Anxiety Disorders in the DSM-5: New Rules on Diagnosis and Treatment By Cara Katz, BSc, Murray B. Stein, MD, FRCPC, and Jitender Sareen, MD, FRCPC

CANMAT Advisory Board Executive

Sagar V. Parikh, MD, FRCPCEducation Chair, TorontoEditor, Mood and Anxiety Disorders Roundssagar.parikh@uhn.ca

Raymond W. Lam, MD, FRCPC Executive Chair, Vancouver

Sidney H. Kennedy, MD, FRCPC Depression Group Chair, Toronto

Lakshmi N. Yatham, MBBS, FRCPC, MRCPsych (UK) Bipolar Group Chair, Vancouver

Jitender Sareen, MD, FRCPC Anxiety Group Chair, Winnipeg

Roger S. McIntyre, MD, FRCPC Business & Research Development Chair,Toronto

Roumen Milev, MD, PhD, FRCPsych, FRCPC International Conference Chair, Kingston

CANMAT Board of DirectorsSerge Beaulieu, MD, PhD, FRCPC Montréal

Glenda MacQueen, MD, PhD, FRCPC Calgary

Diane McIntosh, MD, FRCPCVancouver

Arun V. Ravindran, MB, PhD, FRCPCToronto

Canadian Network for Mood and Anxiety Treatments

Education OfficeRoom 9M-329, Toronto Western Hospital 399 Bathurst St, Toronto, OnCANADA M5T 2S8

CANMAT – or the Canadian Network for Mood andAnxiety Treatments – is a federally incorporatedacademically based not-for-profit researchorganization with representation from multipleCanadian universities. The ultimate goal ofCANMAT is to improve the quality of life ofpersons suffering from mood and anxietydisorders, through conduct of innovative researchprojects and registries, development of evidencebased and best practice educational programsand guideline/policy development.

V O L U M E 1 , I S S U E 1

C U R R E N T C L I N I C A L T O P I C S F R O M L E A D I N G R A S P E C I A L I S T S A C R O S S C A N A D A A N D A R O U N D T H EW O R L D I N V I T E D B Y T H E R E B E C C A M A C D O N A L D C E N T R E F O R A R T H R I T I S A N D A U T O I M M U N E D I S E A S E

V O L U M E 1 , I S S U E

A PHYSICIAN LEARNING RESOURCE FROM THE CANADIAN NETWORK FOR MOOD AND ANXIETY TREATMENTS

2 0 13 V O L U M E 2 , I S S U E 3

Available online at www.moodandanxietyrounds.ca

Anxiety disorders are among the most common mental disorders, with a lifetime prevalence of16%–29%.1,2 In addition to provoking substantial disability, anxiety disorders are highlycomorbid with other mental and physical disorders, thus complicating the treatment of bothtypes of disorders. This issue of Mood and Anxiety Disorders Rounds highlights changes to thediagnostic category of anxiety disorders reflected in the recently published fifth edition of theDiagnostic and Statistical Manual of Mental Disorders and outlines evidence-based treatmentsfor individuals with anxiety disorders.

Anxiety disorders are common in clinical practice and are highly comorbid and disabling.3

Among the anxiety disorders, specific phobia and social anxiety disorder are the most common,with lifetime prevalence rates of 18.4% and 13.0%, respectively.4 Panic disorder, generalized anxiety disorder (GAD), agoraphobia, and separation anxiety disorder each have lifetime prevalencerates of 2%–7%.

While all anxiety disorders share the core features of excessive fear, anxiety, and avoidance,they differ in the specific object or situation of concern.5 They also differ from normal fear or anxiety in terms of duration; symptoms related to an anxiety disorder typically persist for>6 months. Anxiety disorders can only be diagnosed when the physiological effects of substances,other medications, or other medical diagnoses have been ruled out or when the symptoms can-not be better explained by the diagnosis of another mental disorder.5 Thus, thorough patientassessment should include a review of systems, medication history (including over-the-countermedications), substance use, a complete evaluation of anxiety symptoms, a focused physicalexamination of symptomatic areas, and a functional assessment. Inquiries about substance useshould include questions about illicit drugs (particularly stimulants), alcohol, and caffeine.Further investigations should follow based on the results of the initial assessment (Table 1).6

What’s New in the DSM-5 for Anxiety Disorders?

