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Optimum Treatment of Panic Disorder

  • Practical Therapeutics
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Summary

Panic disorder is characterised by the recurrence of acute, unpredictable panic attacks, with associated fear and physiological arousal. The disorder is very common among the general population and has a high rate of associated morbidity and mortality when not treated.

Both pharmacological and psychological treatment approaches are effective in alleviating symptoms of panic attacks. Various psychological treatment approaches have been advocated, with cognitive-behavioural treatment the most systematically studied and applied. A wide range of pharmacological agents are useful in treating attacks, and differ primarily in adverse effect profile, latency of onset and potential for abuse or addiction. Available agents include tricyclic anti-depressants, selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors and benzodiazepines. We consider long term use of SSRIs, in conjunction with benzodiazepines for the short term relief of symptoms, to be the optimum pharmacological management of panic disorder.

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References

  1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd rev. ed. Washington DC: American Psychiatric Association, 1987

    Google Scholar 

  2. Robins LN, Heizer JE, Weissman MM. Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry 1984; 41: 949–58

    Article  PubMed  CAS  Google Scholar 

  3. Pitts FN, McClure JN. Lactate metabolism in anxiety neurosis. N Engl J Med 1967; 277: 1329–36

    Article  PubMed  Google Scholar 

  4. Klein DF. False suffocation alarms, spontaneous panics and related conditions. Arch Gen Psychiatry 1993; 50(4): 306–17

    Article  PubMed  CAS  Google Scholar 

  5. Dager SR, Marro K, Richards TL, et al. Preliminary applications of MRS to investigate lactate-induced panic. Am J Psychiatry 1994; 151: 57–63

    PubMed  CAS  Google Scholar 

  6. Markowitz JS, Weissman MM, Ouellette R, et al. Quality of life in panic disorder. Arch Gen Psychiatry 1989; 46(11): 984–92

    Article  PubMed  CAS  Google Scholar 

  7. Lepine FP, Chignon JM, Teherani M. Suicide attempts in patients with panic disorder. Arch Gen Psychiatry 1993; 50(2): 144–9

    Article  PubMed  CAS  Google Scholar 

  8. Pauls DL, Bucher KD, Crowe RR, et al. A genetic study of panic disorder pedigrees. Am J Hum Genet 1980; 32: 639–44

    PubMed  CAS  Google Scholar 

  9. Torgersen S. Genetic factors in anxiety disorders. Arch Gen Psychiatry 1983; 40(10): 1085–9

    Article  PubMed  CAS  Google Scholar 

  10. Crowe RR, Notes R, Pauls DL, et al. A family study of panic disorder. Arch Gen Psychiatry 1983; 40(10): 1065–9

    Article  PubMed  CAS  Google Scholar 

  11. Klein KF, Fink M. Psychiatric reaction patterns to imipramine. Am J Psychiatry 1962; 119: 432–8

    PubMed  CAS  Google Scholar 

  12. Zitrin CM, Klein DF, Woerner MG. Behavior therapy, supportive psychotherapy, imipramine and phobias. Arch Gen Psychiatry 1978; 35: 307–16

    Article  PubMed  CAS  Google Scholar 

  13. Cross-National Collaborative Panic Study, Second Phase Investigators. Drug treatment of panic disorder: comparative efficacy of alprazolam, imipramine, and placebo. Br J Psychiatry 1992; 160: 191–202

    Article  Google Scholar 

  14. Klerman GL. Overview of the Cross-National Collaborative Panic Study. Arch Gen Psychiatry 1988; 45: 407–12

    Article  PubMed  CAS  Google Scholar 

  15. Charney DS, Woods SW, Goodman WK, et al. Drug treatment of panic disorder: the comparative efficacy of imipramine, alprazolam, and trazodone. J Clin Psychiatry 1986; 47(12): 580–6

    PubMed  CAS  Google Scholar 

  16. Mavissakalian M, Perel J, Bowler K, et al. Trazodone in the treatment of panic disorder and agoraphobia with panic attacks. Am J Psychiatry 1987; 144(6): 785–7

    PubMed  CAS  Google Scholar 

  17. Sheehan DV, Davidson J, Manschreck TC, et al. Lack of efficacy of a new antidepressant (bupropion) in the treatment of panic disorder with phobias. J Clin Psychopharmacol 1983; 3(1): 28–31

    Article  PubMed  CAS  Google Scholar 

  18. Gorman JM, Liebowitz MR, Fyer AJ. An open trial of fluoxetine in the treatment of panic attacks. J Clin Psychopharmacol 1987; 7: 329–39

