Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute panic attack

1st line – reassurance

Back
ACUTE
|
acute panic attack
1st line – 

reassurance

Provide reassurance that the symptoms are not dangerous and that the attack will subside soon.

Patients usually hyperventilate as part of the attack but subjectively experience this as shortness of breath; this should be explained to the patient and an emphasis placed on slowing the breathing.

Using a quiet room and support from a significant other are useful.

In the emergency department setting, benzodiazepines may sometimes be considered to terminate an acute attack, for example if the patient's agitation or anxiety is particularly severe.[4]

ONGOING

panic disorder

1st line – cognitive behavioral therapy (CBT)

Back
ONGOING
|
panic disorder
|
no comorbidity
1st line – 

cognitive behavioral therapy (CBT)

Treatment is individualized taking into account severity, potential adverse effects, past treatment history, patient preference, any comorbid disorders and treatment availability. As a general guide, for those with mild panic disorder, consider offering self-help or CBT alone initially. For those with panic disorder of moderate severity, consider offering CBT, an SSRI/SNRI, or a combination of CBT and medication. For those with severe panic disorder, consider offering both CBT and an SSRI/SNRI from the offset.[4]

CBT may be delivered face-to-face (individual or group) or as digital CBT (dCBT) accessed by computer, tablet or smartphone application. dCBT may be considered as an equal first-line option to face-to-face CBT.[4] dCBT courses may be integrated with face-to-face therapy, and may be supervised by a clinician or completed on a self-help basis. Guided dCBT is generally more effective than unguided dCBT; this involves regular help and contact to complete the course, although this does not necessarily have to be from a clinician.[4]

CBT for panic disorder involves a combination of education, self-monitoring, relaxation training, challenging negative styles of thinking, situational exposure training, and systematic exposure to uncomfortable physical sensations. CBT can be used alone without pharmacotherapy, or may be used as an adjunct to any form of pharmacotherapy.[93]

It is an effective first-line treatment.[95][96][97] [ Cochrane Clinical Answers logo ] [Evidence C] Patients with anxiety disorders (including panic disorder) who are treated with CBT experience significant improvements in symptoms during the 24 months following completion of treatment.[153] Treatment sessions may continue for 12 to 14 visits, although 6 to 7 sessions have also been found to be effective.[105] A referral to a mental health professional with expertise in CBT is recommended. The referring physician and mental health professional should maintain routine collaboration. Evidence also suggests that CBT delivery is beneficial in primary care settings.[81][106]

Exposure therapy involves gradually increasing the patient's tolerance to previously avoided situations. The goal is to have the patient approach fear-provoking situations and sensations without engaging in escape or avoidance behavior or relying on safety cues. Repeated, frequent, controllable, and predictable exposures are associated with optimal outcomes.

1st line – SSRIs or SNRIs

Back
ONGOING
|
panic disorder
|
no comorbidity
1st line – 

SSRIs or SNRIs

Selective serotonin-reuptake inhibitors (SSRIs) are regarded as the optimal class of antidepressants given their broad spectrum of action and improved safety and tolerance.[116][118][123]

Paroxetine is the least stimulating and most sedating of the SSRIs. Fluoxetine has a long half-life and therefore a lower risk of withdrawal symptoms, but it is more stimulating and requires slower titration.

Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine are also effective.

Patients with anxiety disorders may be more susceptible to medication adverse effects; it is therefore advisable to start at the lowest dose and increase the dose with caution ("start low, go slow").[12] Most adverse effects are time-limited during dose titration, and these should be discussed in advance with patients and monitored closely to ensure adherence.

Primary options

paroxetine: 5-10 mg orally (immediate release) once daily initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

OR

sertraline: 25 mg orally once daily initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

OR

fluoxetine: 5-10 mg orally (immediate release) once daily initially, increase by 10-20 mg/day increments every 4 weeks according to response, maximum 80 mg/day

OR

fluvoxamine: 25-50 mg orally (immediate release) once daily initially, increase by 25-50 mg/day every 4-7 days according to response, maximum 300 mg/day

OR

citalopram: 5-10 mg orally once daily initially, increase by 10-20 mg/day increments every 7 days according to response, maximum 40 mg/day

OR

escitalopram: 5 mg orally once daily initially, increase by 5-10 mg/day increments every 4 weeks according to response, maximum 20 mg/day

OR

venlafaxine: 37.5 mg orally (extended release) once daily initially, increase by 37.5 to 75 mg/day increments every 7 days according to response, maximum 225 mg/day

Plus – psychoeducation and lifestyle advice

Back
ONGOING
|
panic disorder
|
no comorbidity
Plus – 

psychoeducation and lifestyle advice

Treatment recommended for ALL patients in selected patient group

Offer psychoeducation as soon as a diagnosis has been made.[12] A key part of any treatment approach is information and education about the nature of panic and anxiety. In particular, panic is an understandable reaction to perceived danger (the "fight or flight" response). Fear arises from the misinterpretation of normal body sensations. Drawing a simple diagram together with the person - linking symptoms, interpretation, anxiety with arrows in a "vicious circle" - can be helpful. It is important for the person to appreciate that the first goal of treatment is not to remove all anxiety, only to manage it successfully. Attempts by the person to cope (e.g., by avoidance or safety seeking) are understandable, but inadvertently lead to maintaining the problem.

Advice on lifestyle factors includes: good sleep; regular exercise; reduced use of caffeine, tobacco, and alcohol; healthy diet; and staying engaged with meaningful activities and healthy social supports.[4]

Consider – cognitive behavioral therapy (CBT)

Back
ONGOING
|
panic disorder
|
no comorbidity
Consider – 

cognitive behavioral therapy (CBT)

Treatment recommended for SOME patients in selected patient group

Increased medication adherence and response rates, with a reduction in the amount of medication required to gain symptom control, are observed with adjunctive CBT.[93][95][106][108][109][110] Patients with anxiety disorders (including panic disorder) who are treated with CBT experience significant improvements in symptoms during the 24 months following completion of treatment.[153]

CBT may be delivered face-to-face (individual or group) or as digital CBT (dCBT) accessed by computer, tablet or smartphone application. dCBT may be considered as an equal first-line option to face-to-face CBT.[4] dCBT courses may be integrated with face-to-face therapy, and may be supervised by a clinician or completed on a self-help basis. Guided dCBT is generally more effective than unguided dCBT; this involves regular help and contact to complete the course, although this does not necessarily have to be from a clinician.[4]

CBT for panic disorder involves a combination of education, self-monitoring, relaxation training, challenging negative styles of thinking, situational exposure training, and systematic exposure to uncomfortable physical sensations.