Several important changes were made to the diagnostic category of Anxiety Disorders in thefifth edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual ofMental Disorders (DSM-5), including “cleaving” certain disorders into multiple new chapters,regrouping, adding new conditions, and refining criteria for some disorders. For example, obses-sive compulsive disorder (OCD) has moved into its own chapter that includes the new entity of“hoarding disorder,” while posttraumatic stress disorder (PTSD) has shifted into a new chapterthat includes acute stress and adjustment disorders. Anxiety disorders in childhood are no longerin a separate chapter. Within Anxiety Disorders, panic disorder and agoraphobia have beendeclared separate disorders since each can occur alone. In order to distinguish the diagnosis ofagoraphobia from that of specific phobia, the criteria for the former require the endorsement offears from ≥2 agoraphobic situations. Additionally, a panic attack specifier has been added to theDSM-5 that can be applied across all mental disorders. Panic attacks outside of panic disorder –but associated with other disorders – are frequently noted and may have value in predicting psy-chopath ology, severity, and outcome.7

Regarding agoraphobia, specific phobia, and social anxiety disorder, the criteria no longerinclude age >18 years in order to recognize that patients’ anxiety is excessive or unreasonable; therationale is that individuals typically overestimate their risk in “phobic” situations. In addition,

older adults tend to incorrectly attribute their phobia to agingand may, therefore, not report it. While there is evidence tosupport this change, the boundary between “routine” and“excessive” anxiety may still require clarification.8,9 Accordingto the DSM-5, it is primarily the clinician who can determinewhether the anxiety is excessive, taking into account thepatient’s report of his symptoms and cultural factors.Additionally, the criterion of a 6-month duration of symp-toms is now extended to all ages.

Another controversial change in the diagnosis of socialanxiety disorder is that the “generalized” specifier has beenremoved and replaced with a “performance only” specifier,noting that this group tends to be distinct in etiology, age ofonset, and physiological and treatment response.5 However, astudy by Kearns et al10 called this new criterion into question,as none of a sample of 204 anxious youth exhibited a discrete“performance” fear without fear in other social circumstances.Clinical and research experience with this new DSM-5 speci -fier will, in the coming year, determine whether this changewas well founded.

Separation anxiety disorder, previously considered in theDisorders Usually First Diagnosed in Infancy, Childhood, orAdolescence section, is now listed under Anxiety Disorders,consistent with evidence that the disorder may persist fromchildhood into adulthood and, in some instances (althoughthis remains controversial), may have onset in adulthood.11

Selective mutism has likewise been added to the AnxietyDisorders category. A summary of these changes by disordercan be found in Table 2.

OCD, PTSD, and acute stress disorder are no longer includ-ed in the Anxiety Disorders chapter, but are now included in theOCD and Related Disorders and Trauma- and Stressor-relatedDisorders chapters, respectively.5 These category changes arecontroversial in that they emphasize how these disorders differfrom one another in terms of biological mechanism and treat-ment approach. On the other hand, these changes may under-emphasize the similarities in these conditions.12 Furthermore, itis unclear if these individuals require a separate or differenttreatment than what was previously provided.

The decision to create a distinct category for OCD is basedon research showing that OCD is related to both anxiety andother disorders, including Cluster C, tic, somatoform, groom-ing, and mood disorders.13 Additionally, hoarding – previous-ly categorized within the diagnosis of OCD – has become itsown disorder. Similarly, evidence suggests that PTSD andacute stress disorder be classified as a distinct category, recog-nizing their common etiology of trauma.14

A new “anxious distressed” specifier has also been addedto the Depressive Disorders and Bipolar and Related Disorderscategories in the DSM-5. The anxious-distressed feature hasbeen noted to be a major feature of bipolar and major depres-sive disorder, and high levels of anxiety are associated withincreased suicidality and burden of illness. Therefore, identi-fying this specifier can help with treatment and management.This specifier is applied to individuals with ≥2 anxious symp-toms as specified in the DSM-5.5 This new criterion, however,does not come with a clause indicating not to diagnose if thereis a comorbid anxiety disorder. This has the potential for indi-viduals with a comorbid mood and anxiety disorder to belabeled with the “anxious-distressed” specifier, rather than aseparate (comorbid) anxiety disorder, which may lead toundertreatment of the anxiety disorder.

