What is the recommended treatment for panic attacks?

Treatment of Panic Attacks

The recommended first-line treatment for panic attacks is cognitive behavioral therapy (CBT), with selective serotonin reuptake inhibitors (SSRIs) as the first-line pharmacological option when medication is needed or preferred. 1

Non-Pharmacological Treatment

Cognitive Behavioral Therapy

• CBT is the psychotherapy of first choice for panic attacks, with strong evidence supporting its efficacy
• Individual CBT sessions are preferred over group therapy due to superior clinical effectiveness
• Structured approach typically includes 12-20 sessions with key components:
  • Education about anxiety and panic
  • Cognitive restructuring to challenge distorted thinking patterns
  • Graduated exposure to feared situations
  • Relaxation techniques (deep breathing, progressive muscle relaxation)
  • Homework assignments to practice skills

Alternative CBT Delivery Options

• If a patient declines face-to-face CBT, offer supported self-help based on CBT principles:
  • Approximately 9 sessions over 3-4 months
  • Self-help materials with therapist support (total of approximately 3 hours)
  • Support provided via face-to-face meetings or telephone

Pharmacological Treatment

First-Line Medications

• SSRIs are the first-line pharmacological treatment for panic disorder 1, 2, 3
  • Sertraline: Starting dose 25-50 mg daily, target dose up to 200 mg daily
  • Escitalopram: 10-20 mg daily
  • Fluoxetine: 10-20 mg daily
• Common side effects include nausea, diarrhea, headache, insomnia, and sexual dysfunction
• Start with lower doses and titrate slowly to minimize side effects

Alternative Medications

• SNRIs (e.g., venlafaxine) are suggested as an alternative first-line option 4, 1
• Benzodiazepines (e.g., alprazolam) should be reserved for:
  • Short-term use during acute panic attacks
  • Treatment-resistant patients who do not have a history of dependence
  • Combination with SSRIs in the first weeks of treatment before SSRIs take effect 5, 3
• Benzodiazepines have rapid onset of action but carry risks of tolerance and dependence 6

Treatment Algorithm

1. Initial Assessment and Treatment Planning

   • Determine severity of panic attacks and impact on functioning
   • Screen for comorbid conditions (depression, other anxiety disorders)
   • Discuss treatment options with patient

2. First-Line Treatment

   • For mild to moderate panic disorder: Begin with CBT
   • For moderate to severe panic disorder: Consider CBT plus SSRI
   • If immediate symptom relief is needed: Consider short-term benzodiazepine while initiating other treatments

3. Monitoring and Adjustment

   • Evaluate initial response after 2-3 weeks
   • Assess full effect at 4-6 weeks using standardized anxiety assessment tools
   • If inadequate response to SSRI after 4-6 weeks at adequate dose:
     • Consider switching to another SSRI or SNRI
     • Consider augmentation strategies for partial responders

4. Maintenance and Discontinuation

   • Continue effective treatment for approximately 1 year following symptom remission
   • When discontinuing medication, reduce dose gradually:
     • For SSRIs: Reduce by no more than 25% every 1-2 weeks
     • For benzodiazepines: Reduce by 25% every 1-2 weeks, with total tapering duration of 8-12 weeks

Special Considerations

Pitfalls to Avoid

• Abrupt discontinuation of medication (especially benzodiazepines) can lead to withdrawal symptoms
• Inadequate duration of treatment increases risk of relapse
• Failure to monitor systematically can lead to poor outcomes
• Overlooking comorbidities may require modification of treatment approach

Complementary Approaches

• Structured physical activity and exercise show benefit for anxiety reduction
• Breathing techniques and relaxation exercises can help manage acute symptoms

By following this evidence-based approach to treating panic attacks, clinicians can help patients achieve significant reduction in symptoms and improved quality of life.