Treatment for Panic Attacks in Teenagers
Cognitive-behavioral therapy (CBT) should be offered as the first-line treatment for teenagers with panic attacks, with selective serotonin reuptake inhibitors (SSRIs) as an alternative for more severe presentations or when quality CBT is unavailable. 1
First-Line Treatment: Cognitive-Behavioral Therapy
CBT has substantial empirical support for treating panic attacks in adolescents:
- Recommended by the American Academy of Child and Adolescent Psychiatry (AACAP) with strong evidence (1C recommendation) 1
- Particularly effective for mild to moderate panic presentations
- Helps teenagers identify and modify catastrophic misinterpretations of bodily sensations that trigger panic
- Typically involves 12-20 individual sessions 2
Key components of effective CBT for teenage panic attacks include:
- Education about the nature of panic and anxiety
- Cognitive restructuring to address catastrophic thoughts
- Interoceptive exposure (controlled exposure to physical sensations)
- In vivo exposure to feared situations
- Relaxation and breathing techniques
Pharmacological Options
For teenagers with more severe panic attacks or when quality CBT is unavailable:
SSRIs (First-line medication)
- Start with fluoxetine at 10 mg daily, then increase to 20 mg daily after one week 3
- Lower starting doses may be advisable as initial adverse effects can include increased anxiety or agitation 1
- Maximum dose generally should not exceed 20 mg daily for teenagers 3
- Close monitoring is essential, especially during the first months of treatment and following dosage adjustments 2
SNRIs (Alternative option)
- Suggested by AACAP (2C recommendation) for anxiety disorders including panic 1
- May be considered when SSRIs are not tolerated or ineffective
- Requires careful monitoring for side effects
Combination Treatment Approach
For teenagers with moderate to severe panic disorder:
- AACAP suggests (2C) that combination treatment (CBT and an SSRI) could be offered preferentially over monotreatment 1
- Based on findings from the Child-Adolescent Anxiety Multimodal Study (CAMS), which showed:
- Improved primary anxiety symptoms
- Enhanced global functioning
- Better response to treatment
- Higher rates of remission
Monitoring and Follow-up
- Evaluate initial response after 2-3 weeks and assess full effect at 4-6 weeks 2
- Use standardized anxiety assessment tools to monitor progress
- Watch for behavioral activation/agitation, which may occur early in SSRI treatment 2
- Continue effective treatment for approximately one year following symptom remission 2
Important Considerations and Cautions
- Parental oversight of medication regimens is crucial for teenagers 1
- Avoid abrupt discontinuation of medications; taper gradually to minimize withdrawal symptoms 2
- Monitor for suicidal ideation, particularly when starting medication or changing doses 2
- For teenagers with panic attacks, assess for comorbid conditions (depression, other anxiety disorders) which may affect treatment planning 2
Treatment Duration
- For medication, continue effective treatment for approximately one year after symptom remission 2
- When discontinuing, reduce medication gradually (no more than 25% every 1-2 weeks) 2
- For CBT, typical treatment involves 12-20 sessions, with booster sessions as needed
The evidence strongly supports starting with CBT for most teenagers with panic attacks, with medication (preferably SSRIs) reserved for more severe cases or when quality CBT is unavailable. For moderate to severe cases, the combination of CBT and an SSRI appears to offer the best outcomes for reducing panic symptoms and improving quality of life.