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Treatment of Panic Disorder

The following treatment guidelines are meant as a reference tool only, and are not intended as treatment advice or to replace the clinical decision-making process of psychiatrists or other health professionals who administer these treatments. In clinical practice there are often good reasons why treatment approaches differ from what is described here.

 

The two main forms of treatment available for Panic Disorder are psychotherapy and medications. See the Panic Disorder guidelines for recommendations on when to consider using each of these different modalities.

Psychotherapy for Panic Disorder

Cognitive Behavioral Therapy (CBT) has been the most extensively studied psychotherapy for Panic Disorder, and would be the first choice for treatment [ref]. It seems to be effective in both individual and group formats. Psychodynamic Psychotherapy has also been shown to be effective, and would be a second option [ref]. Behavioral Therapy has also be found to be effective for this condition [ref], but these techniques are often included in the CBT.

Medications for Panic Disorder

Antidepressants for Panic Disorder

Antidepressants have been shown to be effective for treating Panic Disorder [ref]. These include the SSRIs, Venlafaxine, and the Tricyclic Antidepressants (of which Imipramine and Clomipramine have been most tested). Because of their more tolerable side-effect profile, the SSRIs or Venlafaxine would be preferred options over the Tricyclic Antidepressants. There is some evidence that Mirtazapine may also be effective [ref, ref].

Benzodiazepines for Panic Disorder

Benzodiazepines when used alone have been shown to be as effective as the antidepressants for controlling Panic Disorder symptoms [ref, ref]. They also bring an immediate effect, as opposed to the antidepressants that require about 4 weeks before symptoms can be expected to subside.

Although in studies benzodiazepines are usually prescribed on a regular basis with a consistent daily dose, in practice they are often used on an as-needed basis to control the symptoms of panic and Agoraphobia as they occur, and seem to work equally well in this way [ref].

However, the main problem with using the benzodiazepines is that discontinuing them at the end of treatment tends to be difficult and to produce a significant rebound in symptoms, especially when shorter-acting forms like Alprazolam are used [ref, ref]. Longer-acting benzodiazepines such as Clonazepam or Diazepam are thus preferred.

Contrary to popular belief, the development of abuse or tolerance (needing higher doses for the same effect) to these medications is not a significant risk when used for Panic Disorder [ref, ref].

Other medications for Panic Disorder

Gabapentin [ref], and Atypical Antipsychotics such as Aripiprazole, Olanzapine and Risperidone, may be effective, though the evidence is limited [ref, ref, ref].

Combining Psychotherapy and Medications for Panic Disorder

Combining psychotherapy with antidepressants has been shown to be more effective for treating Panic Disorder than using either one of these treatments alone [ref]. However, the difference is not large, and in the long run (6-24 months after the treatments have ended) having received only psychotherapy seems to be just as helpful as having used both forms of treatment [ref]. Also, fewer individuals tend to drop out of treatment when only psychotherapy is used [ref].

There have also been some studies showing that individuals who are treated with medications relapse more often once the medication is stopped, as opposed to those receiving only psychotherapy [ref, ref, ref]. This may be because using medications makes it harder for individuals with Panic Disorder to become confident in their own abilities to manage the symptoms of the disorder.

For these reasons, either starting with psychotherapy alone, or combining psychotherapy with antidepressants, would both seem to be reasonable options for treating Panic Disorder.

 

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Course & Prevalence

Treatment Guidelines