Exposure therapy involves gradually increasing the patient's tolerance to previously avoided situations. The goal is to have the patient stay in the feared situation long enough to allow fear reduction to occur without engaging in escape or avoidance behavior or relying on safety cues. Repeated, frequent, controllable, and predictable exposures are associated with optimal outcomes.

Consider – benzodiazepines

Back
ONGOING
|
panic disorder
|
no comorbidity
Consider – 

benzodiazepines

Treatment recommended for SOME patients in selected patient group

Benzodiazepines are not recommended for patients with panic disorder by some international guidelines, e.g., those from the UK National Institute for Health and Care Excellence, due to concerns about negative long-term outcomes.[69] However cautious short-term use of benzodiazepines is recommended by other guidelines as a second-line option for selected patients with panic disorders.[4][70] Evidence on benzodiazepines for panic disorder are generally low in quality and cover short-term use only, providing limited guidance for clinical practice.[131]

Benzodiazepines are recommended for short-term use only (e.g., 2 to 4 weeks).[134]

Benzodiazepines may be used for some patients as an adjunctive treatment to achieve a rapid reduction in panic attacks during the initial titration of a selective serotonin-reuptake inhibitor.[4][11][70][154]

They have a rapid onset of action and are generally well tolerated, although physiologic dependence can occur in as little as 2 to 4 weeks.[146][155][156][157] Avoid benzodiazepines in patients with a previous or current history of substance misuse.[4]

If benzodiazepines are indicated, the preference may be for scheduled, longer-acting agents so that medication use is time-dependent rather than response/panic-dependent. "As needed" use of short-acting benzodiazepines may result in the patient developing psychological dependence on these medications, which could diminish the ability for an individual to develop an internal locus of control over these symptoms.

Long-term treatment with benzodiazepines should be rare, supervised, made with caution and based on careful consideration of the anticipated risks and benefits of benzodiazepines for the individual patient; specialist input (e.g., from a psychiatrist or addiction specialist) is advisable. Patients using benzodiazepines long-term should be regularly offered the opportunity to gradually withdraw from long-term use; treatment at the lowest effective dose is recommended.[134][137]

Abrupt discontinuation or rapid tapering schedules can increase risk for withdrawal symptoms.

Primary options

clonazepam: 0.25 mg orally twice daily initially, increase by 0.25 to 0.5 mg/day increments every 3 days according to response, maximum 4 mg/day

Secondary options

alprazolam: 0.25 to 0.5 mg orally (immediate release) four times daily initially, increase by 1 mg/day increments every 3-4 days according to response, maximum 6 mg/day

OR

lorazepam: 0.5 mg orally three times daily initially, increase gradually according to response, maximum 6 mg/day

OR

diazepam: 2.5 mg orally (immediate release) twice daily initially, increase gradually according to response, maximum 40 mg/day

2nd line – tricyclic antidepressants (TCAs)

Back
ONGOING
|
panic disorder
|
no comorbidity
2nd line – 

tricyclic antidepressants (TCAs)

TCAs are indicated in patients for whom treatment with one or more selective serotonin-reuptake inhibitors (SSRIs) has failed, or in patients with neuropathic pain.

They are less favorable with respect to adverse effects and may not be as well tolerated as SSRIs.[123]

Serum imipramine levels may need to be monitored closely due to the relatively narrow therapeutic index.

Primary options

imipramine: 10-25 mg orally once daily initially, increase by 10 mg/day increments every 2-4 days according to response, maximum 300 mg/day

OR

clomipramine: 12.5 to 25 mg orally once daily initially, increase gradually according to response, maximum 250 mg/day

Plus – psychoeducation and lifestyle advice

Back
ONGOING
|
panic disorder
|
no comorbidity
Plus – 

psychoeducation and lifestyle advice

Treatment recommended for ALL patients in selected patient group

Offer psychoeducation as soon as a diagnosis has been made.[12] A key part of any treatment approach is information and education about the nature of panic and anxiety. In particular, panic is an understandable reaction to perceived danger (the "fight or flight" response). Fear arises from the misinterpretation of normal body sensations. Drawing a simple diagram together with the person - linking symptoms, interpretation, anxiety with arrows in a "vicious circle" - can be helpful. It is important for the person to appreciate that the first goal of treatment is not to remove all anxiety, only to manage it successfully. Attempts by the person to cope (e.g., by avoidance or safety seeking) are understandable, but inadvertently lead to maintaining the problem.

Advice on lifestyle factors includes: good sleep; regular exercise; reduced use of caffeine, tobacco, and alcohol; healthy diet; and staying engaged with meaningful activities and healthy social supports.[4]

Consider – cognitive behavioral therapy (CBT)

Back
ONGOING
|
panic disorder
|
no comorbidity
Consider – 

cognitive behavioral therapy (CBT)

Treatment recommended for SOME patients in selected patient group

Increased medication adherence and response rates, with a reduction in the amount of medication required to gain symptom control, are observed with adjunctive CBT.[93][95][106][108][109][110] Patients with anxiety disorders (including panic disorder) who are treated with CBT experience significant improvements in symptoms during the 24 months following completion of treatment.[153]

CBT may be delivered face-to-face (individual or group) or as digital CBT (dCBT) accessed by computer, tablet or smartphone application. dCBT may be considered as an equal first-line option to face-to-face CBT.[4] dCBT courses may be integrated with face-to-face therapy, and may be supervised by a clinician or completed on a self-help basis. Guided dCBT is generally more effective than unguided dCBT; this involves regular help and contact to complete the course, although this does not necessarily have to be from a clinician.[4]

CBT for panic disorder involves a combination of education, self-monitoring, relaxation training, challenging negative styles of thinking, situational exposure training, and systematic exposure to uncomfortable physical sensations.

Exposure therapy involves gradually increasing the patient's tolerance to previously avoided situations. The goal is to have the patient stay in the feared situation long enough to allow fear reduction to occur without engaging in escape or avoidance behavior or relying on safety cues. Repeated, frequent, controllable, and predictable exposures are associated with optimal outcomes.

3rd line – benzodiazepines

Back
ONGOING
|
panic disorder
|
no comorbidity
3rd line – 

benzodiazepines

Some clinicians may consider offering benzodiazepine monotherapy to patients with panic disorder with a history of intolerance or poor response to antidepressants.

