At a glance

  • In one survey, primary-care clinicians identified anxiety without concurrent depression only 20% of the time.
  • Patient education should encourage healthy behavior, including limitations on alcohol, caffeine, and tobacco.
  • When choosing a first treatment, keep the potential for drug-drug interactions in mind.
  • Patients are often fearful of bodily sensations caused by medication and of exposure to situations they customarily avoid, as demanded by cognitive behavioral therapy. 

Panic disorder frequently comes up in the primary-care setting. Such physical symptoms as chest pain and dyspnea are usually prominent and may be more distressing than anxiety per se. Four percent of primary-care patients are believed to suffer from this disorder (three times the prevalence in the general population), and nearly half of all panic patients are treated by primary-care practitioners (PCPs).

The American Psychiatric Association’s (APA) revised Practice Guideline for the Treatment of Patients With Panic Disorder is not dramatically different from its 1997 predecessor, but it does include more data to support recommended treatments, says Peter Roy-Byrne, MD, professor and vice chair in the department of psychiatry and behavioral sciences, University of Washington School of Medicine, Seattle, and a member of the work group that produced the document.

Substantive changes include an addition to the recommendations for psychotherapy, and several medications that have been released since the earlier publication.

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Making the diagnosis

To be treated effectively, panic must be diagnosed—a task that has proven difficult for many PCPs. In one survey, PCPs identified anxiety without concurrent depression only 20% of the time.

The APA guideline offers the standard criteria for diagnosis, as published in the APA’s Diagnostic and Statistical Manual, 4th Edition, Text Revision. Dr. Roy-Byrne suggests a single broad question to identify patients who need closer evaluation: “Have you ever had sudden onset of either anxiety or palpitations, breathlessness, dizziness, or unexplained physical symptoms that made you very frightened, made you stop what you were doing, or interrupted your day?” The subjective experience of anxiety isn’t necessary, Dr. Roy-Byrne points out. Nor is agoraphobia.

Behavior change is a hallmark of panic, explains Dr. Roy-Byrne. “When a patient comes back several times for more tests and evaluations and continues to be apprehensive, that’s also a clue.”

Patient education

The APA guideline stresses the importance of providing accurate information about the patient’s disorder. Education can “relieve some of the symptoms of panic disorder by helping the patient realize that his or her symptoms are neither life-threatening nor uncommon,” and enhance motivation for treatment, the authors say.

Including the family in the educational effort is often appropriate. Family members may share the patient’s belief that his or her symptoms signify heart or lung disease or, conversely, need to be convinced that the condition is a real, potentially disabling illness requiring treatment and support.

Patient education should encourage generally healthy behaviors, including limitations on alcohol, caffeine, and tobacco. There is some limited evidence that aerobic exercise ameliorates panic disorder. However, because some patients may fear exertion, which could trigger a panic attack, exercise might be introduced gradually as symptoms lessen, the authors say.