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 The leading web portal for pharmacy resources, news, education and careers November 17, 2017
Pharmacy Choice - Panic Disorder Disease State Management - November 17, 2017

Panic Disorder Disease State Management

Focus on Panic Disorder
by Darrell Hulisz, RPh, PharmD
Associate Professor of Family Medicine
Case Western Reserve University, School of Medicine

Panic disorder (PD) is a common anxiety disorder that can adversely affect one's psychosocial health. PD is characterized by sudden episodes of fear, anxiety, or impending doom. Panic attacks usually create a feeling of unreality, a sense of going crazy, or a fear of losing control, or even dying. Other symptoms of panic attacks include palpitations, pounding heart, tachycardia, sweating, trembling or shaking, feelings of smothering or choking, chest pain, nausea, dizziness and numbness or tingling sensations. Individuals who suffer from this disorder often have recurrent panic attacks because they worry about the consequences of another panic attack. Individuals develop panic disorder due to heredity, mental/biological illnesses, trauma, specific phobias, and/or short-term triggering causes. Approximately 6 million American adults suffer from PD, and women are twice as likely to have the disorder. Young adults between the ages of 20-25 have the highest risk of developing panic attacks. Patients with PD are at higher risk for co-morbidities such as suicide, agoraphobia, impaired social and marital function, and substance abuse.

PD is broadly grouped into two diagnostic categories: PD without agoraphobia and PD with agoraphobia. Criteria established by the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-V) states that the diagnosis of PD consist of an individual having recurrent, unexpected panic attacks, with at least one of the attacks followed by a month or more of one or both of the following: 1) Persistent concern or worry about additional panic attacks or their consequences, and 2) A significant maladaptive change in behavior related to the attacks, such as avoidance behavior. Patients with PD are generally treated with a combination of psychological or cognitive behavioral therapy (CBT) coupled with pharmacotherapy (discussed below).

The intensity of symptoms in a panic attack varies greatly, as do the frequency of attacks. One can experience panic episodes anywhere from once or twice a year, or in extreme cases, panic episode may occur daily. Often, panic attacks only occur in specific situations or social settings, such as flying, high altitudes, crowded theatres, or in confined areas where "escape" from the situation would be difficult or embarrassing. Substance withdrawal and acute intoxication of cocaine or methamphetamines can precipitate panic attacks. Approximately one-third of individuals with PD have agoraphobia. This is characterized by avoiding public places; fear of leaving one's home, or depending on the company of a relative or friend to ease his or her anxiety when going out.

Non-pharmacologic treatment for PD usually consists of physiological and psychiatric techniques. The use of cognitive behavioral therapy (CBT) is the most common psychiatric approach to treating panic disorder. Methods of cognitive behavioral therapy include relaxation techniques, breathing exercises, monitoring the frequency and number of panic attacks, and psychotherapy. Cognitive restructuring plays an important role in the treatment of PD because it instills a positive attitude about this disorder, which leads to a reduction in anxiety. One form of CBT trains an individual to affirm certain true statements, such as "this feeling I have right now is unpleasant but will soon fade away" and "no one has ever died from a panic attack" and "I am not going crazy or losing my mind, I just need to let this moment pass."

The use of pharmacotherapy reduces the frequency and severity of panic attacks. The three major classes of medications that reduce panic attacks are selective serotonin reuptake inhibitors (SSRIs), benzodiazepines and tricyclic antidepressants (TCAs). SSRIs are generally considered the most effective, first-line medication to treat PD. These drugs penetrate into the hypothalamus and into the amygdala to meditate the anxiety and fear response by increasing neuronal serotonin levels. Examples of SSRIs that are widely used for PD include fluoxetine, sertraline, and paroxetine. Citalopram and escitalopram are also used, but are not FDA-approved for this indication. TCAs are also used, but are not as well tolerated as SSRIs. TCAs increase the activity of both serotonin and norepinephrine. TCAs should not be given to patients with a history of attempted suicide since they are much more lethal in overdose. They are also more sedating than SSRIs and have anticholinergic side effects, such dry mouth, blurry vision, constipation and tachycardia. The most common TCAs used for PD include despiramine, imipramine, and nortriptyline. Benzodiazepines produce beneficial effects in PD much sooner than SSRIs and TCAs since they have almost immediate anxiety-reducing properties. SSRIs and TCAs can take 4-6 weeks for meaningful clinical benefit, but some patients respond sooner. Benzodiazepines produce sedation, euphoria, ataxia, amnesia, and can be addictive. Because of their rapid onset, these drugs are more useful in the early treatment stages of patients with PD, during the time an SSRI or TCA is being initiated. The most common benzodiazepines used to treat PD are clonazepam, lorazepam, and alprazolam. Patients with a history of substance abuse should not receive these medications. Benzodiazepines are not well-suited for chronic treatment of PD due to their potential to cause tolerance, dependence, abuse, and memory impairment.

Pharmacists should advise patients to abstain from excessive amounts of caffeine, over-the-counter stimulants, nicotine, alcohol, and illicit substances, such as cocaine since they can precipitate panic attacks. Additionally, excessive use of energy drinks should be strongly discouraged in those with PD since they contain high amounts of caffeine and other CNS stimulants, such as guarana and ginseng.
  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
  2. Kessler RC, Chiu WT, Jin R, Ruscio AM, Shear K, Walters EE. The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2006 Apr;63(4):415-24.
  3. Roy-Byrne PP, Craske MG, Stein MB, Sullivan G, Bystritsky A, Katon W, Golinelli D, Sherbourne CD. A randomized effectiveness trial of ognitive-behavioral therapy and medication for primary care panic disorder. Arch Gen Psychiatry. 2005 Mar;62(3):290-8.
  4. Imai H, Tajika A, Chen P, Pompoli A, Furukawa TA. Psychological therapies versus pharmacological interventions for panic disorder with or without agoraphobia in adults. Cochrane Database Syst Rev. 2016 Oct 12;10:CD011170.
  5. Roy-Byrne PP, Craske MG, Stein MB. Panic disorder. Lancet. 2006 Sep 16;368(9540):1023-32.
  6. Bystritsky A, Khalsa SS, Cameron ME, Schiffman J. Current Diagnosis and Treatment of Anxiety Disorders. Pharmacy and Therapeutics. 2013;38(1):30-57.

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