Benzodiazepines are not recommended for panic disorder by some international guidelines, e.g., those from the UK National Institute for Health and Care Excellence, due to concerns about negative long-term outcomes.[69] However cautious short-term use of benzodiazepines is recommended by other guidelines as an alternative option for selected patients with panic disorders for example for patients whose symptoms have not responded to other treatments.[4][70] Evidence on benzodiazepines for panic disorder are generally low in quality and cover short-term use only, providing limited guidance for clinical practice.[131] Benzodiazepines are recommended for short-term use only (e.g., 2 to 4 weeks).[134]

Benzodiazepines have a rapid onset of action and are generally well tolerated, although physiologic dependence can occur in as little as 2 to 4 weeks.[146][155][156][157] Avoid benzodiazepines in patients with a previous or current history of substance misuse.[4] 

If benzodiazepines are indicated, the preference may be for scheduled, longer-acting agents so that medication use is time-dependent rather than response/panic-dependent. "As needed" use of short-acting benzodiazepines may result in the patient developing psychological dependence on these medications, which could diminish the ability for an individual to develop an internal locus of control over these symptoms.

Long-term treatment with benzodiazepines should be rare, supervised, made with caution and based on careful consideration of the anticipated risks and benefits of benzodiazepines for the individual patient; specialist input (e.g., from a psychiatrist or addiction specialist) is advisable. Patients using benzodiazepines long-term should be regularly offered the opportunity to gradually withdraw from long-term use; treatment at the lowest effective dose is recommended.[134][137]

Abrupt discontinuation or rapid tapering schedules can increase risk for withdrawal symptoms.

Primary options

clonazepam: 0.25 mg orally twice daily initially, increase by 0.25 to 0.5 mg/day increments every 3 days according to response, maximum 4 mg/day

Secondary options

alprazolam: 0.25 to 0.5 mg orally (immediate release) four times daily initially, increase by 1 mg/day increments every 3-4 days according to response, maximum 6 mg/day

OR

lorazepam: 0.5 mg orally three times daily initially, increase gradually according to response, maximum 6 mg/day

OR

diazepam: 2.5 mg orally (immediate release) twice daily initially, increase gradually according to response, maximum 40 mg/day

Plus – psychoeducation and lifestyle advice

Back
ONGOING
|
panic disorder
|
no comorbidity
Plus – 

psychoeducation and lifestyle advice

Treatment recommended for ALL patients in selected patient group

Offer psychoeducation as soon as a diagnosis has been made.[12] A key part of any treatment approach is information and education about the nature of panic and anxiety. In particular, panic is an understandable reaction to perceived danger (the "fight or flight" response). Fear arises from the misinterpretation of normal body sensations. Drawing a simple diagram together with the person - linking symptoms, interpretation, anxiety with arrows in a "vicious circle" - can be helpful. It is important for the person to appreciate that the first goal of treatment is not to remove all anxiety, only to manage it successfully. Attempts by the person to cope (e.g., by avoidance or safety seeking) are understandable, but inadvertently lead to maintaining the problem.

Advice on lifestyle factors includes: good sleep; regular exercise; reduced use of caffeine, tobacco, and alcohol; healthy diet; and staying engaged with meaningful activities and healthy social supports.[4]

Consider – cognitive behavioral therapy (CBT)

Back
ONGOING
|
panic disorder
|
no comorbidity
Consider – 

cognitive behavioral therapy (CBT)

Treatment recommended for SOME patients in selected patient group

Patients discontinuing benzodiazepines may particularly benefit from adjunctive CBT.[114][115]

Increased medication adherence and response rates, with a reduction in the amount of medication required to gain symptom control, are observed with adjunctive CBT.[93][95][106][108][109][110] Patients with anxiety disorders (including panic disorder) who are treated with CBT experience significant improvements in symptoms during the 24 months following completion of treatment.[153]

CBT may be delivered face-to-face (individual or group) or as digital CBT (dCBT) accessed by computer, tablet or smartphone application. dCBT may be considered as an equal first-line option to face-to-face CBT.[4] dCBT courses may be integrated with face-to-face therapy, and may be supervised by a clinician or completed on a self-help basis. Guided dCBT is generally more effective than unguided dCBT; this involves regular help and contact to complete the course, although this does not necessarily have to be from a clinician.[4]

CBT for panic disorder involves a combination of education, self-monitoring, relaxation training, challenging negative styles of thinking, situational exposure training, and systematic exposure to uncomfortable physical sensations.

Exposure therapy involves gradually increasing the patient's tolerance to previously avoided situations. The goal is to have the patient stay in the feared situation long enough to allow fear reduction to occur without engaging in escape or avoidance behavior or relying on safety cues. Repeated, frequent, controllable, and predictable exposures are associated with optimal outcomes.

1st line – cognitive behavioral therapy (CBT)

Back
ONGOING
|
panic disorder
|
with comorbid depression
1st line – 

cognitive behavioral therapy (CBT)

CBT for panic disorder is effective among patients with severe depression and/or comorbid substance misuse.[144] Exposure-based CBT for panic disorder is effective in reducing anxiety and comorbid depressive symptoms, irrespective of depression severity.[145] Patients with anxiety disorders (including panic disorder) who are treated with CBT experience significant improvements in symptoms during the 24 months following completion of treatment.[153]

CBT may be delivered face-to-face (individual or group) or as digital CBT (dCBT) accessed by computer, tablet or smartphone application. dCBT may be considered as an equal first-line option to face-to-face CBT.[4] dCBT courses may be integrated with face-to-face therapy, and may be supervised by a clinician or completed on a self-help basis. Guided dCBT is generally more effective than unguided dCBT; this involves regular help and contact to complete the course, although this does not necessarily have to be from a clinician.[4]

CBT for panic disorder involves a combination of education, self-monitoring, relaxation training, challenging negative styles of thinking, situational exposure training, and systematic exposure to uncomfortable physical sensations.

Exposure therapy involves gradually increasing the patient's tolerance to previously avoided situations. The goal is to have the patient stay in the feared situation long enough to allow fear reduction to occur without engaging in escape or avoidance behavior or relying on safety cues. Repeated, frequent, controllable, and predictable exposures are associated with optimal outcomes.

1st line – SSRIs or SNRIs

Back
ONGOING
|
panic disorder
|
with comorbid depression
1st line – 

SSRIs or SNRIs

Selective serotonin-reuptake inhibitors (SSRIs) are regarded as the optimal class of antidepressants given their broad spectrum of action and improved safety and tolerance.[116][118][123]

Paroxetine is the least stimulating and most sedating of the SSRIs. Fluoxetine has a long half-life and therefore a lower risk of withdrawal symptoms, but it is more stimulating and requires slower titration.

Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine are also effective.

Patients with anxiety disorders may be more susceptible to medication adverse effects; it is therefore advisable to start at the lowest dose and increase the dose with caution ("start low, go slow").[12] Most adverse effects are time-limited during dose titration, and these should be discussed in advance with patients and monitored closely to ensure adherence.

Primary options

paroxetine: 5-10 mg orally (immediate release) once daily initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

OR

sertraline: 25 mg orally once daily initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

OR

fluoxetine: 5-10 mg orally (immediate release) once daily initially, increase by 10-20 mg/day increments every 4 weeks according to response, maximum 80 mg/day

OR

fluvoxamine: 25-50 mg orally (immediate release) once daily initially, increase by 25-50 mg/day every 4-7 days according to response, maximum 300 mg/day

OR

citalopram: 5-10 mg orally once daily initially, increase by 10-20 mg/day increments every 7 days according to response, maximum 40 mg/day

OR

escitalopram: 5 mg orally once daily initially, increase by 5-10 mg/day increments every 4 weeks according to response, maximum 20 mg/day

OR

venlafaxine: 37.5 mg orally (extended release) once daily initially, increase by 37.5 to 75 mg/day increments every 7 days according to response, maximum 225 mg/day

Plus – psychoeducation and lifestyle advice

Back
ONGOING
|
panic disorder
|
with comorbid depression
Plus – 

psychoeducation and lifestyle advice

Treatment recommended for ALL patients in selected patient group

Offer psychoeducation as soon as a diagnosis has been made.[12] A key part of any treatment approach is information and education about the nature of panic and anxiety. In particular, panic is an understandable reaction to perceived danger (the "fight or flight" response). Fear arises from the misinterpretation of normal body sensations. Drawing a simple diagram together with the person - linking symptoms, interpretation, anxiety with arrows in a "vicious circle" - can be helpful. It is important for the person to appreciate that the first goal of treatment is not to remove all anxiety, only to manage it successfully. Attempts by the person to cope (e.g., by avoidance or safety seeking) are understandable, but inadvertently lead to maintaining the problem.

Advice on lifestyle factors includes: good sleep; regular exercise; reduced use of caffeine, tobacco, and alcohol; healthy diet; and staying engaged with meaningful activities and healthy social supports.[4]

Consider – cognitive behavioral therapy (CBT)

Back
ONGOING
|
panic disorder
|
with comorbid depression
Consider – 

cognitive behavioral therapy (CBT)

Treatment recommended for SOME patients in selected patient group

Adjunctive CBT is also recommended for patients receiving pharmacotherapy.

CBT may be delivered face-to-face (individual or group) or as digital CBT (dCBT) accessed by computer, tablet or smartphone application. dCBT may be considered as an equal first-line option to face-to-face CBT.[4] dCBT courses may be integrated with face-to-face therapy, and may be supervised by a clinician or completed on a self-help basis. Guided dCBT is generally more effective than unguided dCBT; this involves regular help and contact to complete the course, although this does not necessarily have to be from a clinician.[4]

Increased medication adherence and response rates, with a reduction in the amount of medication required to gain symptom control, are observed with adjunctive CBT.[95][106][108][109][110] Patients with anxiety disorders (including panic disorder) who are treated with CBT experience significant improvements in symptoms during the 24 months following completion of treatment.[153]

CBT for panic disorder involves a combination of education, self-monitoring, relaxation training, challenging negative styles of thinking, situational exposure training, and systematic exposure to uncomfortable physical sensations.

Exposure therapy involves gradually increasing the patient's tolerance to previously avoided situations. The goal is to have the patient stay in the feared situation long enough to allow fear reduction to occur without engaging in escape or avoidance behavior or relying on safety cues. Repeated, frequent, controllable, and predictable exposures are associated with optimal outcomes.

2nd line – tricyclic antidepressants (TCAs)

Back
ONGOING
|
panic disorder
|
with comorbid depression
2nd line – 

tricyclic antidepressants (TCAs)

TCAs are indicated in patients for whom treatment with one or more SSRI/SNRIs or CBT has failed, or in patients with neuropathic pain.

They are less favorable with respect to adverse effects and may not be as well tolerated as SSRIs.[123]

Serum imipramine levels may need to be monitored closely due to the relatively narrow therapeutic index.

Primary options

imipramine: 10-25 mg orally once daily initially, increase by 10 mg/day increments every 2-4 days according to response, maximum 300 mg/day

OR

clomipramine: 12.5 to 25 mg orally once daily initially, increase gradually according to response, maximum 250 mg/day

Plus – psychoeducation and lifestyle advice

Back
ONGOING
|
panic disorder
|
with comorbid depression
Plus – 

psychoeducation and lifestyle advice

Treatment recommended for ALL patients in selected patient group

Offer psychoeducation as soon as a diagnosis has been made.[12] A key part of any treatment approach is information and education about the nature of panic and anxiety. In particular, panic is an understandable reaction to perceived danger (the "fight or flight" response). Fear arises from the misinterpretation of normal body sensations. Drawing a simple diagram together with the person - linking symptoms, interpretation, anxiety with arrows in a "vicious circle" - can be helpful. It is important for the person to appreciate that the first goal of treatment is not to remove all anxiety, only to manage it successfully. Attempts by the person to cope (e.g., by avoidance or safety seeking) are understandable, but inadvertently lead to maintaining the problem.

Advice on lifestyle factors includes: good sleep; regular exercise; reduced use of caffeine, tobacco, and alcohol; healthy diet; and staying engaged with meaningful activities and healthy social supports.[4]

Consider – cognitive behavioral therapy (CBT)

Back
ONGOING
|
panic disorder
|
with comorbid depression
Consider – 

cognitive behavioral therapy (CBT)

Treatment recommended for SOME patients in selected patient group

Increased medication adherence and response rates, with a reduction in the amount of medication required to gain symptom control, are observed with adjunctive CBT.[95][106][108][109][110] Patients with anxiety disorders (including panic disorder) who are treated with CBT experience significant improvements in symptoms during the 24 months following completion of treatment.[153]

CBT may be delivered face-to-face (individual or group) or as digital CBT (dCBT) accessed by computer, tablet or smartphone application. dCBT may be considered as an equal first-line option to face-to-face CBT.[4] dCBT courses may be integrated with face-to-face therapy, and may be supervised by a clinician or completed on a self-help basis. Guided dCBT is generally more effective than unguided dCBT; this involves regular help and contact to complete the course, although this does not necessarily have to be from a clinician.[4]

CBT for panic disorder involves a combination of education, self-monitoring, relaxation training, challenging negative styles of thinking, situational exposure training, and systematic exposure to uncomfortable physical sensations.

