Guideline sources The following summarized guidelines for the management of panic disorder (PD) are prepared by our editorial team based on guidelines from the American Association of Family Physicians (AAFP 2015) and the Anxiety Disorders Association of Canada (ADAC 2014). 1 2 Guidelines 1. Medical management General principles: individualize treatment order to maximize treatment success, and consider combining modalities as necessary. B Duration of treatment: continue maintenance therapy for 12 months after symptoms improve before tapering, in order to avoid relapse. B Management of panic attacks: As per AAFP 2015 guidelines, consider using benzodiazepines only during short-term crises in patients with PD, given they are associated with the development of tolerance. C As per ADAC 2014 guidelines, consider using benzodiazepines for the short-term management of acute or severe agitation or anxiety in patients with PD. B First-line therapy: As per AAFP 2015 guidelines, use SSRIs as first-line therapy for patients with PD. B As per ADAC 2014 guidelines, use one of the following options as first-line therapy for patients with PD - listed in alphabetical order: citalopram A https://web.pathway.md/diseases/recKi3FaZsV0vhNiB 1/5 6/29/23, 10:53 PM Panic disorder Pathway c ta op a escitalopram B fluoxetine A fluvoxamine A paroxetine A paroxetine CR B sertraline A venlafaxine XR A Second-line therapy: Use one of the following options as second-line therapy in patients with PD - listed in alphabetical order: alprazolam A clomipramine A clonazepam A diazepam A imipramine A lorazepam A mirtazapine B reboxetine A Consider using benzodiazepines at the initiation of treatment with an selective serotonin release inhibitor, in order to hasten response. B Third-line therapy: Use one of the following options as third-line therapy in patients with PD - listed in alphabetical order: bupropion SR B divalproex B duloxetine B gabapentin B levetiracetam B milnacipran B moclobemide A olanzapine B phenelzine B quetiapine B risperidone B tranylcypromine B Adjunctive therapy: Use one of the following options as first-line adjunctive therapy in patients with PD: alprazolam PO-disintegrating tablet, used short-term - < 8 weeks including taper - at the initiation of SSRI treatment B clonazepam used short-term - < 8 weeks including taper - at the initiation of SSRI treatment A https://web.pathway.md/diseases/recKi3FaZsV0vhNiB 2/5 6/29/23, 10:53 PM Panic disorder Pathway Use one of the following options as second-line adjunctive therapy in patients with PD - listed in alphabetical order: aripiprazole A divalproex B olanzapine B pindolol added to fluoxetine therapy B risperidone B 2. Nonpharmacologic interventions Psychotherapy: use psychotherapy as an effective option for the treatment of PD. CBT has the best level of evidence. A Respiratory training: In an RCT, capnometry-assisted respiratory training was as effective as cognitive training in reducing panic symptom severity and panic-related cognitions and improving perceived control. B However, breathing training did not significantly improve reactivity or recovery after a respiratory challenge in another small trial. B Physical activity: As per AAFP 2015 guidelines, advise physical activity as a cost-effective treatment for PD. B As per ADAC 2014 guidelines: In an RCT, patients with PD randomized to the exercise groups (plus paroxetine or placebo) had a trend toward better improvement compared to relaxation training, but this was not significant. B However, in an open cross-over study, acute aerobic exercise was found to reduce anxiety as well as panic attack frequency and intensity in patients with PD, compared to a quiet rest condition. B 