One of the major implications of the DSM-5 may be itsimpact on research, particularly in terms of childhood anxietydisorders. For example, these changes have encouraged thedevelopment of child-specific assessment tools (eg, PictureAnxiety Tests)15 and disorder-specific treatment (eg, the TAFFprogram for Separation Anxiety Disorder).16 Currently, theDSM-5 changes to the Anxiety Disorders category can be con-sidered a necessary step towards increased evidence-baseddiagnosis, assessment, and treatment of childhood anxiety dis-orders that, to this date, has been lacking.17 However, in theauthors’ opinion, these changes will have a less immediateimpact on clinical practice.

When considering treatment for the patient in this case,an algorithm (Figure 1) can be helpful. She presented withphysiological symptoms of panic attacks and subsequentavoidance of situations that she believed were the cause of her

Table 1: Baseline investigations in patients with anxietydisorders6

• Complete blood count• Fasting glucose• Fasting lipid profile (total, LDL, very LDL, and HDL

cholesterol, and triglycerides)• Electrolytes• Liver enzymes• Serum bilirubin• Serum creatinine• Urinalysis• Urine toxicology for substance use• 24-hour creatinine clearance (if history of renal disease)• Thyroid-stimulating hormone• Electrocardiogram (if age >40 years or if indicated)• Pregnancy test (if relevant)• Prolactin

LDL = low-density lipoprotein; HDL = high-density lipoprotein

Reproduced with permission from Canadian Psychiatric AssociationClinical Practice Guidelines. Management of anxiety disorders. Can JPsychiatry 2006;51(8 Suppl 2):9S-91S. Copyright © 2006, CanadianPsychiatric Association.

CASE STUDY18

A 35-year-old Asian-Canadian woman was referred to apsychiatrist for assessment of anxiety and avoidance. Twoyears earlier, she was awakened one night by chest pain thatshe believed was due to a heart attack. Accompanyingsymptoms were shortness of breath, rapid pulse, sweating,and dizziness. Her family took her to the EmergencyDepartment, where a thorough medical work-up ruled outany cardiac problems. After this event, however, she stoppeddriving and was unable to attend her children’s sportsevents, go on buses, or to her church for fear of recurrence ofthe chest pain. Although she could not define a specificstressor prior to the onset, a number of stressful life eventshad occurred, including the death of a close friend fromcancer and her husband losing his job. There was no priorhistory of emotional problems; however, she had a historyof asthma. As well, when the patient was 12 years old, herfather had suddenly died of a heart attack.

episodes. In keeping with the algorithm, medical causes wereruled out in the Emergency Room. After a complete assess-ment, this patient would likely be diagnosed with panic disor-der. General treatment options for anxiety disorders arepresented in the following section and an update to this casereport is presented later in this issue.18

Evidence-based Treatment of Anxiety Disorders

Treatments are derived from studies using DSM-IV crite-ria and so may need adjustment in view of DSM-5 changes.

General approach

The treatment of anxiety disorders can be extremely grat-ifying for clinicians because patients tend to respond well topsychological and pharmacological therapies. Several practiceguidelines can be referenced for the treatment of anxiety dis-orders, specifically, panic disorder and social anxiety disor-der.6,19-21 A careful, comprehensive assessment of anxietysymptoms, disabilities, the presence of comorbid mental andphysical conditions, patient preferences for treatment, and

access to evidence-based psychotherapies is important.Measuring symptoms using panic or “worry” diaries or the useof self-reported standardized scales (eg, the Overall AnxietySeverity and Interference Scale [OASIS])22 can help bothpatients and therapists track the course and severity of anxietyproblems and are indisputable aids to treatment.

The impact of comorbidity

The presence of a current comorbidity with a mental disor-der (ie, mood, substance use, or a personality disorder) signifi-cantly affects management. If an individual is severely depressed,treatment of the depression – usually with a combination ofmedication(s) and therapy, and attention to anxiety symptoms –is a priority. If a bipolar disorder is comorbid with an anxietydisorder(s), it may affect the type of medications used (eg, choiceof a mood stabilizer or gabapentin). Self-medication with alco-hol and drugs to reduce tension and anxiety is common and isassociated with an increased risk of substance-use disorders.23 Itis important for both patients and clinicians to understand thata vicious cycle can develop when anxiety symptoms lead to self-

Table 2: Highlights of DSM-5 Changes

DSM-5 anxiety disorderDSM-IVdiagnosis Changes in diagnosis

Panic Disorder (PD)

Panic Attack – Specifier (can beadded to any of the DSM-5disorders)

PD with orwithoutAgoraphobia

• Requires presence of recurrent panic attacks AND worry about possibilityof future attacks, development of phobic avoidance OR other change inbehaviour due to attacks

