TREATING PANIC DISORDER - ValueOptions

1 TREATING PANIC DISORDERA Quick Reference GuideBased on Practice Guideline for the Treatment of Patients With PANIC DISORDER ,originally published in May 1998. A guideline watch, summarizing significant developments in the scientific literature since publication of this guideline, may be available in the Psychiatric Practice section of the APA web site at : 5/21/12 American Psychiatric Association Steering Committee on Practice GuidelinesJohn S. McIntyre, , ChairSara C. Charles, , Vice-ChairDaniel J. Anzia, A. Cook, T. Finnerty, R. Johnson, E. Nininger, Summergrad, M. Woods, , Yager, and Component LiaisonsRobert Pyles, (Area I)C. Deborah Cross, (Area II)Roger Peele, (Area III)Daniel J. Anzia, (Area IV)John P. D. Shemo, (Area V)Lawrence Lurie, (Area VI)R. Dale Walker, (Area VII)Mary Ann Barnovitz, Hafter Gray, Saxena, Tonnu, Editors, Quick Reference GuidesMichael B. First, J. Fochtmann, Kunkle, , Senior Program ManagerAmy B.

2 Albert, , Assistant Project ManagerClaudia Hart, Director, Department of Quality Improvement and Psychiatric ServicesDarrel A. Regier, , , Director, Division of ResearchReviewed: 5/21/12 Statement of IntentThe Practice Guidelines and the Quick Reference Guides are not intended to beconstrued or to serve as a standard of medical care. Standards of medical care aredetermined on the basis of all clinical data available for an individual patient andare subject to change as scientific knowledge and technology advance and practicepatterns evolve. These parameters of practice should be considered guidelines to them will not ensure a successful outcome for every individual, norshould they be interpreted as including all proper methods of care or excludingother acceptable methods of care aimed at the same results. The ultimate judg-ment regarding a particular clinical procedure or treatment plan must be made bythe psychiatrist in light of the clinical data presented by the patient and the diag-nostic and treatment options development of the APA Practice Guidelines and Quick Reference Guideshas not been financially supported by any commercial organization.

3 For moredetail, see APA s Practice Guideline Development Process, available as an appen-dix to the compendium of APA practice guidelines, published by APPI, and onlineat : 5/21/12 TREATINGPANIC DISORDER192A. Formulation andImplementation of aTreatment Plan1. TreatmentSetting ..1932. Evaluation ..1933. TreatmentModalities ..1944. Length ofTreatment ..196C. TreatmentInterventions1. PsychosocialInterventions ..2012. Pharmaco-therapies ..202B. Psychiatric Management1. Evaluate particular symptoms ..1972. Evaluate types and severity of functional Establish and maintain a therapeutic alliance ..1984. Monitor the patient s psychiatric Provide education ..1996. Consider issues involved in working with other physicians ..1997. Enhance treatment Address early signs of relapse ..200 OUTLINER eviewed: 5/21/12 TREATINGPANIC DISORDER 193 Outpatient treatment is indicated for most hospitalization for the following indications: Comorbid depression, especially in patients who are at risk ofsuicide attempts Comorbid substance use disorders , especially in patients whorequire detoxification1.

4 Treatment SettingPerform a comprehensive general medical and psychiatric evaluation. Follow principles of APA s Practice Guideline for the PsychiatricEvaluation of Adults. Determine whether diagnosis of PANIC DISORDER is warranted. Assess for comorbid psychiatric or general medical conditions. Consider general medical conditions and substance or medicationuse as causes of PANIC symptoms, especially in patients with newonset of symptoms. Perform indicated diagnostic studies and laboratory EvaluationA. Formulation and Implementation of a Treatment PlanReviewed: 5/21/12 TREATINGPANIC DISORDER194 Consider efficacy, risks and benefits, costs, and patient preference inchoice of modality. PANIC -focused cognitive behavior therapy (CBT) and medicationshave both been shown to be effective treatments for PANIC DISORDER . There is no evidence for superiority of either CBT or , choice of modality is mainly determined by weighingadvantages and disadvantages (see Appendix A in this guide, p.)

5 204). Psychodynamic or other psychotherapies may be the treatment ofchoice for some patients. Combined psychosocial and pharmacological treatments may haveadvantages over either modality treatment modalities to be used in conjunction withpsychiatric section C (p. 201) for more detail about specific PANIC -focused CBT is generally administered in weekly sessionsfor approximately 12 weeks. CBT approaches can be conducted in group formats. Psychodynamic psychotherapy may be useful in reducingsymptoms or maladaptive behaviors in patients withcomplicating comorbid axis I and axis II conditions. Consider employing family and supportive therapy along withother psychosocial and pharmacological treatments. Sessions that include significant others help to relieve stress onfamilies and may facilitate adherence. Psychotherapies and other psychosocial treatments inconjunction with psychiatric management may also helpaddress certain comorbid disorders or environmental orpsychosocial Treatment ModalitiesReviewed: 5/21/12 TREATINGPANIC DISORDER 195 Antidepressant medications Antidepressants generally take 4 to 6 weeks to becomeeffective for PANIC DISORDER .

