treatment resistant panic disorder

however, a third go on to have chronic, persistent symptoms-and the majority of these patients have treatment-resistant panic (trp).1 treatment resistance in pd may be apparent or real. after factors that contribute to apparent resistance have been addressed, the next consideration is a review of the treatment history to ascertain which evidence-based interventions the patient has already received, and to ensure that these have been applied for an adequate period (eg, 8 to 12 weeks) and at an appropriate dose/intensity level. adverse effects such as sedation and incoordination are most apparent in the initial weeks of therapy, and this is when the risks for operating heavy machinery and driving are elevated. accordingly, coadministration of a benzodiazepine is a reasonable first-choice augmentation option and is safe for longer-term treatment.10 if this is not effective or tolerated, coadministration with an atypical antidepressant, such as mirtazapine, is a reasonable second step. in general, the goal of clinical treatment of pd is to achieve a remission state (pdss total score of 4 or lower).

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panic disorder (pd) is a severe and potentially disabling anxiety disorder that affects 3.5%–5% of individuals in the united states during their lives (1, 2). available treatment options, including the pros and cons of each should be reviewed, noting that more than one treatment or treatment modality may be required to find the best “fit” for that individual. the panic disorder severity scale (pdss) (12) is a clinically useful, validated rating scale for assessment of the status of patients with pd (13). fluoxetine, sertraline, paroxetine, and venlafaxine are considered to be equivalent in efficacy for the treatment of pd and have received u.s. food and drug administration (fda) approval. the use of sodium valproate (vpa) is limited to open studies (38) and has been reported to be helpful for patients with comorbid bipolar disorder and pd (39) and those with the additional complication of alcohol abuse (40, 41). advising the patient that this reaction is not dangerous and may even suggest that the diagnosis of panic disorder is correct may help shift the perception of this side effect to a more positive experience. there is wide variation in the dosage required for successful treatment of pd, especially for patients with considerable comorbidity. antidepressant intolerance is sometimes overlooked by the clinician, and should be considered in the differential diagnosis as a potential cause of persistent anxiety. the risk of treatment must be considered in the context of the severity of illness and functional impairment of the individual patient.

one such strategy is to increase the frequency of patient visits, which may strengthen the doctor-patient relationship, provide more confidence in the clinician and promote a sense of caring for and dedication to the progress of the patient. when treatment is switched from one ssri or snri antidepressant to another, it is common practice to add the second agent and increase the dose with gradual up-titration to a moderate dose treatment and then gradual down-titration of the initial agent. a systematic, differential diagnostic approach to the evaluation and optimal treatment of pd has been presented. am j psychiatry 2005; 162:1179–1187crossref, google scholar 8. practice guidelines for the treatment of persons with disorder, 2nd ed. j clin psychopharmacol 1993; 13:16–24google scholar 35. otto mw, bruce se, deckersbach t: benzodiazepine use, cognitive impairment, and cognitive-behavioral therapy for anxiety disorders: issues in the treatment of a patient in need. j clin psychopharmacol 2000; 20:467–471crossref, google scholar 39. baetz m, bowen r: efficacy of divalproex sodium in patients with panic disorder and mood instability who have not responded to conventional therapy. arch gen psychiatry 1989; 46:127–131crossref, google scholar 57. mavissakalian mr, perel jm: imipramine treatment of panic disorder with agoraphobia: dose ranging and plasma level-response relationships. j clin psychopharmacol 2002; 22:584–591crossref, google scholar 75. menaster m: efficacy of quetiapine in panic disorder with agoraphobia and obsessive-compulsive disorder in a patient with bipolar disorder. arch gen psychiatry 2001; 58:681–686crossref, google scholar 90. pollack mh, simon nm, worthington jj, doyle al, peters p, toshkov f, otto mw: combined paroxetine and clonazepam treatment strategies compared to paroxetine monotherapy for panic disorder.

there are four classes of pharmacological treatment with comparable efficacy for pd: selective serotonin reuptake inhibitors (ssris), selective norepinephrine- effective psychotherapies for pd include cbt (strongest evidence), panic-focused psychodynamic psychotherapy, and cbt with a mindfulness sertraline, paroxetine, fluoxetine, fluvoxamine, citalopram, and escitalopram have been empirically shown to be effective for pd (17), as has, off label panic disorder medication, off label panic disorder medication, treatment-resistant panic disorder: clinical significance concept and management, new treatment for panic disorder, panic disorder treatment.

positive preliminary evidences suggest that new compounds such as snri duloxetine, nri reboxetine, nassa mirtazapine, sari nefazodone, atypical antipsychotic- medication and cognitive-behavioral therapy may reduce fear circuit reactivity and prevent panic attacks by acting at different components of the fear circuit. treatment resistance of panic disorder should be defined as the failure to achieve remission criteria mentioned in the above (options 1 and 2), long-term treatment of panic disorder, treatment-resistant panic disorder: a systematic review.

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