## Pharmacological Management of Panic Disorder ### First-Line Agents **Key Point:** SSRIs and SNRIs are the gold-standard first-line pharmacological treatments for panic disorder, with or without agoraphobia. They address both the panic attacks and anticipatory anxiety. | Agent Class | Examples | Evidence | Duration | | --- | --- | --- | --- | | SSRIs | Sertraline, Paroxetine, Fluoxetine | Extensive RCT support | 4–6 weeks for effect | | SNRIs | Venlafaxine (XR), Duloxetine | Strong evidence | 2–4 weeks for effect | | Benzodiazepines | Alprazolam, Clonazepam | Rapid onset but NOT first-line | Immediate | ### Why Benzodiazepines Are NOT First-Line 1. **Dependence and Tolerance:** Alprazolam carries high risk of physical dependence and tolerance with chronic use. 2. **Cognitive and Psychomotor Impairment:** Causes sedation, memory impairment, and reduced alertness. 3. **Withdrawal Syndrome:** Abrupt discontinuation can precipitate severe rebound anxiety and seizures. 4. **Role in Current Practice:** Benzodiazepines are reserved for **acute symptom relief** during the initial weeks while waiting for SSRI/SNRI onset, or for breakthrough anxiety. They are NOT recommended as monotherapy for panic disorder. **High-Yield:** The DSM-5 and most international guidelines (APA, NICE, RANZCP) recommend SSRIs/SNRIs as first-line, with benzodiazepines as adjunctive short-term agents only. ### Clinical Pearl In this patient, sertraline or paroxetine would be initiated at standard doses (sertraline 50 mg daily, paroxetine 20 mg daily), with titration over 4–6 weeks. A short course of alprazolam (e.g., 0.5–1 mg TID for 2–4 weeks) may be added for rapid anxiety relief, then tapered as the SSRI takes effect. **Warning:** Do NOT prescribe benzodiazepines as monotherapy for panic disorder—this is a common trap in exam questions and poor clinical practice.
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