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Clinical Practice Guidelines: Panic Disorder Treatment

To learn about Panic Disorder Treatment, click on the topics on the left-hand side of the page below. For Panic Disorder Diagnosis information, view the Panic Disorder Diagnosis page.

  • If there is a high risk of danger to self or others or grave disability, consider inpatient hospitalization.
  • Unstable patients may respond to structured, multi-disciplinary treatment (IOP, Day Treatment) that emphasizes skills training, family involvement, psychoeducation and psychiatric management.1
  • Outpatient treatment is used almost exclusively.

  • SSRIs, SNRIs, tricyclic antidepressants, benzodiazepines (only appropriate as monotherapy in the absence of a comorbid mood disorder) and/or cognitive-behavioral psychotherapy (CBT) have been shown generally to be equally effective in the acute phase (first 12 weeks) of treatment
  • Recent research with Panic Disorder patients suggests that medication may produce the quickest initial response (although by 12 weeks CBT is equally effective); combined treatment may be better than either medication or CBT alone; and response to CBT may be more durable than the response to medication.
  • Short term use (3 to 4 weeks) of benzodiazepines while initiating antidepressant medication or CBT should be considered if symptoms are too disabling to wait for a response to the other treatments. Although many clinicians express concern about the potential for tolerance and abuse of benzodiazepines, there is little evidence of dose escalation for most patients with anxiety disorders. However, long-term use of benzodiazepines may cause sedation, coordination problems, amnesia, and emergent depression. Benzodiazepine users may also be at increased risk of road traffic accidents. Finally, approximately 25-50% of patients with anxiety disorders, including PD, are substance abusers and use of benzodiazepines with such patients is problematic.

  • Consider a medication evaluation if there has been:
    • a previous positive response to medications
    • an incomplete response to CBT
  • SSRIs and SNRIs are considered first line treatment since they are generally well tolerated, target co-morbid conditions (which are often present), and are easier to administer than other medications.2
  • Tricyclics, while also considered first-line agents, are often more difficult for patients to tolerate and have greater toxicity in overdose.
  • MAOIs, while effective in Panic Disorder, are no longer considered first line due to poor safety and tolerability.
  • Selection of an SSRI or SNRI antidepressant to which a Panic Disorder patient has had prior positive response is recommended.
  • Panic Disorder patients are often extremely sensitive to and fearful of somatic sensations. Therefore, starting doses of SSRIs/SNRIs may need to be lower than those used for depressed patients. Titration to therapeutic levels may also need to progress more slowly.
  • A positive response to antidepressant medication typically occurs within 6 weeks but additional time may be required to stabilize the response.
  • Benzodiazepines may be used when very rapid control of symptoms is critical, or for an acute anxiety reaction. They are not appropriate for first-line treatment because PD is a chronic condition needing appropriate long-term management. Use of benzodiazepines in this manner may be problematic for the reasons noted above.
  • Discontinuation of benzodiazepines frequently results in significant withdrawal symptoms (which occur less frequently and are milder when medications are gradually tapered or when patients are on long half-life rather than short half-life benzodiazepines). Use of CBT may also facilitate successful medication discontinuation and prevent relapse.
  • The duration of the maintenance phase has not yet been established for PD. Until there is additional evidence, medications should be continued for 6-12 months following symptom remission (and possibly longer if there is a history of symptom relapse after prior discontinuation).
  • Abrupt discontinuation of an SSRI or SNRI frequently results in an uncomfortable withdrawal syndrome. Patients should be cautioned regarding this.

  • Consider including psychotherapy if there:
    • has been a previous positive response to psychotherapy
    • is an incomplete response to an adequate trial of medication
    • are excessive medical risks of medication
    • is evidence that coping skills are inadequate to manage psychosocial stressors

  • Individual or group cognitive behavioral therapy has been shown to be effective:
    • Behavioral exposure and systematic desensitization are especially effective for agoraphobia.
    • A positive response to treatment usually occurs within 6 to 8 weeks. A typical course of treatment in research protocols is 12 weeks.
    • Recent research suggests that active patient involvement with between-session assignments can lead to effective outcomes in fewer sessions.
    • Panic-focused psychodynamic therapy (PFPP) has been shown to be effective in some studies, but at this time should only be considered if CBT has failed.

