A 28-year-old man comes to the office due to occasional anxiety attacks over the past 6 months. The patient describes episodes that "come out of nowhere" in which he feels light-headed, sweaty, shaky, and nauseated. He says, "At first I didn't really care because the attacks don't last long, but now I'm worried I'll have one while I'm at work or when I'm driving." The patient has no history of cardiac disease and takes no medications. He has 4 or 5 alcoholic drinks 3 times a week and adds, "Having some beers and watching football really help take my mind off of things." The patient appears calm, and vital signs are within normal limits. Physical examination, ECG, comprehensive metabolic panel, and thyroid function tests show no abnormalities. Which of the following is the most appropriate pharmacotherapy for this patient?
Panic disorder | |
Clinical |
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Treatment |
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SNRI = serotonin-norepinephrine reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor. | |
This patient's recurrent, unexpected anxiety attacks and physical symptoms of dizziness, sweating, shaking, and nausea without an identifiable medical cause are consistent with panic disorder. Affected patients usually worry about having future attacks, as in this case, and frequently develop avoidance behaviors and agoraphobia.
Treatment options for panic disorder include antidepressants and/or cognitive-behavioral therapy. Among the antidepressants, selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors are the preferred first-line therapy because of their relatively benign adverse effect profile compared with that of monoamine oxidase inhibitors and tricyclic antidepressants (Choices C and F).
Benzodiazepines are also effective in panic disorder and have a more rapid onset of action. However, because of the risks for abuse and addiction, they are typically reserved for short-term use in acutely symptomatic and functionally impaired patients who require rapid relief. They should be avoided in patients with a history of or high risk for substance misuse, such as this patient (Choice A).
(Choice B) Although this patient has prominent physical symptoms, beta blockers as monotherapy are not effective in panic disorder. They can be used to treat the physiologic manifestations of performance anxiety.
(Choice D) There is no evidence to support the use of antipsychotics as monotherapy for panic disorder.
Educational objective:
Selective serotonin reuptake inhibitors are first-line pharmacotherapy for panic disorder. Benzodiazepines are reserved for patients who require immediate relief but should be avoided in those with substance misuse.