control, going crazy, dying

- chest pain

- sensations of SOB

- sweating

- tachycardia

- shaking

- palpitations

- nausea/abdominal distress

DSM-5 Criteria

- series of unexpected panic attacks

- followed by 1 mo persistent concern about having another attack

AND clinical presentation sx

Treatment Goals

- remission

- free of panic attacks

- reduction in anticipatory anxiety & avoidance

- no functional impairment

Non-pharm Treatment

- CBT

- self-help books

- exercise

- avoiding substances that trigger attacks (nicotine, caffeine)

Pharmacologic Tx 1st line

- SSRIs

- venlafaxine XR

Pharmacologic Tx 2nd line

- alprazolam

- clomipramine

- clonazepam

- imipramine

Pharmacologic Alternatives

- phenelzine

- gabapentin

- 2nd gen antipsychotic

SSRIs

- equal response rate to all SSRIs

- effect delayed for 4 wks (may take 8-12 wks to see effects)

- initial low doses to avoid stimulatory SEs

- SEs: insomnia, jitteriness, restlessness, agitation

SNRIs

- venlafaxine XR

- similar efficacy to paroxetine

- reduces the severity of anticipatory anxiety, fear, & avoidance

- FDA approved

Benzodiazepines

- clonazepam & alprazolam preferred

- alprazolam = rapid relief for pts in distress

- response in 1-2 weeks

- high relapse rates despite tapering

TCAs

- imipramine

- 2nd line due to side effects (anxiety, insomnia, jitteriness)

- blocks panic attacks within 4 wks (may take up to 8 wks)

Treatment Algorithm 1st Line

- treatment urgent = short-term BZD & SSRI or venlafaxine for 12 wks

- treatment not urgent = SSRI or venlafaxine for 12 wks

Treatment Algorithm 2nd, 3rd & 4th line

- adequate response to 1st line = continue therapy for 12-24 mnths

- no adequate response = switch to diff SSRI or venlafaxine

- continued no adequate response = switch to another antidepressant

- still no response = add BZD or gabapentin or atypical agent

Key Points

- characterized by panic attacks

- optimal treatment duration is 12-24 months

- long term BZD = dependence & withdrawal = taper over 2-4 months

- SSRIs = first-line options

- TCAs = second-line