1. Recurrent unexpected Panic Attacks
   
   

   Criteria for Panic Attack: A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

   1. palpitations, pounding heart, or accelerated heart rate
   2. sweating
   3. trembling or shaking
   4. sensations of shortness of breath or smothering
   5. feeling of choking
   6. chest pain or discomfort
   7. nausea or abdominal distress
   8. feeling dizzy, unsteady, lightheaded, or faint
   9. derealization (feelings of unreality) or depersonalization (being detached from oneself)
   10. fear of losing control or going crazy
   11. fear of dying
   12. paresthesias (numbness or tingling sensations)
   13. chills or hot flushes
   
    
2. At least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:
   
   
   1. persistent concern about having additional attacks
   2. worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")
   3. a significant change in behavior related to the attacks
   
    
3. The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).
   
   
4. The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).

1. Meets the criteria for Panic Disorder
   
   
2. The presence of Agoraphobia:
   
   
   1. Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed Panic Attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus, train, or automobile.
      
      Note: Consider the diagnosis of Specific Phobia if the avoidance is limited to one or only a few specific situations, or Social Phobia if the avoidance is limited to social situations.
      
      
   2. The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion.
      
      
   3. The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as Social Phobia (e.g., avoidance limited to social situations because of fear of embarrassment), Specific Phobia (e.g., avoidance limited to a single situation like elevators), Obsessive-Compulsive Disorder (e.g., avoidance of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., avoidance of leaving home or relatives).
   
    

1. Meets the criteria for Panic Disorder
   
   
2. Absence of Agoraphobia:
   
   

1. Medications
   
   
   • Selective Serotonin Reuptake Inhibitors (SSRIs) are the drugs of choice (currently only Paxil is FDA approved for this indication).
     
     Recommended dosage ranges: Paxil (paroxetine) 10 to 50 mg/day, Luvox (fluvoxamine) 25 to 300 mg/day, and Prozac (fluoxetine) 5 to 60 mg/day. Start at lowest dose and may increase after first week as tolerated (such as Prozac 10 mg PO QOD for week 1, 10 mg QD for week 2, and then 20 mg QD for week 3). Monitor for initial paradoxical anxiety secondary to drug side effect, which usually resolves with time.
     
     
   • Tricyclic Antidepressants (TCAs). For example, start Imipramine at 10 to 25 mg QHS and increase by 10 to 25 mg every 3 or 4 days until effective, side effects predominate, or initial target dose of 150 to 200 mg QHS is reached. If no response after 4 to 6 weeks at target dose, may increase to maximum dose of 300 to 400 mg QHS as tolerated. Clinical experience has shown that serotonergic TCAs are more effective than noradrenergic TCAs.
     
     
   • Benzodiazepines have a quicker onset of action than other drugs; may use as a short-term adjunct to SSRIs if initial paradoxical anxiety arises. They may be used long term if patients fail treatment or are unable to tolerate SSRIs or TCAs.
     
     
   • Monamine Oxidase Inhibitors (MAOIs) are reserved for patients who do not respond to SSRIs or TCAs because of serious adverse drug reactions. Before starting, consider consulting a psychiatrist.
     
     
   • Propanolol (Inderal) is not a first-line agent for panic disorder but is very effective for physical symptoms of panic attacks associated with performance anxiety.
     
     
   • Buspirone (Buspar) has demonstrated little efficacy in patients with panic disorders.
   
    
2. Psychotherapy. Supportive therapy is always included. Addition of cognitive therapy may be beneficial.

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