Table 2.

Differential diagnosis for treatment-resistant panic disorder

PROBLEM REVIEW	DIFFERENTIAL DIAGNOSIS	COMMENT
Persistent panic attacks	Inadequate treatment Dose Duration Situational attacks Medical condition Other psychiatric disorder causing attacks Medication-related	djust dose (plasma levels may help) witch or add agent to existing At least 8 weeks CBT/exposure Address specific conditions ("Table 3) Rule out social phobia, OCD, PTSD
Persistent anticipatory/generalized anxiety	Activation Akathisia Substance-related Interdose rebound from short-acting BZ BZ or alcohol withdrawal Residual anxiety	Adjust dose, add BZ or beta blocker Adjust dose, add beta blocker, BZ Switch to longer-acting agent Assess and treat as indicated Add/increase BZ, add buspirone
Residual phobia	Other etiology Residual agoraphobia	Review for other phobic disorders, depression CBT/exposure, adjust medication treatment
Other disorders	Mood disorder Anxiety disorder Social phobia OCD PTSD Alcohol use disorder Personality disorders Medical disorder	Antidepressant treatment plus anxiolytic; valproate for bipolar disorder SSRIs, MAOIs, BZs, CBT SSRIs, CBT, anxiolytics as indicated Specific treatment for symptoms present, SSRIs, CBT, others Psychosocial treatment for alcohol-related behavior SSRIs, TCA, avoid BZs Specific psychotherapy Review and modify treatment as indicated
Environmental event/stressor(s)	Review work, family events, patient perception of stressor	Family/spouse interview and education Environmental hygiene as indicated Brief adjustment in treatment plan(s) as necessary
Other	Poor adherence Sexual side effects Inadequate understanding of panic disorder/treatment	Add/switch agents,consider brief drug holiday Patient/family education Make resource materials available

BZ

benzodiazepines

CBT

binge eating disorder

MAOI

monoamine oxidase inhibitor

OCD

obsessive compulsive disorder

PTSD

posttraumatic stress disorder

SSRI

selective serotonin reuptake inhibitor

TCA

tricyclic antidepressants