Panic Disorder: The Daily PANCE Blueprint
A 27-year-old woman has had six episodes over the past four months of abrupt chest tightness, pounding heart, shortness of breath, sweating, trembling, and a feeling that she is about to die. Each peaks within ten minutes and resolves in under an hour. She now avoids driving on the freeway for fear of another episode and worries constantly about the next one. Two emergency department visits produced normal ECGs, troponins, and thyroid studies. She uses no stimulants and drinks minimal caffeine. Which of the following is the most appropriate long-term treatment?
A. Scheduled alprazolam
B. Propranolol as needed
C. Quetiapine nightly
D. An SSRI plus cognitive behavioral therapy
E. Reassurance alone
Answer and topic summary
The answer is D. An SSRI plus cognitive behavioral therapy
Recurrent unexpected panic attacks that peak within minutes, plus a month or more of persistent worry about further attacks and behavioral change to avoid them, is panic disorder — and the avoidance of freeway driving marks emerging agoraphobia. The negative cardiac and thyroid workup is doing important work: panic disorder is a diagnosis made after excluding mimics such as arrhythmia, hyperthyroidism, pheochromocytoma, and stimulant use. Long-term treatment is an SSRI combined with cognitive behavioral therapy, the pairing with the best durable outcomes; SSRIs should be started low and titrated slowly, since an ordinary starting dose can transiently worsen anxiety. The trap is scheduled benzodiazepines: alprazolam works within minutes and is tempting, but standing use invites tolerance, dependence, rebound anxiety, and interference with the exposure work that makes CBT effective — it belongs, if at all, as a short bridge while the SSRI takes hold. Propranolol helps performance anxiety rather than panic disorder, an antipsychotic is inappropriate here, and reassurance alone ignores a genuinely disabling and highly treatable illness.
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