Exposure therapy involves gradually increasing the patient's tolerance to previously avoided situations. The goal is to have the patient stay in the feared situation long enough to allow fear reduction to occur without engaging in escape or avoidance behavior or relying on safety cues. Repeated, frequent, controllable, and predictable exposures are associated with optimal outcomes.

3rd line – dual pharmacotherapy

Back
ONGOING
|
panic disorder
|
with comorbid depression
3rd line – 

dual pharmacotherapy

Guidelines from the STAR*D study for treatment-resistant comorbid depression recommend dual pharmacotherapy in non-responding patients if they show a partial response (25% improvement in symptoms) with a maximum dose of 1 antidepressant.[143]

Combining 2 drugs from groups with different mechanisms of action may be considered, the groups being selective serotonin-reuptake inhibitors (paroxetine, sertraline, fluoxetine, fluvoxamine, citalopram, escitalopram), serotonin-norepinephrine reuptake inhibitors (venlafaxine), mirtazapine, and tricyclic antidepressants (imipramine, clomipramine).

Patients with anxiety disorders may be more susceptible to medication adverse effects; it is therefore advisable to start at the lowest dose and increase the dose with caution ("start low, go slow"). [12] Check carefully for drug interactions and consider consulting with a psychiatrist considered before initiating combination therapy.

Primary options

paroxetine: 5-10 mg orally (immediate release) once daily initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

or

sertraline: 25 mg orally once daily initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

or

fluoxetine: 5-10 mg orally (immediate release) once daily initially, increase by 10-20 mg/day increments every 4 weeks according to response, maximum 80 mg/day

or

fluvoxamine: 25-50 mg orally (immediate release) once daily initially, increase by 25-50 mg/day every 4-7 days according to response, maximum 300 mg/day

or

citalopram: 5-10 mg orally once daily initially, increase by 10-20 mg/day increments every 7 days according to response, maximum 40 mg/day

or

escitalopram: 5 mg orally once daily initially, increase by 5-10 mg/day increments every 4 weeks according to response, maximum 20 mg/day

-- AND --

venlafaxine: 37.5 mg orally (extended release) once daily initially, increase by 37.5 to 75 mg/day increments every 7 days according to response, maximum 225 mg/day

OR

paroxetine: 5-10 mg orally (immediate release) once daily initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

or

sertraline: 25 mg orally once daily initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

or

fluoxetine: 5-10 mg orally (immediate release) once daily initially, increase by 10-20 mg/day increments every 4 weeks according to response, maximum 80 mg/day

or

fluvoxamine: 25-50 mg orally (immediate release) once daily initially, increase by 25-50 mg/day every 4-7 days according to response, maximum 300 mg/day

or

citalopram: 5-10 mg orally once daily initially, increase by 10-20 mg/day increments every 7 days according to response, maximum 40 mg/day

or

escitalopram: 5 mg orally once daily initially, increase by 5-10 mg/day increments every 4 weeks according to response, maximum 20 mg/day

-- AND --

mirtazapine: 15 mg orally once daily initially, increase gradually according to response every 1-2 weeks, maximum 45 mg/day

OR

paroxetine: 5-10 mg orally (immediate release) once daily initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

or

sertraline: 25 mg orally once daily initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

or

fluoxetine: 5-10 mg orally (immediate release) once daily initially, increase by 10-20 mg/day increments every 4 weeks according to response, maximum 80 mg/day

or

fluvoxamine: 25-50 mg orally (immediate release) once daily initially, increase by 25-50 mg/day every 4-7 days according to response, maximum 300 mg/day

or

citalopram: 5-10 mg orally once daily initially, increase by 10-20 mg/day increments every 7 days according to response, maximum 40 mg/day

or

escitalopram: 5 mg orally once daily initially, increase by 5-10 mg/day increments every 4 weeks according to response, maximum 20 mg/day

-- AND --

imipramine: 10-25 mg orally once daily initially, increase by 10 mg/day increments every 2-4 days according to response, maximum 300 mg/day

or

clomipramine: 12.5 to 25 mg orally once daily initially, increase gradually according to response, maximum 250 mg/day

OR

venlafaxine: 37.5 mg orally (extended release) once daily initially, increase by 37.5 to 75 mg/day increments every 7 days according to response, maximum 225 mg/day

and

mirtazapine: 15 mg orally once daily initially, increase gradually according to response every 1-2 weeks, maximum 45 mg/day

OR

venlafaxine: 37.5 mg orally (extended release) once daily initially, increase by 37.5 to 75 mg/day increments every 7 days according to response, maximum 225 mg/day

-- AND --

imipramine: 10-25 mg orally once daily initially, increase by 10 mg/day increments every 2-4 days according to response, maximum 300 mg/day

or

clomipramine: 12.5 to 25 mg orally once daily initially, increase gradually according to response, maximum 250 mg/day

OR

mirtazapine: 15 mg orally once daily initially, increase gradually according to response every 1-2 weeks, maximum 45 mg/day

-- AND --

imipramine: 10-25 mg orally once daily initially, increase by 10 mg/day increments every 2-4 days according to response, maximum 300 mg/day

or

clomipramine: 12.5 to 25 mg orally once daily initially, increase gradually according to response, maximum 250 mg/day

Plus – psychoeducation/lifestyle advice

Back
ONGOING
|
panic disorder
|
with comorbid depression
Plus – 

psychoeducation/lifestyle advice

Treatment recommended for ALL patients in selected patient group

Offer psychoeducation as soon as a diagnosis has been made.[12] A key part of any treatment approach is information and education about the nature of panic and anxiety. In particular, panic is an understandable reaction to perceived danger (the "fight or flight" response). Fear arises from the misinterpretation of normal body sensations. Drawing a simple diagram together with the person - linking symptoms, interpretation, anxiety with arrows in a "vicious circle" - can be helpful. It is important for the person to appreciate that the first goal of treatment is not to remove all anxiety, only to manage it successfully. Attempts by the person to cope (e.g., by avoidance or safety seeking) are understandable, but inadvertently lead to maintaining the problem.