3. Therapeutic procedures Brain stimulation: in open-label case series, noninvasive brain stimulation using a radioelectric asymmetric conveyor demonstrated efficacy for panic symptoms and agoraphobia. B Show 2 more Clinical findings Symptoms Vital signs A churning stomach Tachycardia A feeling of dread or a fear of dying https://web.pathway.md/diseases/recKi3FaZsV0vhNiB 3/5 6/29/23, 10:53 PM Panic disorder Pathway A need to go to the toilet Anxiety Chest pain Chills Choking sensation Dizziness Dry mouth Feeling faint Feeling like you're not connected to your body Hot flashes Nausea Numbness Perception of noise or ringing in the ears Shaky limbs Shortness of breath Sweating Tingling in the fingers Trembling References 1. Locke AB, Kirst N, Shultz CG. Diagnosis and management of generalized anxiety disorder and panic disorder in adults. Am Fam Physician. 2015 May 1;91 9 617 24. Open 2. Katzman MA, Bleau P, Blier P et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14 Suppl 1 S1. Open 3. R Bruce Lydiard. Recognition and treatment of panic disorder. J Clin Psychiatry. 2007 Nov;68 11):e26. Open 4. Liisa Hantsoo, C Neill Epperson. Anxiety Disorders Among Women: A Female Lifespan Approach. Focus Am Psychiatr Publ). Spring 2017;15 2 162 172. Open 5. Janice H Goodman, Kerry L Chenausky, Marlene P Freeman. Anxiety disorders during pregnancy: a systematic review. J Clin Psychiatry. 2014 Oct;75 10):e1153 84. Open 6. Debra Siegel Levine, Joseph A Himle, Robert Joseph Taylor et al. Panic disorder among African Americans, Caribbean blacks and non-Hispanic whites. Soc Psychiatry Psychiatr Epidemiol. 2013 May;48 5 711 23. Open 7. Anu Asnaani, Cassidy A Gutner, Devon E Hinton et al. Panic disorder, panic attacks and panic attack symptoms across race-ethnic groups: results of the collaborative psychiatric epidemiology studies. CNS Neurosci Ther. Fall 2009;15 3 249 54. Open 8. Jasmijn M de Lijster, Bram Dierckx, Elisabeth M W J Utens et al. The Age of Onset of Anxiety Disorders. Can J Psychiatry. 2017 Apr;62 4 237 246. Open 9. Andreas Str hle, Jochen Gensichen, Katharina Domschke. The Diagnosis and Treatment of Anxiety Disorders. Dtsch Arztebl Int. 2018 Sep 14;155 37 611 620. Open https://web.pathway.md/diseases/recKi3FaZsV0vhNiB 4/5 6/29/23, 10:53 PM Panic disorder Pathway 10. Benedikt Klauke, J rgen Deckert, Andreas Reif et al. Life events in panic disorder-an update on "candidate stressors". Depress Anxiety. 2010 Aug;27 8 716 30. Open 11. Amanda Kutz, Erin Marshall, Amit Bernstein et al. Evaluating emotional sensitivity and tolerance factors in the prediction of panic-relevant responding to a biological challenge. J Anxiety Disord. 2010 Jan;24 1 16 22. Open 12. Jieun E Kim, Stephen R Dager, In Kyoon Lyoo. The role of the amygdala in the pathophysiology of panic disorder: evidence from neuroimaging studies. Biol Mood Anxiety Disord. 2012 Nov 20;2 20. Open 13. Martin A Katzman, Pierre Bleau, Pierre Blier et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14 Suppl 1 Suppl 1 S1. Open 14. Eduardo Lattari, Henning Budde, Fl via Paes et al. Effects of Aerobic Exercise on Anxiety Symptoms and Cortical Activity in Patients with Panic Disorder: A Pilot Study. Clin Pract Epidemiol Ment Health. 2018 Feb 21;14 11 25. Open 15. Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Panic Disorder and Agoraphobia. Australian and New Zealand clinical practice guidelines for the treatment of panic disorder and agoraphobia. Aust N Z J Psychiatry. 2003 Dec;37 6 641 56. Open 16. Curt Cackovic, Saad Nazir, Raman Marwaha. Panic Disorder. In: StatPearls Internet]. Treasure Island FL StatPearls Publishing; 2021 Jan. 2020 Nov 29. Open https://web.pathway.md/diseases/recKi3FaZsV0vhNiB 5/5