Immediate Treatment for Panic Attacks
The immediate treatment for a panic attack should include psychological first aid techniques such as relaxation breathing, reassurance, and if necessary, benzodiazepines like alprazolam for rapid symptom relief. 1
First-Line Interventions
- Apply psychological first aid principles for individuals experiencing acute distress 1
- Implement relaxation techniques including diaphragmatic breathing and cooling the face 1
- Provide reassurance that the symptoms, while distressing, are not life-threatening 1
- Position the patient comfortably, such as in a seated position with upper body elevated 1
- Open windows or use small ventilators to help with the sensation of breathlessness 1
Pharmacological Management
- For severe panic attacks not responding to non-pharmacological interventions, benzodiazepines may be considered 2, 3
- Alprazolam is effective for acute panic symptoms, with an initial dose of 0.25-0.5 mg 2, 4
- In elderly patients or those with liver disease, start with a lower dose of 0.25 mg 2
- Avoid long-term benzodiazepine use due to risks of dependence and tolerance 3, 5
Specific Techniques
Breathing Control
- Guide the patient to take slow, deep breaths through the nose, hold briefly, and exhale slowly through pursed lips 1
- Encourage the patient to focus on their breathing pattern to interrupt catastrophic thinking 1
Physical Interventions
- Apply cooling to the face (cold compress or cool air) to help reduce physiological arousal 1
- Encourage the patient to sit in a "coachman's seat" position (leaning forward slightly with arms resting on knees) to optimize breathing 1
Important Considerations
- Distinguish panic attacks from other medical emergencies that may present similarly (e.g., cardiac events) 1
- For patients with recurrent panic attacks, cognitive behavioral therapy (CBT) principles should be considered for long-term management 1
- Avoid psychological debriefing as it may worsen outcomes 1
- SSRIs are more appropriate for long-term management of panic disorder rather than immediate treatment of acute attacks 3, 6
Follow-Up Recommendations
- Educate the patient about panic attacks and their benign nature despite intense physical symptoms 1
- Consider referral for CBT, which has strong evidence for treating panic disorder 1
- For patients with recurrent attacks, develop a written plan for managing future episodes 1
- Teach patients to recognize early warning signs to implement coping strategies before symptoms escalate 1
Cautions
- Benzodiazepines should be used cautiously and for short periods only (ideally less than 4 weeks) 5
- Diazepam may be an effective alternative to alprazolam with similar efficacy but potentially less risk of dependence 7
- Avoid benzodiazepines in patients with a history of substance abuse or dependence 5
- Be aware that elderly patients may be especially sensitive to benzodiazepine effects 2