Panic disorder clinical practice guideline

Panic Disorder Clinical Practice Guideline
Policy Number: NMP472
Effective Date*: December 2005
Updated: November

2007, May 2009, May 2010, May
This National Medical Policy is subject to the terms in the
at the end of this document
Panic Disorder (PD) is a treatable condition that is estimated to affect about 6 million Americans. Women are twice as likely to be affected as men. The onset is usually in late adolescence or early adult life. The disorder is characterized by the sudden onset of a feeling of terror or panic, accompanied by physical symptoms such as heart palpitations, diaphoresis, nausea, chest pain and/or difficulty breathing. While many people experience one or two such attacks in their lives, they do not go on to develop the disorder. That occurs when the attacks come repeatedly and the patient develops a fear of the attacks themselves. This fear can lead the development of Panic Disorder with Agorophobia, a situation in which people begin to avoid the places where the attacks have occurred and over time their lives become increasingly restricted as to where they can go and what they can do. Left untreated, significant functional disability can occur. It is estimated that 85% of PD patient’s first present in a general medical setting, such as their primary care physician's office or hospital emergency room, but are often undiagnosed. Patients with Panic Disorders seek medical services more frequently than patients with other psychiatric disorders. Coordination of care with other medical providers is essential to reduce unnecessary or duplicative procedures or medications. Diagnostic Considerations
Check for:
When assessing a patient for panic disorder, check for the presence of
these symptoms:
• Recurrent, unexpected panic attacks—a discrete period of intense fear or discomfort with 4 or more of the following symptoms:
Panic Disorder Clinical Practice Guidelines May 11 • Shortness of breath, sensation of smothering or feeling of choking • Fear of losing control or going crazy • Feelings of unreality or depersonalization • Symptoms typically develop abruptly and reach a peak within 10 minutes • 1 month or more of persistent concern about having another attack OR worry about the implications or consequences of panic OR a significant behavioral change related to the attacks or fear of future attacks Panic Disorder with Agoraphobia includes the above AND:
• there is anxiety about being in situations in which escape is difficult or help may not be available if a panic attack occurs AND;
• those situations are avoided or endured with marked distress. RULE OUT:
Look for the presence of other factors, which may suggest a different or co-
existing diagnosis, including
• Direct physiological effects of a medication or other substance (e.g., caffeine) • General medical disorders that have panic-like symptoms (e.g., cardiovascular, pulmonary, neurological, endocrinological and gastrointestinal conditions) • Substance abuse (including excessive use of caffeine) Other possible diagnoses:
Other important assessment considerations:
• All patients presenting with a possible Panic Disorder should have a medical history and physical examination performed, with appropriate laboratory studies and imaging studies as indicated. • Coordination of care with the patient’s PCP is very important at the time of diagnosis and ongoing. Consider using the MHN Behavioral Health Coordination Form available Panic Disorder Clinical Practice Guidelines May 11 • Frequency and severity of panic attacks (Having the patient keep a diary of frequency and severity of attacks can be helpful in both the initial assessment • Severity of impairment in work, school, and social functioning • Presence of suicidal ideation and/or history of suicide attempts. Panic disorder and panic attacks are associated with elevated risk of suicidal • Initial and ongoing assessment for co-morbid conditions, especially Depressive Disorders and Substance Abuse. Between 30-60% of patients with lifetime panic disorder have or have had a major depressive episode. • Family History of Panic Disorder (since the risk of having Panic Disorder is significantly elevated if there is a first-degree relative with this diagnosis) • Consider the use of a rating scale, such as the Panic Disorder Severity Scale, • Co-Morbidity is common, with Panic Disorder patients usually having at least one other Anxiety Disorder. In clinical populations nearly a third of panic disorder patient meet criteria for social anxiety disorder. Treatment Considerations
General Treatment Considerations
• Panic Disorder often has a direct impact on disability, resulting in increased absenteeism, decreased productivity and reduced ability to carry out daily activities. Monitoring improvements in functioning, as well as in symptoms, should be part of evaluating treatment effectiveness. • Treatment compliance should be addressed directly. Panic Disorder patients tend to stop treatment when they become anxious about somatic sensations from medications or confronting fearful internal or external cues during CBT. • Different symptoms of Panic Disorder often resolve at different times. Full panic attacks may be controlled, but "sub threshold" panic attacks may continue. Anticipatory anxiety (i.e., worry about future attacks) tends to decrease after panic attacks are controlled. Agoraphobia (i.e., phobic avoidance), if present, is often the last to be positively impacted by treatment. Level of Care
• If there is a high risk of danger to self or others or grave disability, consider • Unstable patients may respond to structured, multi-disciplinary treatment (IOP, Day Treatment) that emphasizes skills training, family involvement, psychoeducation and psychiatric management. MHN care managers offer • Outpatient level of care is used almost exclusively Panic Disorder Clinical Practice Guidelines May 11 General Factors to Consider in the Use of Medications
