Approach to treating panic disorder with or without agoraphobia in adults
- Peter P Roy-Byrne, MD
Peter P Roy-Byrne, MD
- Editor-in-Chief — Psychiatry
- Section Editor — Depressive Disorders
- Professor of Psychiatry and Behavioral Sciences
- University of Washington School of Medicine
- Michelle Craske, PhD
Michelle Craske, PhD
- Director, Anxiety Research Center
- University of California, Los Angeles Department of Psychology
Panic disorder (with or without agoraphobia; DSM-5 codes agoraphobia as a separate disorder) is characterized by recurrent, unexpected panic attacks along with one month of either worry about future attacks or the consequences of attacks (eg, medical concerns), or a significant change in behavior due to the attacks (eg, phobic avoidance or repetitive seeking of medical evaluations).
Panic disorder is a relatively common disorder, most often with an adult onset and chronic course [1-4]. It can lead to significant impairments in role functioning, diminished quality of life, and high health care costs [5,6]. The disorder can be effectively treated with cognitive-behavioral therapy, medication, or a combination of the two modalities . Other psychotherapies may also have efficacy though their efficacy has been less well established.
This topic and an accompanying algorithm describe our approach to selecting among treatments for panic disorder (algorithm 1). The efficacy and administration of individual psychotherapies and medications for panic disorder are reviewed separately. The epidemiology, pathogenesis, clinical manifestations, course, and diagnosis of panic disorder are also reviewed separately. The epidemiology, pathogenesis, clinical manifestations, course, and diagnosis of agoraphobia are also reviewed separately. (See "Psychotherapy for panic disorder with or without agoraphobia in adults" and "Pharmacotherapy for panic disorder with or without agoraphobia in adults" and "Panic disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Agoraphobia in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis".)
NEWLY DIAGNOSED PATIENTS
Need for treatment — Once a patient has been diagnosed with panic disorder, the next step is to determine, based on clinical assessment of severity, the extent of distress or impairment and patient preferences regarding treatment. Patients with mild panic disorder whose symptoms do not interfere significantly with functioning may reasonably elect to forgo treatment initially. These are patients with limited to no phobic avoidance and no health concerns, whose day-to-day functioning is not being compromised by frequent panic attacks. Some of these patients may respond to education and reassurance with reduced anxiety about panic and come to have less frequent attacks and gradual disappearance of symptoms.
Clinical follow-up with the patient every six months is important to monitor the course of the disorder, and determine if symptoms were worsening and/or impeding functioning – indications that treatment may then be advisable. (See "Panic disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis", section on 'Assessment'.)
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- NEWLY DIAGNOSED PATIENTS
- Need for treatment
- Choosing between psychotherapy versus medication
- - Preference for psychotherapy
- - Preference for medication
- Subgroups needing specialized treatment
- - Suicidality or co-occurring mental disorders
- - Marked initial distress or impairment
- - Co-occurring substance use disorder
- PATIENT RESPONSE TO FIRST-LINE TREATMENT
- - Poor/partial response
- - Robust response
- - Poor response to first SRI
- - Partial response to first SRI
- Active or past SUD
- - Robust response
- - Active or past SUD
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