Advice on lifestyle factors includes: good sleep; regular exercise; reduced use of caffeine, tobacco, and alcohol; healthy diet; and staying engaged with meaningful activities and healthy social supports.[4]

Consider – cognitive behavioral therapy (CBT)

Back
ONGOING
|
panic disorder
|
with comorbid depression
Consider – 

cognitive behavioral therapy (CBT)

Treatment recommended for SOME patients in selected patient group

Increased medication adherence and response rates, with a reduction in the amount of medication required to gain symptom control, are observed with adjunctive CBT.[95][106][108][109][110] Patients with anxiety disorders (including panic disorder) who are treated with CBT experience significant improvements in symptoms during the 24 months following completion of treatment.[153]

CBT may be delivered face-to-face (individual or group) or as digital CBT (dCBT) accessed by computer, tablet or smartphone application. dCBT may be considered as an equal first-line option to face-to-face CBT.[4] dCBT courses may be integrated with face-to-face therapy, and may be supervised by a clinician or completed on a self-help basis. Guided dCBT is generally more effective than unguided dCBT; this involves regular help and contact to complete the course, although this does not necessarily have to be from a clinician.[4]

CBT for panic disorder involves a combination of education, self-monitoring, relaxation training, challenging negative styles of thinking, situational exposure training, and systematic exposure to uncomfortable physical sensations.

Exposure therapy involves gradually increasing the patient's tolerance to previously avoided situations. The goal is to have the patient stay in the feared situation long enough to allow fear reduction to occur without engaging in escape or avoidance behavior or relying on safety cues. Repeated, frequent, controllable, and predictable exposures are associated with optimal outcomes.

1st line – cognitive behavioral therapy (CBT)

Back
ONGOING
|
panic disorder
|
with comorbid anxiety
1st line – 

cognitive behavioral therapy (CBT)

Patients with anxiety disorders (including panic disorder) who are treated with CBT experience significant improvements in symptoms during the 24 months following completion of treatment.[153]

CBT may be delivered face-to-face (individual or group) or as digital CBT (dCBT) accessed by computer, tablet or smartphone application. dCBT may be considered as an equal first-line option to face-to-face CBT.[4] dCBT courses may be integrated with face-to-face therapy, and may be supervised by a clinician or completed on a self-help basis. Guided dCBT is generally more effective than unguided dCBT; this involves regular help and contact to complete the course, although this does not necessarily have to be from a clinician.[4]

CBT for panic disorder involves a combination of education, self-monitoring, relaxation training, challenging negative styles of thinking, situational exposure training, and systematic exposure to uncomfortable physical sensations.

Exposure therapy involves gradually increasing the patient's tolerance to previously avoided situations. The goal is to have the patient stay in the feared situation long enough to allow fear reduction to occur without engaging in escape or avoidance behavior or relying on safety cues. Repeated, frequent, controllable, and predictable exposures are associated with optimal outcomes.

1st line – SSRIs or SNRIs

Back
ONGOING
|
panic disorder
|
with comorbid anxiety
1st line – 

SSRIs or SNRIs

Selective serotonin-reuptake inhibitors (SSRIs) are regarded as the optimal class of antidepressants given their broad spectrum of action and improved safety and tolerance.[116][118][123]

Paroxetine is the least stimulating and most sedating of the SSRIs. Fluoxetine has a long half-life and therefore a lower risk of withdrawal symptoms, but it is more stimulating and requires slower titration.

Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine are also effective.

Patients with anxiety disorders may be more susceptible to medication adverse effects; it is therefore advisable to start at the lowest dose and increase the dose with caution ("start low, go slow").[12] Most adverse effects are time-limited during dose titration, and these should be discussed in advance with patients and monitored closely to ensure adherence.

Primary options

paroxetine: 5-10 mg orally (immediate release) once daily initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

OR

sertraline: 25 mg orally once daily initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

OR

fluoxetine: 5-10 mg orally (immediate release) once daily initially, increase by 10-20 mg/day increments every 4 weeks according to response, maximum 80 mg/day

OR

fluvoxamine: 25-50 mg orally (immediate release) once daily initially, increase by 25-50 mg/day every 4-7 days according to response, maximum 300 mg/day

OR

citalopram: 5-10 mg orally once daily initially, increase by 10-20 mg/day increments every 7 days according to response, maximum 40 mg/day

OR

escitalopram: 5 mg orally once daily initially, increase by 5-10 mg/day increments every 4 weeks according to response, maximum 20 mg/day

OR

venlafaxine: 37.5 mg orally (extended release) once daily initially, increase by 37.5 to 75 mg/day increments every 7 days according to response, maximum 225 mg/day

Plus – psychoeducation and lifestyle advice

Back
ONGOING
|
panic disorder
|
with comorbid anxiety
Plus – 

psychoeducation and lifestyle advice

Treatment recommended for ALL patients in selected patient group

Offer psychoeducation as soon as a diagnosis has been made.[12] A key part of any treatment approach is information and education about the nature of panic and anxiety. In particular, panic is an understandable reaction to perceived danger (the "fight or flight" response). Fear arises from the misinterpretation of normal body sensations. Drawing a simple diagram together with the person - linking symptoms, interpretation, anxiety with arrows in a "vicious circle" - can be helpful. It is important for the person to appreciate that the first goal of treatment is not to remove all anxiety, only to manage it successfully. Attempts by the person to cope (e.g., by avoidance or safety seeking) are understandable, but inadvertently lead to maintaining the problem.

Advice on lifestyle factors includes: good sleep; regular exercise; reduced use of caffeine, tobacco, and alcohol; healthy diet; and staying engaged with meaningful activities and healthy social supports.[4]

Consider – cognitive behavioral therapy (CBT)

Back
ONGOING
|
panic disorder
|
with comorbid anxiety
Consider – 

cognitive behavioral therapy (CBT)

Treatment recommended for SOME patients in selected patient group

Increased medication adherence and response rates, with a reduction in the amount of medication required to gain symptom control, are observed with adjunctive CBT.[95][106][108][109][110] Patients with anxiety disorders (including panic disorder) who are treated with CBT experience significant improvements in symptoms during the 24 months following completion of treatment.[153]

CBT may be delivered face-to-face (individual or group) or as digital CBT (dCBT) accessed by computer, tablet or smartphone application. dCBT may be considered as an equal first-line option to face-to-face CBT.[4] dCBT courses may be integrated with face-to-face therapy, and may be supervised by a clinician or completed on a self-help basis. Guided dCBT is generally more effective than unguided dCBT; this involves regular help and contact to complete the course, although this does not necessarily have to be from a clinician.[4]

CBT for panic disorder involves a combination of education, self-monitoring, relaxation training, challenging negative styles of thinking, situational exposure training, and systematic exposure to uncomfortable physical sensations.