• Decoupled from agoraphobia

• Types of panic attacks described as “unexpected” versus “expected”

Social Anxiety Disorder (SAD) Social Phobia • Removal of “generalized social phobia”• Newly defined “performance only” specifier• No longer a requirement for individuals aged >18 years to recognize fear

as excessive; instead, anxiety must be out of proportion to actual dangeror threat in the situation, after taking cultural context into accounta

• 6-month duration extended to all ages (not just to those aged <18 years)

Agoraphobia Agoraphobiawithout ahistory ofpanicdisorder

• Decoupled from PD• No longer a requirement for individuals aged >18 years to recognize fear

as excessive (Instead, anxiety must be out of proportion to actual dangeror threat in the situation after taking cultural context into account)a

• 6-month duration extended to all ages (not just to those aged <18 years)• Endorsement of fears from ≥2 agoraphobia situations required (in order

to distinguish it from specific phobia)

Specific Phobia No change • Includes specifiers for different types of situations or objects involved(ie., animal, natural environment, blood-injection-injury, situational, andothers)

• No longer a requirement for individuals aged >18 years to recognize fearas excessive (Instead, anxiety must be out of proportion to actual dangeror threat in the situation, after taking cultural context into account)a

• 6-month duration extended to all ages (not just to those aged <18 years)

Generalized Anxiety Disorder (GAD) No change No change

Separation Anxiety Disorder • Now considered an anxiety disorder, (formerly in the Disorders UsuallyFirst Diagnosed in Infancy, Childhood, or Adolescence category)

• No longer specifies that age of onset must be before age 18 years• Duration criterion of ≥6 months added

Selective Mutism No change • Now considered an anxiety disorder (formerly in the Disorders UsuallyFirst Diagnosed in Infancy, Childhood, or Adolescence category

a Also new in DSM-5, this judgment of fear or anxiety being excessive is made by the clinicianDSM = Diagnostic and Statistical Manual of Mental Disorders

medication with alcohol and drugs, resulting in reboundanxiety. Past recommendations insisted on abstinencebefore treating comorbid anxiety and substance use disor-ders; however, current thinking favours concurrent treat-ment of both disorders whenever feasible.

Most patients prefer treating anxiety with psy-chotherapy alone or in combination with medication.24

However, evidence-based psychotherapy may not bereadily accessible to all patients. Thus, medication oftenbecomes the de facto treatment of anxiety disorders. Evenin such circumstances, it should be possible to optimizepatient care with appropriate educational, motivational,and behavioural instructions and resources.

Psychotherapy

Among the interventions for anxiety disorders, cogni-tive behavioural therapy (CBT) has the most robust evi-

dence for efficacy.19,21,24 It can be delivered via a variety offormats, including individual, group, bibliotherapy, tele-phone, and the computer. Although there have been fewchanges in the treatment of anxiety disorders since theCanadian Psychiatric Association’s 2006 clinical practiceguidelines,6 Internet-based CBT (iCBT) has become awell-established treatment for depression, panic disorder,and social anxiety disorder, with the potential to reducecomorbidity.25,26 Mobile CBT applications are increasing-ly available but have not been evaluated. CBT for the var-ious anxiety disorders differ somewhat in focus andcontent, but are similar in underlying principles andapproaches.27 Core components include psychoeducation,relaxation training, cognitive restructuring, and exposuretherapy. Over the course of CBT, patients slowly face theiranxiety-provoking situations and learn that if they stay inthe situation long enough, their anxiety resolves.

Adapted from Canadian Psychiatric Association Clinical Practice Guidelines. Management of anxiety disorders. Can J Psychiatry2006;51(8 Suppl 2):9S-91S, and Stein MB, Sareen J. Anxiety disorders. In: Hales R, Yudofsky S, Gabbard G, eds. The American PsychiatricPublishing Textbook of Psychiatry. 6th ed. In press.

