Panic Disorder

Background

• Panic disorder is characterized by unexpected and recurrent panic attacks and a persistent, disabling concern over the potential for additional attacks.
• Panic attacks, which are sudden episodes of severe anxiety accompanied by several physical symptoms, such as, palpitations, sweating, or trembling, may be accompanied by agoraphobia, but agoraphobia is currently considered a separate psychiatric condition from panic disorder.
• The onset of panic disorder most commonly occurs in early adulthood and is about twice as common in women than in men.
• The pathogenesis of panic disorder is unclear but it may result from a combination of genetic and environmental influences on fear-processing and fear responses.
• The clinical course of panic disorder is frequently relapsing and remitting. Symptoms often persist over many years and may severely impact psychological and physical functioning.
• Other psychiatric conditions, including other anxiety disorders, mood disorders, and substance use disorders (especially alcohol use disorder), may be comorbid with panic disorder.

Evaluation

• Suspect panic disorder in patients with recurrent, unexpected panic attacks and persistent (at least 1 month or more) disabling concern or worry over future panic attacks.
• Diagnosis is generally clinical, with laboratory or other testing indicated only if it is needed to rule out other causes of anxiety, such as, heart disease, hyperthyroidism and other endocrine disorders, seizure disorders, or substance abuse.
• Differential diagnosis includes panic attacks related to other psychiatric disorders, substance use disorders, or medical conditions, such as, cardiopulmonary illnesses, thyroid or other endocrine dysfunction, and neurologic conditions.

Management

• For the initial management of panic disorder, advise psychotherapy or medication treatment based on patient preference (Strong recommendation). Consider a combination therapy with counseling and medication if the patient prefers (Weak recommendation).
• For psychotherapy, cognitive behavioral therapy (CBT), specifically panic-focused therapy, is recommended as the first-line option (Strong recommendation).
• First-line medications for the treatment of panic disorder include:
  • selective serotonin reuptake inhibitors (SSRIs), such as, citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, or sertraline (Strong recommendation)
  • serotonin norepinephrine reuptake inhibitors (SNRIs), such as, venlafaxine extended-release (Strong recommendation)
• Consider a benzodiazepine, such as, alprazolam, clonazepam, or lorazepam, in combination with antidepressants for patients with very distressing or impairing symptoms in whom rapid symptom control is critical. However, benzodiazepines are appropriate as monotherapy only in the absence of a co-occuring mood disorder (Weak recommendation).
• Second-line medications to consider for the treatment of panic disorder include:
  • benzodiazepines, such as, alprazolam, clonazepam, or lorazepam (Weak recommendation)
  • tricyclic antidepressants, such as, imipramine or clomipramine (Weak recommendation)
• For patients unresponsive to the initial treatment, options include augmentation with another first-line treatment or switching to another first-line treatment (Strong recommendation). Adding a benzodiazepine to an antidepressant to target residual symptoms may also be considered (Weak recommendation).
• For pregnant or breastfeeding patients, discuss the risks and benefits of pharmacotherapy including the risks of untreated comorbid psychiatric conditions (Strong recommendation).
• For children with panic disorder, consider CBT. For persistent symptoms or children who are unable to perform CBT, consider an SSRI antidepressant.
• Monitor patients during follow-up for changes in symptoms and potential adverse effects of medications (Strong recommendation).