What are the treatment options for a panic attack (anxiety disorder)?

From the Guidelines

Treatment for panic attacks should prioritize cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) as first-line interventions, given their strong evidence base for reducing symptoms and improving quality of life. During an acute panic attack, immediate strategies such as slow, deep breathing - inhaling slowly through the nose for 4 seconds, holding briefly, then exhaling through the mouth for 6 seconds - and grounding techniques like the 5-4-3-2-1 method can help reconnect with the present moment 1.

For long-term management, CBT is recommended as a strong option due to its ability to identify and change thought patterns triggering attacks, with benefits outweighing harms and intermediate evidence quality 1. SSRIs, such as sertraline starting at 25-50mg daily, are also effective in reducing panic attack frequency by addressing both physiological and psychological components of panic attacks. Regular exercise, adequate sleep, limiting caffeine and alcohol, and practicing mindfulness meditation can further reduce panic attack frequency.

While benzodiazepines like lorazepam or alprazolam provide rapid relief, they should be used sparingly due to dependency risks. The most recent and highest quality study supporting the use of CBT and SSRIs for panic attacks is from 2023, emphasizing the importance of evidence-based treatments in clinical practice 1.

Key considerations in treating panic attacks include:

• Addressing both physiological and psychological aspects of panic attacks
• Using evidence-based treatments like CBT and SSRIs as first-line interventions
• Implementing lifestyle changes such as regular exercise and mindfulness meditation to reduce panic attack frequency
• Minimizing the use of benzodiazepines due to dependency risks, as suggested by recent guidelines 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. Dose Titration 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.

Treatment for Panic Attack:

• The dose of alprazolam for treating panic attacks can be initiated at 0.5 mg three times daily.
• The dose may be increased at intervals of 3 to 4 days in increments of no more than 1 mg per day to achieve a maximum therapeutic effect.
• The mean dosage employed in controlled trials was approximately 5 to 6 mg daily.
• Some patients may require doses greater than 4 mg daily, with occasional patients requiring as much as 10 mg a day to achieve a successful response 2.

From the Research

Treatment Options for Panic Attacks

• The treatment of panic disorder includes psychological and pharmacological interventions, such as antidepressants and benzodiazepines 3.
• Selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines are standard first-line pharmacologic treatments for panic disorder 4.
• Other antidepressants can be considered as alternatives to SSRIs, including serotonin-norepinephrine reuptake inhibitors, serotonin multimodal agents, tricyclic antidepressants, monoamine oxidase inhibitors, and mirtazapine 4.
• Cognitive-behavioral therapy (CBT) is a psychotherapy with strong evidence of efficacy for panic disorder 4, 5.

Medications for Panic Disorder

• Diazepam, alprazolam, and clonazepam are ranked as the most effective medications for panic disorder 3.
• SSRIs, such as paroxetine and fluoxetine, have stronger evidence of efficacy than sertraline 3.
• Benzodiazepines appear to have a small but significant advantage in terms of tolerability over other classes of medications 3, 6.
• SSRIs cause more adverse events than benzodiazepines in short-term treatment, including diaphoresis, fatigue, nausea, diarrhea, and insomnia 6.

Psychotherapy for Panic Disorder

• CBT is the psychotherapy with the most evidence of efficacy for anxiety disorders, including panic disorder 5.
• Combining an antidepressant with exposure in vivo produces the greatest treatment gains 7.
• CBT can be used in primary care and has a large effect size compared to psychological or pill placebo 5.