What are the treatment options for panic attacks?

Treatment Options for Panic Attacks

Cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are the first-line treatments for panic attacks, with combination therapy offering potentially superior outcomes for many patients. 1

First-Line Treatment Options

Psychotherapy

• CBT is highly effective for panic attacks and should be offered as a first-line treatment 1
• Key elements of effective CBT for panic include:
  • Education about anxiety and panic mechanisms
  • Behavioral goal setting with contingent rewards
  • Self-monitoring of connections between fears, thoughts, and behaviors
  • Relaxation techniques (deep breathing, progressive muscle relaxation)
  • Cognitive restructuring to challenge catastrophic thinking
  • Graduated exposure to feared situations
  • Problem-solving and social skills training 1
• Graduated exposure is particularly important for panic disorder, creating a fear hierarchy that is mastered in a stepwise manner 1

Pharmacotherapy

• SSRIs are recommended as first-line medication treatment for panic attacks 1, 2
• SSRIs improve primary anxiety symptoms, response to treatment, and remission rates with moderate to high strength of evidence 1
• Available SSRIs include fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram, and escitalopram 1
• Paroxetine and sertraline have FDA approval specifically for panic disorder 3
• SSRIs work by inhibiting presynaptic reuptake of serotonin, increasing its availability at the synaptic cleft 1
• Common side effects include nausea, headache, somnolence, dry mouth, insomnia, and sexual dysfunction 4

Second-Line Treatment Options

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

• SNRIs could be offered as an alternative treatment option for panic attacks 1
• SNRIs inhibit reuptake of both serotonin and norepinephrine 1
• Available SNRIs include venlafaxine, desvenlafaxine, duloxetine, and levomilnacipran 1
• SNRIs may cause more fatigue/somnolence compared to placebo 1

Benzodiazepines

• Benzodiazepines (such as alprazolam) should be reserved for short-term use or treatment-resistant cases 2
• Alprazolam has demonstrated efficacy in panic disorder in placebo-controlled trials 5
• Benzodiazepines carry risks of dependence and withdrawal symptoms, limiting their long-term utility 6
• They may be useful in combination with SSRIs during the initial weeks of treatment before SSRIs take effect 2

Combination Therapy

• Combined treatment with CBT and an SSRI may be more effective than either treatment alone 1
• Combination therapy has shown superior outcomes in reducing panic attacks and improving global function compared to monotherapy 1
• Meta-analyses suggest that combining antidepressants with exposure therapy produces the greatest treatment gains 7

Treatment Implementation Considerations

For CBT:

• Specialized education, training, and experience are necessary for effective delivery 1
• Family-directed interventions can supplement individual treatment by improving parent-child relationships and reducing parental anxiety 1
• School-directed interventions may be beneficial for students with anxiety 1

For Medication:

• Start with lower doses and gradually increase to minimize side effects 5
• SSRIs typically require 4-6 weeks for full therapeutic effect 6
• Treatment should continue for at least 9-12 months after symptom resolution to prevent relapse 1
• Gradual tapering is essential when discontinuing medication to avoid withdrawal symptoms 5

Special Populations

• For elderly patients or those with advanced liver disease, lower starting doses of medication are recommended 5
• For children and adolescents, parental oversight of medication regimens is crucial 1
• In patients with comorbid depression (common with panic disorder), antidepressants are particularly appropriate 6

Common Pitfalls to Avoid

• Premature discontinuation of treatment before adequate trial period (at least 4-6 weeks for medications) 4
• Abrupt discontinuation of benzodiazepines or SSRIs, which can lead to withdrawal symptoms 5
• Overreliance on benzodiazepines for long-term management due to dependence risk 6
• Neglecting to address comorbid conditions that may complicate treatment 6
• Failure to combine pharmacotherapy with appropriate psychotherapy when indicated 7