Figure 1: Algorithm for the Treatment and Management of Anxiety Disorders

Identify Anxiety Symptoms1. Assess impact on function2. Assess suicide risk

Comorbid Mental Disorder1. If substance abuse: prescribe

benzodiazepines with caution2. If another anxiety disorder:

use therapies that are first-linefor both disorders

3. If mood disorder: usetherapies that are effective forboth disordersTreatment

1. Consider patient preference2. Provide psychoeducation to patient and

family3. Consider comorbid mental and physical

disorder(s) in management of theanxiety disorder

Social anxiety disorder, panic disorder, generalized anxiety disorder, agoraphobia, separation anxiety disorder

1. CBT2. Antidepressants3. Consider addition of benzodiazepines, atypical antipsychotics

Specific Phobia1. Cognitive behaviour therapy (CBT)2. Benzodiazepines PRN

Treatment by Disorder Type

Comorbid Medical Condition1. Consider risks and benefits of

medication for anxietydisorder and consider impactof untreated anxiety

Identify Specific Anxiety DisorderSpecific phobia, social anxietydisorder, panic disorder, generalizedanxiety disorder, agoraphobia,separation anxiety disorder

Differential Diagnosis1. Rule out medical or substance induced anxiety2. Consider comorbidity with another medical or psychiatric condition3. Conduct physical and laboratory examinations

While other psychotherapies – eg, psychodynamicpsychotherapy, acceptance and commitment therapy,mindfulness-based stress reduction, or other therapiesthat target emotion regulation – are promising, furtherresearch is necessary to establish both efficacy and link-age to patient preferences. Acceptability and response toCBT for anxiety disorders is high; however, there is ampleroom for new treatments to meet the needs of patientswho fail standard therapies.

Pharmacotherapy

Pharmacotherapy is an important option for manypatients with anxiety disorders, either in combinationwith CBT or as stand-alone treatment.28 Pharmaco therapyshould never be prescribed without additional educationalmaterials. These can be provided at low or no cost online byaccessing unbiased sources of high-quality information,including the National Institutes of Health, the Anxiety andDepression Association of America (ADAA), UpToDateTM

(written expressly for consumers), or anxieties.com. Several classes of medications are indicated by Health

Canada and similar regulatory agencies in other countriesfor the treatment of specific anxiety disorders. Althoughadherence to approved medications guarantees that a cer-tain level of evidence has been attained in granting theirapproval, any licensed practitioner can choose to prescribeoff-label, provided the marketed medication has a base ofsolid, peer-reviewed, published evidence for efficacy andsafety in the particular clinical condition and specific topatient circumstances. The classes of medications with thebest evidence of safety (when used appropriately) and effi-cacy for the treatment of anxiety disorders (with theexception of specific phobias) are the antidepressants,including selective serotonin reuptake inhibitors (SSRIs),serotonin-norepinephrine reuptake inhibitors (SNRIs),tricyclic antidepressants (TCAs), monoamine oxidaseinhibitors (MAOIs), and the benzodiazepine anxiolytics.

TCAs and MAOIs have been rarely used since theadvent of the SSRIs because they are less well-tolerated.Some experts, however, believe that MAOIs may be effi-cacious for patients whose symptoms do not respond toother treatments, particularly in the treatment of socialanxiety disorder. There is also evidence that several non-benzodiazepine anxiolytics (eg, buspirone and prega-balin) can play a role and, for refractory anxiety, possiblythe atypical antipsychotics can help.

SSRIs and SNRIs. There are currently 6 SSRIs (fluox-etine, sertraline, paroxetine, fluvoxamine, citalopram,and escitalopram) and 3 SNRIs (extended-release venla -faxine, desvenlafaxine, and duloxetine) available inCanada. Although the SSRIs have different indicationsfor particular anxiety disorders, clinicians tend to treatthem as having equal efficacy since there is no evidence tothe contrary. As a class, the SSRIs are considered first-lineagents for each of the anxiety disorders (with the notableexception of specific phobia) due to their overall levels ofefficacy, safety, and tolerability.6

It is recommended to begin a treatment trial with thelowest available dose of an SSRI. Follow-up should occurafter the first week to assess medication tolerability and

patient compliance. The dose is then gradually increaseduntil a therapeutic dose is reached. An initial response istypically seen in 4–6 weeks and an optimal responseachieved in 12–16 weeks. Follow-up should occurbiweekly for the first 6 weeks and then monthly there-after. There is a misconception that patients with anxietydisorders respond to lower doses of antidepressants thanpatients with depression. In fact, average doses for treat-ing anxiety disorders are as high or higher than fordepression.6,18 In addition, many patients presenting withanxiety also have major depression, necessitating the useof a full antidepressant dose. Clinicians may take an extra1–2 weeks to reach these doses in patients with anxietydisorders, comorbid or otherwise. Progress can be mea-sured at each appointment with clinician-rated tools (eg,the Clinical Global Impression scale) or self-report scales(eg, the Depression Anxiety Stress scale).6

In patients who fail to respond to an SSRI, the nextstep is to try a different SSRI or to switch to an SNRI.Patients who experience a partial response to an SSRI orSNRI may be considered for adjunctive treatment with abenzodiazepine or another anti-anxiety agent. Pharma -co therapy may be needed for 1–2 years, or longer.

