What is the first line of treatment for panic attacks?

First-Line Treatment for Panic Attacks

Cognitive Behavioral Therapy (CBT) is the first-line treatment for panic attacks, with Selective Serotonin Reuptake Inhibitors (SSRIs) recommended as the first-line pharmacological option when medication is needed. 1, 2

Psychological Treatment Approach

• CBT should be structured with approximately 14 sessions over 4 months, with each individual session lasting 60-90 minutes 2
• Key elements of effective CBT for panic disorder include:
  • Education about anxiety and panic
  • Behavioral goal setting with contingent rewards
  • Self-monitoring for connections between worries, thoughts, and behaviors
  • Relaxation techniques (deep breathing, progressive muscle relaxation)
  • Cognitive restructuring to challenge distortions
  • Graduated exposure to feared situations
  • Problem-solving and social skills training 1
• Graduated exposure, in which the patient creates a fear hierarchy that is then mastered in a stepwise manner, is the cornerstone of treatment 1
• Individual therapy is generally preferred over group therapy due to superior clinical and economic effectiveness 2
• For patients who cannot or do not want face-to-face CBT, self-help with support based on CBT principles is a viable alternative 2

Pharmacological Treatment Options

• SSRIs are the first-line pharmacological treatment for panic disorder due to their efficacy and favorable side effect profile 3, 4
• SSRIs have been shown to be effective in reducing panic attack frequency and improving associated symptoms 5, 6
• The FDA has approved specific SSRIs (paroxetine and sertraline) for the treatment of panic disorder 4
• Common side effects of SSRIs include nausea, headache, somnolence, dry mouth, tremor, insomnia, and sexual dysfunction 5
• Important considerations when starting SSRIs:
  • Begin with lower doses than those used for depression to minimize initial anxiety exacerbation
  • Gradually increase to therapeutic doses
  • Continue treatment for at least 4-12 months after symptom remission 2
  • Avoid abrupt discontinuation to prevent withdrawal symptoms 2

Alternative Pharmacological Options

• SNRIs (such as venlafaxine) are effective alternatives if SSRIs are not tolerated or ineffective 1, 2
• Benzodiazepines (such as alprazolam) may be considered for short-term use or in treatment-resistant cases 7, 3
  • Alprazolam can be started at 0.5 mg three times daily and titrated as needed up to a maximum of 10 mg daily in divided doses 7
  • Benzodiazepines should be reserved for short-term use due to risk of dependence and tolerance 3
  • They can be combined with SSRIs in the first weeks of treatment before the onset of SSRI response 3
• Tricyclic antidepressants (TCAs) are equally effective as SSRIs but less well tolerated due to side effects 3, 6
• Monoamine oxidase inhibitors (MAOIs) can be efficacious but have unwanted effects that preclude their use as first-line treatments 3, 8

Combination Therapy

• Combination treatment (CBT plus SSRI) may be more effective than either treatment alone 2
• This approach can improve primary anxiety symptoms, global functioning, response to treatment, and remission rates 2

Special Considerations

• For elderly patients, escitalopram and sertraline are preferred due to their favorable safety profiles and lower potential for drug interactions 2
• For children and adolescents (6-18 years old), a combination of CBT and SSRI with parental oversight is recommended 1, 2
• When discontinuing medication, dosage should be reduced gradually to prevent withdrawal symptoms 7

Common Pitfalls to Avoid

• Starting with full therapeutic doses of SSRIs can temporarily worsen anxiety symptoms 2
• Abrupt discontinuation of shorter-acting SSRIs can lead to withdrawal symptoms 2
• Underestimating the importance of graduated exposure in CBT treatment 1
• Using benzodiazepines as first-line or long-term treatment due to dependence risk 3
• Failing to continue treatment for an adequate duration after symptom remission 2