  • Panic Disorder has a chronic, fluctuating course. Therefore, strong consideration should be given to psychoeducational interventions early in treatment.
  • Patients and family members, when appropriate, should be educated about symptoms, course of illness and the possibility of residual anxiety during or after treatment terminates.
  • PD patients should be taught about the use of relaxation/meditation; cognitive restructuring; anxiety support groups; newsletters and online newsgroups; and about the possible beneficial effects of involvement in national anxiety associations.
  • Education should also include the promotion of healthy behaviors, including exercise, good sleep hygiene and decreased use of substances such as caffeine, tobacco and alcohol.

  • 85% of PD patients first present in a general medical setting, such as their primary care physician's office or hospital emergency room, but are often undiagnosed. Patients with Panic Disorders seek medical services more frequently than patients with other psychiatric disorders. Coordination of care with other medical providers is essential to reduce unnecessary or duplicative procedures or medications.3
  • Panic Disorder often has a direct impact on disability, resulting in increased absenteeism, decreased productivity and reduced ability to carry out daily activities. Monitoring improvements in functioning, as well as in symptoms, should be part of evaluating treatment effectiveness.
  • Treatment compliance should be addressed directly. Panic Disorder patients tend to stop treatment when they become anxious about somatic sensations from medications or confronting fearful internal or external cues during CBT.
  • Different symptoms of Panic Disorder often resolve at different times. Full panic attacks may be controlled, but "subthreshold" panic attacks may continue. Anticipatory anxiety (ie, worry about future attacks) tends to decrease after panic attacks are controlled. Agoraphobia (ie, phobic avoidance), if present, is often the last to be positively impacted by treatment.

Patient Handouts

Patient Websites

Patient Self Test


  • Mind over mood: Change How You Feel by Changing the Way You Think, by Dennis Greenberger & Christine Podesky. The Guilford Press, 1995.
  • Mastery of Your Anxiety and Panic, Fourth Edition. [workbook]. Craske & Barlow, 2006.
  • When Panic Attacks, by David Burns. Morgan Road Books, 2006.


  • Anxiety Disorder Association of America (info, newsletter, conference for professionals and patient/consumers). Phone: 240-485-1001.
  • National Institute of Mental Health: Patient information phone number: 800-647-2642.

American Psychiatric Association. (2009). Practice Guideline for the Treatment of Patients with Panic Disorder, Second Edition. American Journal of Psychiatry, Supplement.

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, text revision. Washington D.C., American Psychiatric Association Press.

American Psychiatric Association Psychiatric Evaluation of Adults, Second Edition (2006)

American Psychiatric Association. Assessment and Treatment of Patients with Suicidal Behaviors (2003)

Barlow, D.H., Gorman, J.M., Shear, M.K., & Woods, S.W. (2000). Cognitive-behavioral therapy, imipramine, or their combination for panic disorder. Journal of the American Medical Association, 283, 2529-2536.

Betelan N, de Graaf R, Van Balkom A, Vollebergh W and Beckman A: Threshholds for Health and Thresholds for Illness: Panic Disorder Versus Subthreshold Panic Disorder. Psychol. Med 2007; 37:247-256.

Bradwejn J, Ahokas A, Stein DJ, SalinasE, Emilien G, Whitaker, T: Venlafaxine Extended-Release Capsules in Panic Disorder: Flexible-Dose, Double-Blinded, Placebo-Contolled Sty. Br J Psychiatry 2005; 187:352-359.

Clark, D.M., Salkovskis, P.M., Hackmann, A., Wells, A., Ludgagte, J., & Gelder, M. (1999). Brief cognitive therapy for panic disorder: A randomized clinical trail. Journal of Consulting and Clinical Psychology, 67, 583-589.

Furukawa TA, Watanabe N, Churchill R: Psychotherapy Plus Antidepressant for Panic Disorder With or Without Agoraphobia: Systemic Reviews. Br J Psychiatry 2006; 188:305-312.

Gorman, J.M. (2001). A 28-year-old woman with panic disorder. Journal of the American Medical Association, 286, 450-457.

Greenberg, P.E., Sisitsky, T., Kessler, R.C., Finkelstein, S.N., Berndt, E.R., Davidson, J.R.T., Ballenger, J.C. & Fyer, A.J. (1999). The economic burden of anxiety disorders in the 1990s. Journal of Clinical Psychiatry, 60, 427-435.

Levitt, J.T., Hoffman, E.C., Grisham, J.R., & Barlow, D.H. (2001). Empirically supported treatments for panic disorder. Psychiatric Annals, 21, 478-487.