• SSRIs, SNRIs, tricyclic antidepressants, benzodiazepines (only appropriate as monotherapy in the absence of a comorbid mood disorder) and/or cognitive-behavioral psychotherapy (CBT) have been shown generally to be equally effective in the acute phase (first 12 weeks) of treatment • Recent research with Panic Disorder patients suggests that medication may produce the quickest initial response (although by 12 weeks CBT is equally effective); combined treatment may be better than either medication or CBT alone; and response to CBT may be more durable than the response to • Short term use (3 to 4 weeks) of benzodiazepines while initiating antidepressant medication or CBT should be considered if symptoms are too disabling to wait for a response to the other treatments. Although many clinicians express concern about the potential for tolerance and abuse of benzodiazepines, there is little evidence of dose escalation for most patients with anxiety disorders. However, long-term use of benzodiazepines may cause sedation, coordination problems, amnesia, and emergent depression. Benzodiazepine users may also be at increased risk of road traffic accidents. Finally, approximately 25-50% of patients with anxiety disorders, including PD, are substance abusers and use of benzodiazepines with such patients is Medications
• Consider a medication evaluation if there has been: o a previous positive response to medications o an incomplete response to CBT • SSRIs and SNRIs are considered first line treatment since they are generally well tolerated, target co-morbid conditions (which are often present), and are easier to administer than other medications. 6 • Tricyclics, while also considered first-line agents, are often more difficult for patients to tolerate and have greater toxicity in overdose. • MAOIs, while effective in Panic Disorder, are no longer considered first line • Selection of an SSRI or SNRI antidepressant to which a Panic Disorder patient has had prior positive response is recommended. • Panic Disorder patients are often extremely sensitive to and fearful of somatic sensations. Therefore, starting doses of SSRIs/SNRIs may need to be lower than those used for depressed patients. Titration to therapeutic levels may also need to progress more slowly. • Patients should be screened for a history of mania before initiating treatment with an antidepressant. For those with a history of mania consideration should be given to using a mood stabilizer before initiating an antidepressant. A patient self-report screening instrument with good psychometric properties is • A positive response to antidepressant medication typically occurs within 6 weeks but additional time may be required to stabilize the response. • Benzodiazepines may be used when very rapid control of symptoms is critical, or for an acute anxiety reaction. They are not appropriate for first-line treatment because PD is a chronic condition needing appropriate long-term Panic Disorder Clinical Practice Guidelines May 11 management. Use of benzodiazepines in this manner may be problematic for the reasons noted above. • Discontinuation of benzodiazepines frequently results in significant withdrawal symptoms (which occur less frequently and are milder when medications are gradually tapered or when patients are on long half-life rather than short half-life benzodiazepines). Use of CBT may also facilitate successful medication • The duration of the maintenance phase has not yet been established for PD. Until there is additional evidence, medications should be continued for 6-12 months following symptom remission (and possibly longer if there is a history of symptom relapse after prior discontinuation). • Abrupt discontinuation of an SSRI Or SNRI frequently results in an uncomfortable withdrawal syndrome. Patients should be cautioned regarding Psychotherapy
• Consider including psychotherapy if there: o has been a previous positive response to psychotherapy o is an incomplete response to an adequate trial of medication o are excessive medical risks of medication o is evidence that coping skills are inadequate to manage psychosocial • Individual or group cognitive behavioral therapy (CBT) has been shown to be o Behavioral exposure and systematic desensitization are especially o A positive response to treatment usually occurs within 6 to 8 weeks. A typical course of treatment in research protocols is 12 weeks. o Recent research suggests that active patient involvement with between-session assignments can lead to effective outcomes in fewer sessions. • Panic-focused psychodynamic therapy (PFPP) has been shown to be effective in some studies, but at this time should only be considered if CBT has failed. Psychoeducational Components
• Panic Disorder has a chronic, fluctuating course. Therefore, strong consideration should be given to psychoeducational interventions early in treatment. • Patients and family members, when appropriate, should be educated about symptoms, course of illness and the possibility of residual anxiety during or after treatment terminates. • PD patients should be taught about the use of relaxation/meditation; cognitive restructuring; anxiety support groups; newsletters and online newsgroups, and about the possible beneficial effects of involvement in national anxiety associations. Panic Disorder Clinical Practice Guidelines May 11 • Education should also include the promotion of healthy behaviors, including exercise, good sleep hygiene and decreased use of substances such as Resources for Patients