    Article  PubMed  CAS  Google Scholar 

  19. Schneier FR, Liebowitz MR, Davies SO, et al. Fluoxetine in panic disorder. J Clin Psychopharmacol 1990; 10: 119–21

    Article  PubMed  CAS  Google Scholar 

  20. Solyom L, Solyom C, Ledwidge B. Fluoxetine in panic disorder. Can J Psychiatry 1991; 36: 378–80

    PubMed  CAS  Google Scholar 

  21. Den Boer JA, Westenberg HGM. Serotonin function in panic disorder: a double-blind, placebo controlled study with fluvoxamine and ritanserin. Psychopharmacology 1990; 102: 85–94

    Article  Google Scholar 

  22. Black DW, Wesner R, Bowers W, et al. A comparison of fluvoxamine, cognitive therapy, and placebo in the treatment of panic disorder. Arch Gen Psychiatry 1993; 50: 44–50

    Article  PubMed  CAS  Google Scholar 

  23. Hoehn-Saric R, McLeod DR, Hipsley PA. Effect of fluvoxamine on panic disorder. Clin Psychopharmacol 1993; 13(5): 321–6

    Article  CAS  Google Scholar 

  24. Teicher MH, Glod C, Cole JD. Emergence of intense suicidal preoccupation during fluoxetine treatment. Am J Psychiatry 1990; 147: 207–10

    PubMed  CAS  Google Scholar 

  25. Brewerton TD. Does fluoxetine induce suicidality? [comment]. J Clin Psychiatry 1991; 52: 479–80

    PubMed  CAS  Google Scholar 

  26. Fava M, Rosenbaum JF. Suicidality and fluoxetine: is there a relationship. J Clin Psychiatry 1991; 52: 108–11

    PubMed  CAS  Google Scholar 

  27. Sheehan DV, Ballenger J, Jacobsen G. Treatment of endogenous anxiety with phobic, hysterical and hypochondriacal symptoms. Arch Gen Psychiatry 1980; 37: 51–9

    Article  PubMed  CAS  Google Scholar 

  28. Garcia-Borreguero D, Lauer CJ, Ozdaglar A, et al. Brofaromine in panic disorder: a pilot study with a new reversible inhibitor of monamine oxidase-A. Pharmacopsychiatry 1992; 25(6): 261–4

    Article  PubMed  CAS  Google Scholar 

  29. Bakish D. Reversible monoamine-A inhibitors in panic disorder. Clin Neuropharmacol 1992; 15 Suppl. 1A: 432A–433A

    Article  PubMed  Google Scholar 

  30. Itil TM, Polvan NI, Egilmes S, et al. Anxiolytic effects of a new triazolobenzodiazepine, U-31,889. Curr Ther Res 1973; 15(9): 603–15

    PubMed  CAS  Google Scholar 

  31. Chouinard G, Annable L, Fontaine R, et al. Alprazolam in the treatment of generalized anxiety and panic disorders: a double-blind, placebo-controlled study. Psychopharmacology 1982; 77: 229–33

    Article  PubMed  CAS  Google Scholar 

  32. Shehi M, Patterson WM. Treatment of panic attacks with alprazolam and propranolol. Am J Psychiatry 1984; 141(7): 900–1

    PubMed  CAS  Google Scholar 

  33. Sheehan DV, Coleman DJ, Jones KJ, et al. Some biochemical correlates of panic attacks with agoraphobia and their response to a new treatment. J Clin Psychopharmacol 1984; 4(2): 66–75

    Article  PubMed  CAS  Google Scholar 

  34. Dager SR, Roy-Byrne PP, Hendrickson H, et al. Long-term outcome of panic states during double-blind treatment and after withdrawal of alprazolam and placebo. Ann Clin Psychiatry 1986; 47: 458–60

    Google Scholar 

  35. Dunner DL, Dean I, Avery DH, et al. Effect of alprazolam and diazepam on anxiety and panic attacks in panic disorders: a controlled study. J Clin Psychiatry 1986; 47: 458–60

    PubMed  CAS  Google Scholar 

  36. Ballenger JC, Burrows GD, DuPont RL, et al. Alprazolam in panic disorders and agoraphobia: results from a multicenter trial: efficacy in short-term treatment. Arch Gen Psychiatry 1988; 45: 413–22

    Article  PubMed  CAS  Google Scholar 

  37. Fontaine R, Chouinard G. Antipanic effect of clonazepam. Am J Psychiatry 1984; 141: 149

    PubMed  CAS  Google Scholar 

  38. Spier SA, Tesar GE, Rosenbaum JF, et al. Treatment of panic disorder and agoraphobia with clonazepam. J Clin Psychiatry 1986; 47: 238–42

    PubMed  CAS  Google Scholar 

  39. Noyes R, Anderson DJ, Clancy J, et al. Diazepam and propranolol in panic disorder and agoraphobia. Arch Gen Psychiatry 1984; 41: 287–92