Benzodiazepines are among the best tolerated andmost efficacious of all the anti-anxiety agents, with broad-spectrum efficacy across the anxiety disorders, includingspecific phobia. They can be used as first-line agents fortreating anxiety and are the best-established pharma-cotherapy for treating anxiety that is predictable and lim-ited to particular situations (eg, a specific phobia such asflying or social phobia such as public speaking) as theycan be prescribed on an as-needed (prn) basis.29 However,benzodiazepines need to be prescribed with caution dueto the potential for abuse. They should only be prescribedwith great care and strict supervision to patients with ahistory of alcohol or other substance abuse.

Prescription of prn benzodiazepines for unpre-dictable anxieties (eg, panic disorder) or chronic anxiety(eg, GAD) is not recommended. Benzodiazepines shouldgenerally be prescribed for anxiety on a regular schedule(ie, 1–4 times daily depending on the pharmacokineticand pharmacodynamic properties of the particular ben-zodiazepine), with prn use for occasionally recurring,predictable specific phobias.

Nonbenzodiazepine anxiolytics. Buspirone is a non-benzodiazepine anxiolytic with efficacy limited to thetreatment of GAD. Gabapentin and pregabalin have lim-ited evidence for efficacy in treating anxiety disorders,although they are sometimes used as an alternative to thebenzodiazepines, often as an adjunct to antidepressants.

Atypical antipsychotics. There is very limited evidencethat ayptical antipsychotics may be efficacious asmonotherapy or as an adjunct to antidepressants fortreatment-resistant anxiety disorders.30

Combining psychotherapy and pharmacotherapy

Several studies suggest, albeit with few data, thatcombining CBT and pharmacotherapy for anxiety disor-ders is superior to either one alone, particularly in chil-dren.31,32 However, the efficacy of either treatment

© 2013 CANMAT or the Canadian Network for Mood and Anxiety Treatments, which is solely responsible for the contents. Publisher: SNELL Medical Communication Inc. in co -operation with CANMAT. Mood and Anxiety Disorders Rounds is a trademark of SNELL Medical Communication Inc. All rights reserved. The administration of any therapies discussedor referred to in Mood and Anxiety Disorders Rounds should always be consistent with the recognized prescribing information in Canada. SNELL Medical Communication Inc. iscommitted to the development of superior Continuing Medical Education.

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modality is sufficiently high that clinicians may choose one orthe other as initial therapy, based primarily on patient prefer-ence, and subsequently add the other option in patients whofail to respond adequately to a therapeutic trial.

Conclusion

Anxiety disorders are highly prevalent and frequently dis-abling conditions that often begin in childhood and persistinto adulthood. They are generally very responsive to CBTand/or pharmacotherapy. All patients should receive educa-tion regarding their anxiety disorder, options for treatment,prognosis, triggering factors, and signs of relapse.

Ms. Katz is a graduate student in the Department of Psychiatry andmember of the Manitoba Population Mental Health ResearchGroup, University of Manitoba, Winnipeg, Manitoba. Dr. Stein is aProfessor of Psychiatry and Family & Preventive Medicine,University of California San Diego. Dr. Sareen is a Professor ofPsychiatry, Psychology and Community Health Sciences, and GroupLeader of the Manitoba Population Mental Health Research Group,University of Manitoba, Winnipeg, Manitoba.

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The authors stated that they have no disclosures to report in asso-ciation with the contents of this issue.

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CASE STUDY (cont.)Our patient, after being diagnosed with panic disorder, wastaught about the panic model. The therapist asked her tokeep a diary of her panic attacks, including details such aswhere the attack occurred, her symptoms during the attack,and what she did to manage her anxiety. During treatmentsessions, she learned how to identify the “hot” thoughts thatincreased her anxiety and ways to challenge this thinking byconsidering the evidence for and against her fear of havinga heart attack. Along with CBT, she was offered a trial of anSSRI. She started on 50 mg/day of sertraline that was titrat-ed up until an optimal therapeutic dose was achieved. After6 weeks, the patient did not demonstrate a meaningful clin-ical response and the panic attacks continued. The treatingphysician then decided to switch her to paroxetine, anotherSSRI. After 6 weeks, the patient reported benefit with theparoxetine, and was maintained on this medication.