Exposure therapy involves gradually increasing the patient's tolerance to previously avoided situations. The goal is to have the patient stay in the feared situation long enough to allow fear reduction to occur without engaging in escape or avoidance behavior or relying on safety cues. Repeated, frequent, controllable, and predictable exposures are associated with optimal outcomes.

Consider – benzodiazepines

Back
ONGOING
|
panic disorder
|
with comorbid anxiety
Consider – 

benzodiazepines

Treatment recommended for SOME patients in selected patient group

Benzodiazepines are not recommended for patients with panic disorder by some international guidelines, e.g., those from the UK National Institute for Health and Care Excellence, due to concerns about negative long-term outcomes.[69] However cautious short-term use of benzodiazepines is recommended by other guidelines as an alternative option for selected patients with panic disorders, for example for patients whose symptoms have not responded to other treatments.[4][70] Evidence on benzodiazepines for panic disorder are generally low in quality and cover short-term use only, providing limited guidance for clinical practice.[131]

Benzodiazepines are recommended for short-term use only (e.g., 2 to 4 weeks).[134] Short-term benzodiazepines may be used for some patients as an adjunctive treatment to achieve a rapid reduction in panic attacks during the initial titration of a SSRI, for example if intense, persistent anxiety symptoms are interfering with treatment adherence and engagement, and if rapid control over anxiety symptoms is necessary.[4][11][70][146][154]

They have a rapid onset of action and are generally well tolerated, although physiologic dependence can occur in as little as 2 to 4 weeks.[146][155][156][157] Avoid benzodiazepines in patients with a previous or current history of substance use disorders.[4]

If benzodiazepines are indicated, the preference may be for scheduled, longer-acting agents so that medication use is time-dependent rather than response/panic-dependent. "As needed" use of short-acting benzodiazepines may result in the patient developing psychological dependence on these medications, which could diminish the ability for an individual to develop an internal locus of control over these symptoms.

Long-term treatment with benzodiazepines should be rare, supervised, made with caution and based on careful consideration of the anticipated risks and benefits of benzodiazepines for the individual patient; specialist input (e.g., from a psychiatrist or addiction specialist) is advisable. Patients using benzodiazepines long-term should be regularly offered the opportunity to gradually withdraw from long-term use; treatment at the lowest effective dose is recommended.[134][137]

Abrupt discontinuation or rapid tapering schedules can increase risk for withdrawal symptoms.

Primary options

clonazepam: 0.25 mg orally twice daily initially, increase by 0.25 to 0.5 mg/day increments every 3 days according to response, maximum 4 mg/day

Secondary options

alprazolam: 0.25 to 0.5 mg orally (immediate release) four times daily initially, increase by 1 mg/day increments every 3-4 days according to response, maximum 6 mg/day

OR

lorazepam: 0.5 mg orally three times daily initially, increase gradually according to response, maximum 6 mg/day

OR

diazepam: 2.5 mg orally (immediate release) twice daily initially, increase gradually according to response, maximum 40 mg/day

2nd line – tricyclic antidepressants (TCAs)

Back
ONGOING
|
panic disorder
|
with comorbid anxiety
2nd line – 

tricyclic antidepressants (TCAs)

TCAs are indicated in patients for whom treatment with one or more SSRI/SNRIs or CBT has failed, or in patients with neuropathic pain.

They are less favorable with respect to adverse effects and may not be as well tolerated as SSRIs.[123]

Serum imipramine levels may need to be monitored closely due to the relatively narrow therapeutic index.

Primary options

imipramine: 10-25 mg orally once daily initially, increase by 10 mg/day increments every 2-4 days according to response, maximum 300 mg/day

OR

clomipramine: 12.5 to 25 mg orally once daily initially, increase gradually according to response, maximum 250 mg/day

Plus – psychoeducation and lifestyle advice

Back
ONGOING
|
panic disorder
|
with comorbid anxiety
Plus – 

psychoeducation and lifestyle advice

Treatment recommended for ALL patients in selected patient group

Offer psychoeducation as soon as a diagnosis has been made.[12] A key part of any treatment approach is information and education about the nature of panic and anxiety. In particular, panic is an understandable reaction to perceived danger (the "fight or flight" response). Fear arises from the misinterpretation of normal body sensations. Drawing a simple diagram together with the person - linking symptoms, interpretation, anxiety with arrows in a "vicious circle" - can be helpful. It is important for the person to appreciate that the first goal of treatment is not to remove all anxiety, only to manage it successfully. Attempts by the person to cope (e.g., by avoidance or safety seeking) are understandable, but inadvertently lead to maintaining the problem.

Advice on lifestyle factors includes: good sleep; regular exercise; reduced use of caffeine, tobacco, and alcohol; healthy diet; and staying engaged with meaningful activities and healthy social supports.[4]

Consider – cognitive behavioral therapy (CBT)

Back
ONGOING
|
panic disorder
|
with comorbid anxiety
Consider – 

cognitive behavioral therapy (CBT)

Treatment recommended for SOME patients in selected patient group

Increased medication adherence and response rates, with a reduction in the amount of medication required to gain symptom control, are observed with adjunctive CBT.[95][106][108][109][110] Patients with anxiety disorders (including panic disorder) who are treated with CBT experience significant improvements in symptoms during the 24 months following completion of treatment.[153]

CBT may be delivered face-to-face (individual or group) or as digital CBT (dCBT) accessed by computer, tablet or smartphone application. dCBT may be considered as an equal first-line option to face-to-face CBT.[4] dCBT courses may be integrated with face-to-face therapy, and may be supervised by a clinician or completed on a self-help basis. Guided dCBT is generally more effective than unguided dCBT; this involves regular help and contact to complete the course, although this does not necessarily have to be from a clinician.[4]

CBT for panic disorder involves a combination of education, self-monitoring, relaxation training, challenging negative styles of thinking, situational exposure training, and systematic exposure to uncomfortable physical sensations.

Exposure therapy involves gradually increasing the patient's tolerance to previously avoided situations. The goal is to have the patient stay in the feared situation long enough to allow fear reduction to occur without engaging in escape or avoidance behavior or relying on safety cues. Repeated, frequent, controllable, and predictable exposures are associated with optimal outcomes.