6 Because of their side effects and the need for dietaryrestrictions, MAOIs are generally reserved for patients who donot respond to other treatments. With all antidepressants, use doses approximately half of thosegiven to depressed patients at the beginning of treatmentbecause of potentially greater sensitivity to side effects. Increase to a full therapeutic dose over subsequent days andweeks and as tolerated by the patient. Observe patients closely for potential emergence of suicidalthoughts or behaviors with antidepressant initiation or dosetitration. Maintenance pharmacotherapy lasting 6 12 months should beconsidered for most patients as a means of preventingrecurrent PANIC DISORDER symptoms and promoting (for early symptom control) In combination with other treatment modalities,benzodiazepines are useful during initial treatment for moreurgent relief of disabling anticipatory anxiety and panicattacks. Weigh the potential benefits of benzodiazepines against thefollowing risks:- The patient may misattribute the entire treatment response toinitial administration of the benzodiazepine and havedifficulty with benzodiazepine Anxiety relief may reduce motivation to engage in Some patients experience withdrawal reactions upondiscontinuation, even after relatively brief periods ofbenzodiazepine treatment.

7 To counteract these risks, reassure the patient that definitivetreatment takes a few weeks. To prevent development of high steady-state benzodiazepinelevels and the risk of dependency, avoid unnecessarily : 5/21/12 TREATINGPANIC DISORDER196 When determining length of treatment, consider the following: Successful treatment in the acute phase is indicated by markedlyfewer and less intense PANIC attacks, less worry about panicattacks, and minimal or no phobic avoidance. With either CBT or antipanic medication, the acute phase oftreatment lasts approximately 12 weeks. Some improvement is likely with either medication or CBT within 6 to 8 weeks (although full response may take longer). If there is no improvement within 6 to 8 weeks with a particulartreatment, reevaluate the diagnosis and consider the need for adifferent treatment or the need for a combined treatment approach. If response to medication or CBT is not as expected, or if there arerepeated relapses, evaluate for possible addition of apsychodynamic or other psychosocial intervention.

8 After CBT treatment during the acute phase, decrease visitfrequency and eventually discontinue treatment within severalmonths. After 12 to 18 months, discontinuation of medication can beattempted with close follow-up. In case of relapse, resume the treatment that had proven Length of TreatmentReviewed: 5/21/12 TREATINGPANIC DISORDER 197 Promote patient perception that the psychiatrist accuratelyunderstands the patient s individual experience of aware that a particular constellation of symptoms and otherproblems may influence the patient to self-monitor ( , by maintaining a dailydiary) the frequency and nature of PANIC attacks plus the relationshipbetween PANIC and internal and external Evaluate particular anticipatory anxiety in addition to PANIC the extent of phobic avoidance, which may determine thedegree of impairment. Encourage the patient to define a desirable level of Evaluate types and severity of functional Psychiatric ManagementReviewed: 5/21/12 TREATINGPANIC DISORDER198 Support the patient s efforts to confront phobic the patient of therapist availability in case of emergencies tocounteract patient s sensitivity to attuned and responsive to transference and Establish and maintain a therapeutic that different elements of PANIC DISORDER often resolve atdifferent to monitor the status of all presenting the success of the treatment plan on an ongoing to the possibility of emergent any contributing comorbid psychiatric Monitor the patient s psychiatric : 5/21/12 TREATINGPANIC DISORDER 199 Provide initial and ongoing education to the patient.

9 Educate the patient about the DISORDER , its clinical course, and itscomplications. Emphasize that PANIC DISORDER is a real illness requiring supportand treatment. Reassure the patient that PANIC attacks reflect real physiologicalevents, but that the attacks themselves are not acutely dangerous orlife appropriate, provide education to the family. Provide family members and significant others with informationsimilar to that given to the patient. Help the family understand that attacks are terrifying to the patientand that PANIC DISORDER is debilitating if Provide nonpsychiatric physicians who are also TREATING the patient. Recognize that a variety of general medical physicians may beinvolved because patients are often convinced that attacks are amanifestation of serious medical abnormalities. Educate other physicians as necessary about the ability of panicattacks to masquerade as many other general medical as necessary to ensure that the patient continues to receivean appropriate level of medical care from the primary care physicianand medical Consider issues involved in working with other : 5/21/12 TREATINGPANIC DISORDER200 Respond to exacerbations that occur during treatment.

10 Reassure the patient that fluctuations in symptoms can occur duringtreatment. Evaluate whether changes in the treatment plan are to relapses that occur after treatment patients that it is important to reinitiate treatment quickly toavoid the onset of complications such as phobic Address early signs of aware that treatment ( , taking medication, confronting phobicstimuli) may initially increase anxiety and lead to treatment in a supportive the patient s fears and provide reassurance, nonpunitiveacceptance, and educational enlisting the assistance of family members in improving thepatient s persistent nonadherence, consider a psychodynamic treatmentapproach to address possible unconscious Enhance treatment : 5/21/12 TREATINGPANIC DISORDER 201 Cognitive behavior therapyCBT may include the following components: Psychoeducation- Identify and name the patient s Provide a direct explanation of the basis for the Outline a plan for treatment.