Pharmacological management of panic disorder

Figures & data

Table 1 Diagnostic criteria for panic disorder, according to DSM-IV TR (APA 2000)

Recurrent unexpected panic attacks* At least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: - persistent concern about having additional attacks; - worry about the implication of the attack or its consequences; - a significant change in behaviour related to the attacks. The panic attacks are not due to the direct physiological effects of a substance or a general medical condition The panic attacks are not better accounted for by another mental disorder, such as social phobia, obsessive-compulsive disorder, posttraumatic stress disorder, or separation anxiety disorder

* A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

1. palpitation, pounding heart, or accelerated heart rate;

2. sweating;

3. trembling or shaking;

4. sensation of shortness of breath or smothering;

5. feeling of choking;

6. chest pain or discomfort;

7. nausea or abdominal distress;

8. feeling dizzy, unsteady, lightheaded or faint;

9. derealization or depersonalisation;

10. fear of loosing control or going crazy;

11. fear of dying.

Table 2 Advantages and disadvantages of pharmacotherapy and cognitive-behavior therapy (CBT) in the treatment of panic disorder

	Pharmacotherapy	CBT
Side-effects	++	0
Rapid onset of action	++*	+
Efficacy on more severe panic attacks and anticipatory anxiety	++	+
Efficacy on phobic avoidance	+	++
Efficacy on severe depression	++§	+
Persistence of effect after stopping treatment	0	+
Use in primary care setting	++	0
Used by experienced therapist	+	++
Need to perform “homework” or to confront feared situations	0	++

* Note: Particularly benzodiazepines

§ antidepressants.

Table 3 Advantages and disadvantages of the different classes of drugs commonly used in the treatment of panic disorder

	SSRI	TCA	BDZ
Rapidity of effect	+	+	+++
Antidepressant efficacy	+++	+++	0
Efficacy in anxiety comorbidity	+++	+++	0
Sedation	0	+/++	++
Cognitive impairment	0	+	++
Anticholinergic effects	0	++	0
Orthostatic hypotension	0	++	0
Hyperstimulation	++	+	0
Nausea	++	0	0
Weight gain	0/+	++	0
Sexual dysfunction	++	+	0
Physical dependence	0	0	++
Discontinuation symptoms	+	+	+++
Risk of abuse	0	0	++
Cardiovascular effects	0	++	0
Safety in overdose	0	++	0
Drug interaction	0/++	0	0

Table 4 Differences among the SSRI medications

	Citalopram	Escitalopram	Fluoxetina	Fluvoxamina	Paroxetina	Sertraline
Anticholinergic effects	0	0	0/+	0	0/+	0
Sedation	0/+	0	0	0/+	0/+	0
Insomnia	0/+	+	+	0/+	+	+
Orthostatic hypotension	0	0	0	0	0	0
Hyperstimulation	+	+	++	+	++	+
Nausea	+	+	+	+	+	+
Weight gain	0/+	0	0	0	+	0/+
Sexual dysfunction	+	+	+	+	++	+
Discontinuation symptoms	+	+	0/+	+	++	+
Cardiovascular effects	0	0	0	0	0	0
Safety in overdose	0/+	0/+	0/+	0/+	0/+	0/+
Half-life (longer than 24 h)	+	+	+++	0	0	+
Inhibition cytochrome P450	0	0/+	++	++	+	0

Table 5 Doses of effective medication in the treatment of panic disorder

	mg/day
	Starting dose	Therapeutic dose
Citalopram	10	20–60	Once a day
Escitalopram	5	10–30	Once a day
Fluoxetine	10	20–60	Once a day
Fluvoxamine	25	100–300	Bis intra day
Paroxetine	10	20–60	Once a day
Sertaline	25	50–200	Once a day
Clomipramine	25	75–250	Once a day
Imipramine	25	75–300	Once a day
Alprazolam	0.75	2–9	Three times a day
Clonazepam	0.75	1.5–4.5	Three times a day
Lorazepam	1	2–7.5	Three times a day

[APA] American Psychiatric AssociationDiagnostic and stastical manual of mental disorders2000FourthWashington, DCAmerican Psychiatric Association

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