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Answer 2
  1. SSRI and a benzodiazepine. Both SSRIs2,3 and benzodiazepines4,5 are effective for the treatment of panic disorder with agoraphobia. Based on this patient’s severity of symptoms and associated impairment, rapid symptom reduction is critical. Thus, using a benzodiazepine for rapid symptom control as well as initiating an SSRI for long-term management is the treatment of choice. Discontinuation of the benzodiazepine may be considered in the future once symptoms are under control. Tricyclic antidepressants are effective for panic disorder but are considered second-line therapy because of possible adverse effects, such as weight gain, dizziness, headache, and somnolence as well as serious side effects, such as cardiac dysrhythmia.6,7 Due to the severity of symptoms, psychotherapy alone would not be recommended for this patient.

    2. Wade AG, Lepola U, Koponen HJ, et al. The effect of citalopram in panic disorder. Br J Psychiatry 1997;170:549-53.

    3. Ballenger JC, Wheadon DE, Steiner M, et al. Double-blind, fixed-dose, placebo-controlled study of paroxetine in the treatment of panic disorder. Am J Psychiatry 1998;155:36-42.

    4. Lydiard RB, Lesser IM, Ballenger JC, et al. A fixed-dose study of alprazolam 2 mg, alprazolam 6 mg, and placebo in panic disorder. J Clin Psychopharmacol 1992;12:96-103.

    5. Jacobs RJ, Davidson JR, Gupta S, Meyerhoff AS. The effects of clonazepam on quality of life and work productivity in panic disorder. Am J Manag Care 1997;3:1187-96.

    6. Andersch S, Rosenberg NK, Kullingsjš H, et al. Efficacy and safety of alprazolam, imipramine and placebo in treating panic disorder. A Scandinavian multicenter study. Acta Psychiatr Scand Suppl 1991;365:18-27.

    7.  Davidson JR, Conner KM. Treatment of anxiety disorders. In: Schatzberg AF, Nemeroff CB, editors. Textbook of psychopharmacology. Washington (DC): American Psychiatric Publishing; 2004:913-34.

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