3rd line – benzodiazepines

Back
ONGOING
|
panic disorder
|
with comorbid anxiety
3rd line – 

benzodiazepines

Some clinicians may consider offering benzodiazepine monotherapy to patients with panic disorder and comorbid anxiety with a history of intolerance to antidepressants. Benzodiazepines are not recommended for patients with panic disorder by some international guidelines, e.g., those from the UK National Institute for Health and Care Excellence, due to concerns about negative long-term outcomes.[69] However cautious short-term use of benzodiazepines is recommended by other guidelines as an alternative option for selected patients with panic disorders.[4][70] Evidence on benzodiazepines for panic disorder are generally low in quality and cover short-term use only, providing limited guidance for clinical practice.[131] Benzodiazepines are recommended for short-term use only (e.g., 2 to 4 weeks).[134]

Benzodiazepines have a rapid onset of action and are generally well tolerated, although physiologic dependence can occur in as little as 2 to 4 weeks.[146][155][156][157] Avoid benzodiazepines in patients with a previous or current history of substance misuse.[4]

If benzodiazepines are indicated, the preference may be for scheduled, longer-acting agents so that medication use is time-dependent rather than response/panic-dependent. "As needed" use of short-acting benzodiazepines may result in the patient developing psychological dependence on these medications, which could diminish the ability for an individual to develop an internal locus of control over these symptoms.

Long-term treatment with benzodiazepines should be rare, supervised, made with caution and based on careful consideration of the anticipated risks and benefits of benzodiazepines for the individual patient; specialist input (e.g., from a psychiatrist or addiction specialist) is advisable. Patients using benzodiazepines long-term should be regularly offered the opportunity to gradually withdraw from long-term use; treatment at the lowest effective dose is recommended.[134][137]

Abrupt discontinuation or rapid tapering schedules can increase risk for withdrawal symptoms.

Primary options

clonazepam: 0.25 mg orally twice daily initially, increase by 0.25 to 0.5 mg/day increments every 3 days according to response, maximum 4 mg/day

Secondary options

alprazolam: 0.25 to 0.5 mg orally (immediate release) four times daily initially, increase by 1 mg/day increments every 3-4 days according to response, maximum 6 mg/day

OR

lorazepam: 0.5 mg orally three times daily initially, increase gradually according to response, maximum 6 mg/day

OR

diazepam: 2.5 mg orally (immediate release) twice daily initially, increase gradually according to response, maximum 40 mg/day

Plus – psychoeducation and lifestyle advice

Back
ONGOING
|
panic disorder
|
with comorbid anxiety
Plus – 

psychoeducation and lifestyle advice

Treatment recommended for ALL patients in selected patient group

Offer psychoeducation as soon as a diagnosis has been made.[12] A key part of any treatment approach is information and education about the nature of panic and anxiety. In particular, panic is an understandable reaction to perceived danger (the "fight or flight" response). Fear arises from the misinterpretation of normal body sensations. Drawing a simple diagram together with the person - linking symptoms, interpretation, anxiety with arrows in a "vicious circle" - can be helpful. It is important for the person to appreciate that the first goal of treatment is not to remove all anxiety, only to manage it successfully. Attempts by the person to cope (e.g., by avoidance or safety seeking) are understandable, but inadvertently lead to maintaining the problem.

Advice on lifestyle factors includes: good sleep; regular exercise; reduced use of caffeine, tobacco, and alcohol; healthy diet; and staying engaged with meaningful activities and healthy social supports.[4]

Consider – cognitive behavioral therapy (CBT)

Back
ONGOING
|
panic disorder
|
with comorbid anxiety
Consider – 

cognitive behavioral therapy (CBT)

Treatment recommended for SOME patients in selected patient group

Patients discontinuing benzodiazepines may particularly benefit from adjunctive CBT.[114][115]

Increased medication adherence and response rates, with a reduction in the amount of medication required to gain symptom control, are observed with adjunctive CBT.[95][106][108][109][110] Patients with anxiety disorders (including panic disorder) who are treated with CBT experience significant improvements in symptoms during the 24 months following completion of treatment.[153]

CBT may be delivered face-to-face (individual or group) or as digital CBT (dCBT) accessed by computer, tablet or smartphone application. dCBT may be considered as an equal first-line option to face-to-face CBT.[4] dCBT courses may be integrated with face-to-face therapy, and may be supervised by a clinician or completed on a self-help basis. Guided dCBT is generally more effective than unguided dCBT; this involves regular help and contact to complete the course, although this does not necessarily have to be from a clinician.[4]

CBT for panic disorder involves a combination of education, self-monitoring, relaxation training, challenging negative styles of thinking, situational exposure training, and systematic exposure to uncomfortable physical sensations.

Exposure therapy involves gradually increasing the patient's tolerance to previously avoided situations. The goal is to have the patient stay in the feared situation long enough to allow fear reduction to occur without engaging in escape or avoidance behavior or relying on safety cues. Repeated, frequent, controllable, and predictable exposures are associated with optimal outcomes.

panic attacks without panic disorder

1st line – counseling and monitoring

Back
ONGOING
|
panic attacks without panic disorder
1st line – 

counseling and monitoring

Explain to patients that panic attacks affect up to one third of individuals in their lifetime but with less than 10% developing full panic disorder, and that although the attacks are uncomfortable, they are not dangerous and are time-limited.

Encourage patients to monitor the intensity, frequency, and duration of attacks, and whether the episodes are expected or unexpected.

Self-help materials based on principles of cognitive behavioral therapy are also beneficial. Bibliotherapy, either alone or in combination with brief phone contact, may be helpful in reducing panic-related symptoms.[87][88]

Schedule a follow-up evaluation or a telephone check within 2 weeks to reassess the patient's symptoms. See above for recommended management of patients who then go on to meet DSM-5-TR criteria for panic disorder.

Plus – psychoeducation and lifestyle advice

Back
ONGOING
|
panic attacks without panic disorder
Plus – 

psychoeducation and lifestyle advice

Treatment recommended for ALL patients in selected patient group

A key part of any treatment approach is information and education about the nature of panic and anxiety. In particular, panic is an understandable reaction to perceived danger (the "fight or flight" response). Fear arises from the misinterpretation of normal body sensations. Drawing a simple diagram together with the person - linking symptoms, interpretation, anxiety with arrows in a "vicious circle" - can be helpful. It is important for the person to appreciate that the first goal of treatment is not to remove all anxiety, only to manage it successfully. Attempts by the person to cope (e.g., by avoidance or safety seeking) are understandable, but inadvertently lead to maintaining the problem.

Advice on lifestyle factors includes: good sleep; regular exercise; reduced use of caffeine, tobacco, and alcohol; healthy diet; and staying engaged with meaningful activities and healthy social supports.[4]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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