The American Psychiatric Association Practice Guideline for the Treatment of Patients With Panic Disorder: Recommendations and Controversies

Fredric N. Busch, MD and Barbara L. Milrod, MD

Disclosures
In This Article

Discussion of Specific Treatments: General Recommendations

Reassurance, education, and support are important components of psychiatric management, given that patients commonly fear their symptoms represent catastrophic medical events and may experience extensive agoraphobic avoidance. The clinician should help the patient to cope with the effects of panic and to deal with the possibility that it may be chronic and require long-term treatment. It is important to assess for any medical sources of panic and psychiatric comorbidity and to determine the types and severity of functional impairment. Comorbid conditions, if severe, may take precedence over treatment of panic. If comorbid depression is severe, hospitalization should be considered. Panic patients have a higher than average rate of suicide attempts, and in patients with major depression, comorbid panic is associated with an increased suicide rate. It is important for the therapist to be available in the early phase of treatment. The guideline emphasizes the importance of establishing a strong therapeutic alliance and an awareness of transference and countertransference issues to aid the patient in overcoming their anxiety about the recommended treatment interventions and dealing with feared situations. It is helpful for patients to monitor their panic attacks, such as by keeping a daily diary. The patient should be informed that different elements of panic may resolve at different points. For example, panic attacks may end more rapidly, but sub-threshold panic, anticipatory anxiety, or comorbid disorders can persist. Educating the patient and the family may be of value, and it is occasionally necessary to intervene with frustrated internists to assure appropriate level of medical care. As anxiety may lead to noncompliance, it is supportive to help the patient confront and articulate fears. It may be necessary for the clinician to work with patients when their fears of somatic sensations are triggered by the medication.

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