Mind over mood: Change how you feel by changing the way you think by Dennis Greenberger & Christine Podesky. The Guilford Press, 1995 Mastery of Your Anxiety and Panic, Workbook. 4th Edition (Craske and Barlow, The Oxford Press, paperback, 2006) When Panic Attacks, by David Burns. Morgan Road Books, 2006. Support: • Anxiety Disorder Association of America (info, newsletter, conference for professionals and patient/consumer] Phone: 240-485-1001 • National Institute of Mental Health: Patient information phone number: (866) Resources for Clinicians

Review History:

Panic Disorder Clinical Practice Guidelines May 11 Initial Approval Medical Advisory Council Update Approved by MHN Clinical Policy Committee Update Approved by Medical Advisory Council Update Approved by MHN Clinical Policy Committee Update Approved by Medical Advisory Council Update Approved by MHN Clinical Policy Committee Update Approved by Medical Advisory Council Update Approved by MHN Clinical Leadership Committee Update Approved by Medical Advisory Council

1. American Psychiatric Association. (2009). Practice guideline for the treatment of patients with panic disorder, second edition. American Journal of Psychiatry, 2. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington D.C., American 3. American Psychiatric Association Psychiatric Evaluation of Adults, Second Edition 4. American Psychiatric Association. Assessment and Treatment of Patients with 5. Barlow, D.H., Gorman, J.M., Shear, M.K., & Woods, S.W. (2000). Cognitive- behavioral therapy, imipramine, or their combination for panic disorder. Journal of the American Medical Association, 283, 2529-2536. 6. Betelan N, de Graaf R, Van Balkom A, Vollebergh W and Beckman A: Threshholds for health and thresholds for illness: panic disorder versus subthreshold panic disorder. Psychol. Med 2007; 37:247-256. 7. Bradwejn J, Ahokas A, Stein DJ, SalinasE, Emilien G, Whitaker, T: Venlafaxine extended-release capsules in panic disorder: flexible –se, double-blinded, placebo-contolled sty. Br J Psychiatry 2005; 187:352-359. 8. Clark, D.M., Salkovskis, P.M., Hackmann, A., Wells, A., Ludgagte, J., & Gelder, M. (1999). Brief cognitive therapy for panic disorder: A randomized clinical trail. Journal of Consulting and Clinical Psychology, 67, 583-589. 9. Fava L, Morton J. Causal modeling of panic disorder theories. Clin Psychol Rev. 10. Furukawa TA, Watanabe N, Churchill R: Psychotherapy plus antidepressant for panic disorder with or withour agoraphobia: systemic reviews. Br J Psychiatry 2006; 188:305-312. 11. Gorman, J.M. (2001). A 28-year-old woman with panic disorder. Journal of the American Medical Association, 286, 450-457. 12. Greenberg, P.E., Sisitsky, T., Kessler, R.C., Finkelstein, S.N., Berndt, E.R., Davidson, J.R.T., Ballenger, J.C. & Fyer, A.J. (1999). The economic burden of anxiety disorders in the 1990s. Journal of Clinical Psychiatry, 60, 427-435. 13. Levitt, J.T., Hoffman, E.C., Grisham, J.R., & Barlow, D.H. (2001). Empirically supported treatments for panic disorder. Psychiatric Annals, 21, 478-487. 14. McIntosh, A., Cohen, A., Turnbull, N., Esmonde, L., Dennis, P., Eatock, J., Feetam, C., Hague, J., Hughes, I., Kelly, J., Kosky, N., Lear, G., Owens, L., Ratcliffe, J., Salkovskis, P. ( 2004). Clinical Guidelines for the management of anxiety. Management of anxiety (panic disorder, with or without agoraphobia, Panic Disorder Clinical Practice Guidelines May 11 and generalized anxiety disorder) in adults in primary, secondary, and community care. London (UK): National Institute for Clinical Excellence (NICE); 15. Milrod B, Leon AC, Busch F, Rudden M, Schwalberg M, Clarken J, Aronson A, Singer M, Turchin W, Klass ET, Graf E, Teres JJ, Shear MK: A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. Am J 16. Milrod B, Busch F, Cooper A, Shapiro T: Manual of Panic-Focused Psychoanalytic Psychotherapy. Washington, DC, American Psychiatric Press, 1997. 