What is the recommended treatment for panic attacks?

Treatment of Panic Attacks

Cognitive Behavioral Therapy (CBT) is the first-line treatment for panic attacks, with selective serotonin reuptake inhibitors (SSRIs) as the preferred pharmacological option when medication is indicated. 1, 2

Psychotherapy Approach

• CBT has demonstrated significant efficacy in reducing panic frequency, avoidance behavior, anxiety sensitivity, and associated depressive symptoms, typically consisting of 12-15 sessions conducted in either individual or group format 1, 3

• Key components of effective CBT for panic attacks include:

  • Psychoeducation about panic and anxiety 1
  • Diaphragmatic breathing techniques 1, 2
  • Cognitive restructuring to address catastrophic misinterpretations of bodily sensations 1, 4
  • Interoceptive exposure to feared bodily sensations 1, 2
  • In vivo exposure to feared situations 1

• Treatment should be continued for at least 9-12 months after recovery to prevent relapse 1

Pharmacological Treatment

• SSRIs are the preferred pharmacological option for panic disorder 2, 5
• Fluoxetine treatment should be initiated with 10 mg/day, increased to 20 mg/day after one week, with most patients responding to 20 mg/day 5
• If inadequate response to SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine can be considered as a second-line option 2
• High-potency benzodiazepines may be useful for short-term treatment due to their rapid onset of action, but are not recommended for long-term management due to risk of dependence 2

Cultural Considerations

• Cultural adaptations to CBT may be necessary for optimal efficacy 1, 2:
  • For Asian American patients, incorporating mindfulness techniques and addressing culturally specific manifestations of panic (such as "blocked wind" beliefs) 4
  • For Vietnamese and Cambodian refugees with panic attacks, culturally adapted CBT including muscle relaxation, diaphragmatic breathing, visualization, and mindfulness has shown significant improvement 4
  • Group therapy may be particularly effective for patients with interdependent self-construal, common in Asian American populations 1

Treatment Algorithm

1. First-line treatment: Begin with CBT (12-15 sessions) focusing on psychoeducation, breathing techniques, cognitive restructuring, and exposure 1, 3
2. If medication is indicated: Start with an SSRI such as fluoxetine at 10 mg/day, increasing to 20 mg/day after one week 5
3. For inadequate response: Consider switching to an SNRI 2
4. For severe, acute symptoms: Short-term benzodiazepine use may be considered while waiting for SSRI effect, but avoid long-term use 2
5. Continue treatment: Maintain therapy for at least 9-12 months after recovery to prevent relapse 1

Common Pitfalls to Avoid

• Using benzodiazepines as sole first-line treatment due to risk of dependence and tolerance development 1, 2
• Stopping medication treatment too early, before 9-12 months after recovery 1
• Failing to differentiate panic disorder from medical conditions with similar presentations 1
• Overlooking cultural factors that may influence symptom presentation and treatment response 1, 2
• Neglecting to use standardized assessment tools to monitor treatment progress 2

Long-term Management

• CBT offers relatively quick onset of action and long-term maintenance of treatment benefits compared to medication alone 6
• CBT facilitates benzodiazepine withdrawal and has stable long-term effects 7
• The combination of CBT with SSRIs may be beneficial in the short term, but the positive effects of these combinations are primarily found in the short term 7
• Patients should be periodically reassessed to determine the need for continued treatment 5