Panic disorder: treatment and management

John was a professional in his 30s who was driving to work when he experienced sudden difficulty breathing, chest tightness, dizziness, tingling in his arms, nausea and thought that he was having a heart attack and losing control. He called for an ambulance and was taken to the emergency department where he had numerous tests that came back negative for a heart attack or medical problem. He was told that he probably had a panic attack. Over the next few weeks, John became anxious about having another panic attack and started avoiding driving. He had another panic attack at a café with his partner and started avoiding the café. Soon, his life had become restricted and he was generally anxious in anticipation of further panic attacks.

Anxiety is a normal emotion that can be helpful, up to a certain level, in improving one’s performance. However, when anxiety becomes excessive and affects functioning, it may indicate the presence of an anxiety disorder that requires treatment. Panic attacks can occur in the setting of many anxiety disorders and other conditions such as substance use or a general medical condition. However, people who experience panic disorder have repeated panic attacks and become worried about having another panic attack or the implications of an attack. Some attacks have clear triggers, others will come out of the blue, but most of the time, there is some warning sign prior to it developing. In some cases, agoraphobia may be present. Agoraphobia is a fear of places or situations in which escape may be difficult or help may be unavailable, and leads to anxiety or avoidance.

Panic disorder is not uncommon, with a 12 month prevalence rate of 2.6% in Australia3. It is important to initially see your GP for an assessment so that medical causes of panic-like symptoms can be excluded. Once a medical cause has been excluded, then referral for a psychiatric assessment may occur. This involves exploring the symptoms, thoughts, behaviours and consequences of a panic attack. Consequences of panic attacks include avoidance, tolerating situations that trigger distress by using a coping mechanism called a safety behaviour, and functional impairment. It is also important to exclude other mental health conditions that may predate, coexist with or be secondary to the panic attacks. Depression, other anxiety disorders, obsessive compulsive disorder and substance use are not uncommon comorbidity.

There are proven treatments for panic disorder. Psychoeducation is the first step to ensure that patients and their families understand the condition. Lifestyle modifications such as reducing caffeine or other substance use, good sleep hygiene and exercise may be an early intervention. Cognitive Behavioural Therapy (CBT), when administered by a professional with expertise, is an effective treatment and should be offered to most people either individually or in a group program. Pharmacotherapy in the form of a Selective Serotonin Reuptake Inhibitor as a first line medication may be used as an alternative treatment or in combination with CBT. Medications should be started at a low dose and increased gradually as people with panic disorder are often sensitive to the side effects of medication. Other antidepressants, including Serotonin Noradrenaline Reuptake Inhibitors or Tricyclic Antidepressants may also be considered. The treatment plan needs to be individualized and will need to be discussed with your treating doctor. Effective treatment should lead to reduced frequency or intensity of panic attacks, reduced use of avoidance or safety behaviours, and improvement in functioning1 2.

References:
1. Working Group on Panic Disorder. American Psychiatric Associations. Practice Guidelines for the Treatment of Patients with Panic Disorder. 2nd Edition
2. CPG Team for Panic and Agoraphobia. Australian and New Zealand Clinical Practice Guidelines for the Treatment of Panic Disorder and Agoraphobia. ANZJP 2003; 37:641-656
3. http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/4326.0Main%20Features32007

 


Dr Karen GweeAUTHOR | Dr Karen Gwee
Dr Karen Gwee is an adult psychiatrist and CPT therapist at Epworth Camberwell with an interest in providing holistic care for anxiety disorders including panic disorder. She also has a public appointment at Austin Health.
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PH | 03 9805 4309  FAX | 03 9805 4388  ROOMS | Epworth Clinic, Level 3, 888 Toorak Road, Camberwell, VIC 3124

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