McIntosh, A., Cohen, A., Turnbull, N., Esmonde, L., Dennis, P., Eatock, J., Feetam, C., Hague, J., Hughes, I., Kelly, J., Kosky, N., Lear, G., Owens, L., Ratcliffe, J., Salkovskis, P. (2004). Clinical Guidelines for the management of anxiety. Management of anxiety (panic disorder, with or without agoraphobia, and generalized anxiety disorder) in adults in primary, secondary, and community care. London (UK): National Institute for Clinical Excellence (NICE); 165p.

Milrod B, Busch F, Cooper A, Shapiro T: Manual of Panic-Focused Psychoanalytic Psychotherapy. Washington, DC, American Psychiatric Press, 1997.

National Institutes of Health. (1994). Panic Disorder Treatment and Referral: Information for Health Care Professionals. NIH Publication No. 94-3642.

Otto, M. (1996). Anxiety disorders: Cognitive Behavior Therapy, Pharmacotherapy, or Both? Guest Transcript. Practical Reviews in Psychiatry, 20 (7).

Perugi, G., Frare, F., Toni, C. (2007). Diagnosis and Treatment of Agoraphobia with Panic Disorder. CNS Drugs, 21:9.

Pollack, M.H., Allgulander, C., Bandelow, B., Cassano, G.B., Greist, J.H., Hollander, E., Nutt, D.J., Okasha, A., & Swinson, R.P. (2003). WCA Recommendations for the Long-Term Treatment of Panic Disorder. CNS Spectrums, 8 (Suppl 1), 17-30.

Pollack, MH, Lepola U, Kpoponen H, Simon NM, Worthington JJ, Tzanis, E, Salinas E, Whitaker T, Gao B: A Double-Blind Study of the Efficacy of Venlafaxine Extended-Release, Paroxetine, and Placebo in the Treatment of Panic Disorder. Depression and Anxiety 2007; 24:1-14.

Practice Guidelines Coalition. (1999). Panic Disorder.

Rayburn, N.R., & Otto, M.W. (2003). Cognitive-behavioral therapy for panic disorder: A review of treatment elements, strategies, and outcomes. CNS Spectrums, 8, 356-362.

Roy-Byrne, P.P., Stein, M., Bystritsky, A., Katon, W. (1998). Pharmacotherapy of panic disorder: Proposed Guidelines for the Family Physician. Journal of the American Board of Family Practice, 11, 282-290.

Roy-Byrne, P.P., Stein, M.B., Russo, J., Mercier, E., Thomas, R., McQuaid, J., Katon, W.J., Craske, M.G., Bystritsky, A., & Sherbourne, C.D. (1999). Panic Disorder in the Primary care Setting: Comorbidity, Disability, Service Utilization, and Treatment. Journal of Clinical Psychiatry, 60, 492-499.

Roy-Byrne, P.P., Wagner, A.W., Schraufnagel, T.J. (2005). Understanding and treating panic disorder in the primary care setting. Journal of Clinical Psychiatry, 66, suppl 4.

Shear MK, Rucci P, Williams J, Frank E, Gchocinski V, Vander BJ, Houck P, Wang T: Reliability and Validity of the Panic Disorder Severity Scale: Replication and Extension. J Psychiatrric Res 2001; 35:293-296.

Shear, M.K., Houck, P., Greeno, C., & Masters, S. (2001). Emotion-Focused Psychotherapy for Patients with Panic Disorder. American Journal of Psychiatry, 158, 1993-1998.

Telch, M.J., Lucas, J.A., Schmidt, N.B., Hanna, H.H., LaNae, J.T., & Lucas, R.A. (1993). Group CBT of panic disorder. Behavioral Research and Therapy, 31, 279-287.

Wade, W.A., Treat, T.A., & Stuart, G.L. (1998). Transporting an Empirically Supported Treatment for Panic Disorder to a Service Clinic Setting: A Benchmarking Strategy. Journal of Consulting and Clinical Psychology, 66, 231-239.

Watanabe, N., Churchill, R., Furukawa, T., (2007). Combination of Psychotherapy and Benzodiazepines Versus Either Therapy Alone for Panic Disorder: A Systematic Review. BMC Psychiatry 7:18.


1MHN care managers offer assistance finding such programs.

2Patients should be screened for a history of mania before initiating treatment with an antidepressant. For those with a history of mania consideration should be given to using a mood stabilizer before initiating an antidepressant. A patient self-report screening instrument with good psychometric properties is the Mood Disorder Questionnaire (73K PDF).

3Consider using the MHN Behavioral Health Coordination Form.

Level of care

General factors to consider:



Psychoeducational components

Other considerations


Resources for patients

Resources for clinicians


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