Tx Panic Disorder

Front 1

What is goal of therapy in panic disorder?

Back 1

remission, free of panic attacks, no or minimal anticipatory anxiety and agoraphobic avoidance, no functional impairment

Front 2

If panic disorder without agoraphobic avoidance, what is tx?

Back 2

pharmacotherapy alone

Front 3

If agoraphobia is present, what is tx?

Back 3

CBT with pharmacotherapy

Front 4

What nonpharm for panic disorder?

Back 4

avoid substances that precipitate panic attacks (caffeine, drugs of abuse, non prescription stimulants)
CBT, bibliotherapy (self help books), exercise, internet based CBT

Front 5

How long is CBT for panic disorder?

Back 5

16-20 hours over 4 months

Front 6

What drugs are used in panic disorder?

Back 6

SSRIs, SNRI venlafaxine XR, TCA imipramine, BDZ alprazolam and clonazepam

Front 7

What drugs are approved for panic disorder?

Back 7

alprazolam, clonazepam, sertraline, paroxetine, fluoxetine, and venlafaxine

Front 8

What are first line for panic disorder?

Back 8

SSRIs

Front 9

What are used most commonly for panic disorder?

Back 9

BDZ

Front 10

figure 73-2 pg 1171
table 73-11

Back 10

figure 73-2 1171

Front 11

What alternative tx for panic disorder?

Back 11

none, buspirone, trazodone, bupropion, antipsychotics, antihistamines, and BB are ineffective

Front 12

What is preferred for management of panic disorder in elderly and youth?

Back 12

SSRIs, BDZ second line

Front 13

How long for imipramine (TCA) to block panic attacks?

Back 13

at least 4 weeks, max improvement in 8-12 weeks

Front 14

What AE from TCAs?

Back 14

stimulant like SE (anxiety, insomnia, jitteriness), anticholinergic AE, othostatic hypotension, delayed onset antipanic effects, toxicity, wt gain

Front 15

How is imipramine dose titrated?

Back 15

10mg every 2-4 days as tolerated

Front 16

Which SSRIs are effective in panic disorder?

Back 16

all of them

Front 17

How long for antipanic effect from SSRI?

Back 17

4 weeks, 8-12 weeks for max effect

Front 18

What AE from SSRIs?

Back 18

insomnia, jitteriness, restlessness, and agitation
transient GI disturbances
sleep disturbances, HA, sexual dysfunction

Front 19

How are SSRIs dosed?

Back 19

low initial dose for week, may need dose at upper end of dosing range to achieve response

Front 20

What AE from venlafaxine XR?

Back 20

nausea, somnolence, tremors, sweating, abnormal sexual functioning (ejaculation difficulties and anorgasmia)

Front 21

How is dose of venlafaxine XR increased?

Back 21

weekly

Front 22

What BDZ are the preferred agents for panic disorder?

Back 22

clonazepam and alprazolam
diazepam and lorazepam also possibly effective

Front 23

What is ideal agent in panic disorder if need rapid relief?

Back 23

alprazolam

Front 24

How long for therapeutic response to BDZ in panic disorder?

Back 24

1-2 weeks

Front 25

What is drawback of using BDZ for panic disorder?

Back 25

high relapse rate (50%)

Front 26

What AE for BDZ in panic disorder?

Back 26

sedation only one

Front 27

How is clonazepam dose titrated?

Back 27

0.25-0.5mg every 3 days to 4mg/day

Front 28

How is alprazolam dose titrated?

Back 28

slowly over several weeks, most need 3-6mg/day

Front 29

Why is extender release alprazolam and clonazepam preferred over immediate release alprazolam for panic disorder?

Back 29

immediate release duration is 4-6 hrs and may result in breakthrough symptoms

Front 30

What are reasons for tx failure in panic disorder?

Back 30

comorbid psychiatric disorder, rapid dosage increase with intolerable SE, underdosage

Front 31

What should be done if pt has partial response in panic disorder?

Back 31

augment with another antipanic agent

Front 32

What are the phases of therapy in panic disorder?

Back 32

acute phase, maintenance phase, and discontinuation

Front 33

What is the main goal in the acute phase of panic disorder?

Back 33

reduction of symptoms

Front 34

What is duration of acute phase?

Back 34

1-3 months depending on therapy
12 weeks for antidepressant, 1 month for BDZ

Front 35

When should antidepressant therapy be adjusted in panic disorder?

Back 35

6-8 weeks

Front 36

How long is maintanance phase and discontinuation?

Back 36

unknown, duration usually 12-24 months, then drug d/c over 4-6 months

Front 37

What dose is used in maintenance phase?

Back 37

same as acute

Front 38

What drugs have shown to maintain clinical effects with up to 1 year of tx?

Back 38

citalopram, clomipramine, fluoxetine, sertraline, imipramine

Front 39

How did rate of relapse change for pts taking imipramine for 6 months vs 12-30 months?

Back 39

it didnt

Front 40

What is the most important determinant of compliance with maintenance therapy?

Back 40

tolerability of AE

Front 41

Which SSRI doesnt have discontinuation symptoms?

Back 41

fluoxetine

Front 42

How often should pt on panic disorder therapy return to clinic?

Back 42

every 2 weeks first couple weeks to make dosage adjustments, then every 2 months

Front 43

What should panic disorder pt be counseled to do?

Back 43

maintain a diary to record the date, time, frequency, and duration of panic episodes and the severity of symptoms

Front 44

How can tx outcomes of panic disorder be assessed?

Back 44

Hamilton Rating Scale for Anxiety (goal 7-10) , Sheehan Disability Scale (goal less than or equal to 1 on each item)