    Article  PubMed  Google Scholar 

  40. Hollister LE, Motzenbecker FP, Degan RO. Withdrawal reactions from chlordiazepoxide. Psychopharmocolia 1961; 2: 63–8

    Article  CAS  Google Scholar 

  41. Greenblatt DJ, Shader RL Dependence, tolerance and addiction to benzodiazepines: clinical and pharmacokinetic considerations. Drug Metab Rev 1978; 8_(1): 13–28

    Article  Google Scholar 

  42. Noyes R, Garvey JM, Cook BL, et al. Benzodiazepine withdrawal: a review of the evidence. J Clin Psychiatry 1988; 49: 382–9

    PubMed  Google Scholar 

  43. Roy-Byrne PP, Dager SR, Cowley DS, et al. Relapse and rebound following discontinuation of benzodiazepine treatment of panic attacks: alprazolam versus diazepam. Am J Psychiatry 1989; 146(7): 860–5

    PubMed  CAS  Google Scholar 

  44. Klein E, Uhde TW. Controlled study of verapamil for treatment of panic disorder. Am J Psychiatry 1988; 145(4): 431–4

    PubMed  CAS  Google Scholar 

  45. Sheehan DV, Raj AB, Harnett-Sheehan K, et al. The relative efficacy of high dose buspirone and alprazolam in the treatment of panic disorder: a double-blind, placebo-controlled study with buspirone. Acta Psychiatr Scand 1993; 88(1): 1–11

    Article  PubMed  CAS  Google Scholar 

  46. Pohl R, Balon R, Teragari VK, et al. Serotonergic anxiolytics with the treatment of panic disorder: a controlled study with buspirone. Psychopathology 1989; 22 Suppl. 1: 60–7

    Article  PubMed  Google Scholar 

  47. Schneier FR, Canasco JL, Hollander E, et al. Alpidem in the treatment of panic disorder. J Clin Psychopharmacol 1993; 13(2): 150–3

    Article  PubMed  CAS  Google Scholar 

  48. Sokol L, Beck AT, Greenberg RL, et al. Cognitive therapy of panic disorder: a non-pharmacological alternative. J Nerv MentDis 1989; 177(12): 711–6

    Article  CAS  Google Scholar 

  49. Clark MD, Salkovskis PM. Respiratory control as a treatment of panic attacks. J Behav Ther Exp Psychiatry 1985; 16(1): 23–30

    Article  PubMed  CAS  Google Scholar 

  50. Clum GA, Surls R. A meta-analysis of treatments for panic disorder. J Consult Clin Psychol 1993; 61(2): 317–26

    Article  PubMed  CAS  Google Scholar 

  51. Barlow DH, Craske MG, Cerny JA, et al. Behavioral treatment of panic disorder. Behav Ther 1989; 20: 261–82

    Article  Google Scholar 

  52. Welkowitz LA, Papp LA, Cloitre M, et al. Cognitive-behavior therapy for panic disorder delivered by psychopharmacological-oriented clinicians. J Nerv Ment Dis 1991; 179(8): 473–7

    Article  PubMed  CAS  Google Scholar 

  53. Shear MK, Pilkonis PA, Cloitre M, et al. Cognitive behavioural treatment compared with non-prescriptive treatment of panic disorder. Arch Gen Psychiatry 1994; 51: 395–401

    Article  PubMed  CAS  Google Scholar 

  54. Dager SR, Khan A, Cowley DS, et al. Characteristics of placebo response during long-term treatment of panic disorder. Psychopharmacol Bull 1990; 26(3): 273–8

    PubMed  CAS  Google Scholar 

  55. Roy-Byrne PP. Integrated treatment of panic disorder. Am J Med 1992; 92(1A): 49S–54S

    Article  Google Scholar 

  56. Harnett DS. Panic disorder: integrating psychotherapy and psychopharmacology. Psychiatr Med 1990; 8(3): 211–22

    PubMed  CAS  Google Scholar 

  57. Liebowitz MR, Fyer AJ, Gorman JM, et al. Lactate provocation of panic attacks: clinical and behavioral findings. Arch Gen Psychiatry 1984; 41: 764–70

    Article  PubMed  CAS  Google Scholar 

  58. Dager SR, Cowley DS, Dunner DL. Biological markers in panic states: lactate-induced panic and mitral valve prolapse. Biol Psychiatry 1987; 22: 339–59

    Article  PubMed  CAS  Google Scholar 

  59. Cowley DS, Dager SR, Dunner DL. Lactate-induced panic in primary affective disorder. Am J Psychiatry 1986; 143(5): 646–8

    PubMed  CAS  Google Scholar 

  60. Cowley DS, Dager SR, Roy-Byrne PP, et al. Lactate vulnerability after alprazolam versus placebo treatment of panic disorder. Biol Psychiatry 1991; 30(1): 49–56

    Article  PubMed  CAS  Google Scholar 

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Layton, M.E., Dager, S.R. Optimum Treatment of Panic Disorder. CNS Drugs 2, 208–215 (1994). https://doi.org/10.2165/00023210-199402030-00005

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