What are the management strategies for panic attacks?

From the Guidelines

To manage a panic attack, it is crucial to focus on evidence-based therapies such as cognitive behavioral therapy (CBT), which has been shown to be highly effective in reducing symptoms of anxiety and panic attacks 1. When experiencing a panic attack, techniques such as slow, deep breathing by inhaling through your nose for 4 counts and exhaling through your mouth for 6 counts can help calm the body. Grounding techniques, including the 5-4-3-2-1 method, where you identify 5 things you can see, 4 things you can touch, 3 things you can hear, 2 things you can smell, and 1 thing you can taste, can also be beneficial. Reminding yourself that panic attacks are temporary and not dangerous, despite feeling frightening, is important. Additionally, trying progressive muscle relaxation by tensing and then releasing each muscle group in your body, finding a quiet space if possible, and using positive self-talk such as "This will pass" or "I am safe" can help alleviate symptoms. For long-term management, CBT, as recommended by the ASCO guideline update 1, should be considered as a first-line treatment option, alongside other therapies like structured physical activity and exercise, or psychosocial interventions with empirically supported components. While medications like benzodiazepines or SSRIs may be prescribed for acute or long-term management, respectively, the most recent and highest quality evidence supports the use of non-pharmacological interventions as the primary approach to managing panic attacks 1. Regular exercise, adequate sleep, limiting caffeine and alcohol, and practicing mindfulness are also important for preventing future attacks. Panic attacks trigger the body's fight-or-flight response, causing physical symptoms, but these techniques help activate the parasympathetic nervous system, counteracting the stress response. It's worth noting that while beta-blockers are sometimes used for symptom relief in panic disorder, as mentioned in the context of treating high blood pressure 1, the current recommendation prioritizes non-pharmacological interventions like CBT for the management of panic attacks 1.

From the FDA Drug Label

The successful treatment of many panic disorder patients has required the use of alprazolam tablets at doses greater than 4 mg daily. In controlled trials conducted to establish the efficacy of alprazolam tablets in panic disorder, doses in the range of 1 to 10 mg daily were used The mean dosage employed was approximately 5 to 6 mg daily. Treatment may be initiated with a dose of 0.5 mg three times daily. Depending on the response, the dose may be increased at intervals of 3 to 4 days in increments of no more than 1 mg per day.

Tips for managing panic attacks:

• Medication: Alprazolam tablets may be used to treat panic disorder, with doses ranging from 1 to 10 mg daily.
• Dose titration: Treatment may be initiated with a dose of 0.5 mg three times daily, with increases of no more than 1 mg per day every 3 to 4 days.
• Gradual discontinuation: When discontinuing therapy, the daily dosage should be decreased by no more than 0.5 mg every 3 days to minimize the risk of withdrawal symptoms 2.
• Panic disorder treatment: Fluoxetine and paroxetine may also be used to treat panic disorder, with fluoxetine doses ranging from 10 to 60 mg/day and paroxetine doses not specified in the provided text 3, 4.

From the Research

Symptoms of Panic Attack

• A panic attack is a discrete period of fear or anxiety that has a rapid onset and reaches a peak within 10 minutes 5
• The main symptoms involve bodily systems, such as racing heart, chest pain, sweating, shaking, dizziness, flushing, churning stomach, faintness and breathlessness 5
• Other recognised panic attack symptoms involve fearful cognitions, such as the fear of collapse, going mad or dying, and derealisation (the sensation that the world is unreal) 5

Treatment Options

• The treatment of panic disorder includes psychological and pharmacological interventions, including antidepressants and benzodiazepines 5
• Selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines are among the most frequently prescribed drugs for panic disorder 6
• SSRIs, such as fluvoxamine, fluoxetine, paroxetine, sertraline and citalopram, have been proven to be superior to pill-placebo in the treatment of panic disorder and agoraphobia 7
• Benzodiazepines, such as alprazolam and clonazepam, have a rapid onset of action, but can cause tolerance and dependence 6

Comparison of Treatment Options

• A meta-analysis found that SSRIs cause more adverse events than benzodiazepines in short-term panic disorder treatment 8
• SSRIs were associated with diaphoresis, fatigue, nausea, diarrhea, and insomnia, whereas benzodiazepines were associated with memory problems, constipation, and dry mouth 8
• Cognitive-behavioral therapy (CBT) is a strongly supported treatment for panic disorder, and can be used in combination with pharmacologic treatments 9

Tips for Managing Panic Attacks

• Seek professional help from a mental health expert 9
• Learn relaxation techniques, such as deep breathing and progressive muscle relaxation 9
• Avoid triggers that can cause panic attacks, such as caffeine and nicotine 9
• Consider keeping a panic diary to track symptoms and identify patterns 5