17. National Institutes of Health. (1994). Panic Disorder Treatment and Referral: Information for Health Care Professionals. NIH Publication No. 94-3642 18. Otto, M. (1996). Anxiety disorders: Cognitive behavior therapy, pharmacotherapy, or both? Guest transcript. Practical Reviews in Psychiatry, 20 19. Perugi, G., Frare, F., Toni, C. (2007). Diagnosis and treatment of agoraphobia 20. Pfaltz MC, Grossman P, Michael T, Margraf J, Wilhelm FH. Physical activity and respiratory behavior in daily life of patients with panic disorder and healthy controls. Int J Psychophysiol. 2010 Oct;78(1):42-9. 21. Pilecki B, Arentoft A, McKay D. An evidence-based causal model of panic disorder. 22. Pollack, M.H., Allgulander, C., Bandelow, B., Cassano, G.B., Greist, J.H., Hollander, E., Nutt, D.J., Okasha, A., & Swinson, R.P. (2003). WCA recommendations for the long-term treatment of panic disorder. CNS Spectrums, 23. Pollack, MH, Lepola U, Kpoponen H, Simon NM, Worthington JJ, Tzanis, E, Salinas E, Whitaker T, Gao B: A double-blind study of the efficacy of venlafaxine extended-release, paroxetine, and placebo in the treatment of panic disorder. Depress Anxiety 2007; 24:1-14. 24. Practice Guidelines Coalition. (1999). Panic Disorder. 25. Rayburn, N.R., & Otto, M.W. (2003). Cognitive-behavioral therapy for panic disorder: A review of treatment elements, strategies, and outcomes. CNS Spectrums, 8, 356-362. 26. Roy-Byrne, P.P., Stein, M., Bystritsky, A., Katon, W. (1998). Pharmacotherapy of panic disorder: Proposed guidelines for the family physician. Journal of the American Board of Family Practice, 11, 282-290. 27. Roy-Byrne, P.P., Stein, M.B., Russo, J., Mercier, E., Thomas, R., McQuaid, J., Katon, W.J., Craske, M.G., Bystritsky, A., & Sherbourne, C.D. (1999). Panic disorder in the primary care setting: Comorbidity, disability, service utilization, and treatment. Journal of Clinical Psychiatry, 60, 492-499. 28. Roy-Byrne, P.P., Wagner, A.W., Schraufnagel, T.J. (2005). Understanding and treating panic disorder in the primary care setting. Journal of Clinical Psychiatry, 29. Sanchez-Meca J, Rosa-Alcazar AI, Marin-Martinez f and Gomez-Conesa A (2010). Psychological treatment of panic disorder with or without agoraphobia: a meta-analysis. Clin Psycholg Rev, 2010 Feb; 30(1):37-50 30. Sanders.KM (2010). Mindfulness and Psychotherapy. Focus, 8;1: 19-24. 31. Shear MK, Rucci P, Williams J, Frank E, Gchocinski V, Vander BJ, Houck P, Wang T: Reliability and validity of the Panic Disorder Severity Scale: replication and extension. J Psychiatrric Res 2001; 35:293-296 32. Shear, M.K., Houck, P., Greeno, C., & Masters, S. (2001). Emotion-focused psychotherapy for patients with panic disorder. American Journal of Psychiatry, 158, 1993-1998. Panic Disorder Clinical Practice Guidelines May 11 33. Ströhle A, Stoy M, Graetz B, Scheel M, Wittmann A, Gallinat J, Lang UE, Dimeo F, Hellweg R. Acute exercise ameliorates reduced brain-derived neurotrophic factor in patients with panic disorder. Psychoneuroendocrinology. 2010 Apr;35(3):364-8. 34. Telch, M.J., Lucas, J.A., Schmidt, N.B., Hanna, H.H., LaNae, J.T., & Lucas, R.A. (1993). Group CBT of panic disorder. Behavioral Research and Therapy, 31, 279- 35. Wade, W.A., Treat, T.A., & Stuart, G.L. (1998). Transporting an empirically supported treatment for panic disorder to a service clinic setting: A benchmarking strategy. Journal of Consulting and Clinical Psychology, 66, 231-239. 36. Watanabe, N., Churchill, R., Furukawa, T., (2007). Combination of psychotherapy and benzodiazepines versus either therapy alone for panic disorder: a systematic review. BMC Psychiatry 7:18. 37. Watson HJ, Swan A, Nathan PR. Psychiatric diagnosis and quality of life: the additional burden of psychiatric comorbidity. Compr Psychiatry. 2011 May-Jun;52(3):265-72. Important Notice
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Panic Disorder Clinical Practice Guidelines May 11


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