What are the treatments for a panic attack?

Treatment of Panic Attacks

For acute panic attacks, use immediate grounding and breathing techniques, while for panic disorder with recurrent attacks, initiate cognitive behavioral therapy (CBT) as first-line treatment, with SSRIs (particularly paroxetine) or benzodiazepines (alprazolam) as pharmacologic options when needed. 1

Acute Management During a Panic Attack

Immediate interventions focus on preventing escalation and maintaining safety:

• Move the patient to a safe space where they are unlikely to injure themselves 2
• Provide reassurance that they are safe, but avoid constant reassurance or physical restraint 2
• Apply sensory grounding techniques to keep the person present in the moment: noticing environmental details (colors, textures, sounds), cognitive distractions (word games, counting backwards), or sensory-based distractors (flicking a rubber band on the wrist, feeling textured items) 2
• Implement breathing techniques such as diaphragmatic breathing to help regulate physiological arousal 2

A common pitfall is treating panic attacks like medical emergencies requiring sedation—most panic attacks resolve within minutes with supportive measures alone 2.

First-Line Treatment: Cognitive Behavioral Therapy

CBT is the evidence-based psychotherapy of choice for panic disorder and should include these core components:

• Psychoeducation about panic and anxiety, explaining the physiological fight-or-flight response 2, 1
• Diaphragmatic breathing techniques to counteract hyperventilation and restore normal respiratory patterns 2, 1
• Cognitive restructuring to address catastrophic thoughts and fear networks 2, 1
• Interoceptive exposure to desensitize patients to feared bodily sensations 2, 1
• In vivo exposure to feared situations that trigger panic 1

The evidence shows CBT produces significant improvements in panic attack frequency, PTSD severity, and overall distress 2. Treatment should continue for at least 9-12 months after recovery to prevent relapse 1.

Pharmacologic Treatment Options

SSRIs (Preferred Medication)

Paroxetine is FDA-approved for panic disorder and should be considered when pharmacotherapy is indicated 3:

• Effective for treating panic attacks characterized by palpitations, sweating, trembling, shortness of breath, chest pain, dizziness, and fear of losing control 3
• Long-term maintenance demonstrated in 3-month relapse prevention trials, with lower relapse rates compared to placebo 3
• Physician should periodically re-evaluate long-term usefulness for extended treatment 3

Benzodiazepines (Short-Term Use)

Alprazolam is FDA-approved for panic disorder but carries significant risks 4:

• Initial dosing: Start with 0.5 mg three times daily, may increase at 3-4 day intervals to maximum 4 mg/day in divided doses 4
• For panic disorder specifically: Doses of 1-10 mg daily were used in controlled trials, with mean dosage of 5-6 mg/day; some patients required up to 10 mg/day 4
• Critical warning: Risk of dependence increases with dose and duration; abrupt discontinuation must be avoided 4
• Tapering protocol: Decrease by no more than 0.5 mg every 3 days when discontinuing; some patients require even slower reduction 4

A major pitfall is using benzodiazepines as sole first-line treatment due to dependence risk—they should not replace CBT or SSRIs as primary therapy 1.

Adjunctive Interventions

Additional anxiety management strategies can augment primary treatment:

• Progressive muscle relaxation to reduce physiological tension 2, 1
• Mindfulness techniques that align with patient's cultural or religious practices 2, 5
• Regular cardiovascular exercise to reduce baseline anxiety 2
• Structured daily routines to prevent cognitive overload and minimize stress 2
• Graded exposure to anxiety-provoking tasks in stepwise fashion 2

Relaxation training may be considered as adjunctive treatment but should not replace evidence-based interventions 1.

Cultural Considerations

Cultural adaptation of CBT improves outcomes for specific populations:

• For Southeast Asian refugees: Incorporate culturally appropriate visualization (lotus blossom imagery), address "blocked wind" conceptualizations of panic, and consider treatment in culturally comfortable settings like Buddhist temples 2, 5
• Assessment of acculturation level is crucial—patients with lower acculturation benefit more from culturally adapted approaches 5
• Use culturally appropriate interpreters with mental health experience for accurate communication 5

The evidence demonstrates that culturally adapted CBT produces significant improvements in somatic sensations, panic attack frequency, and PTSD severity in refugee populations with treatment-resistant panic 2, 5.

Treatment Duration and Monitoring

Maintain treatment for adequate duration:

• Continue therapy for at least 9-12 months after recovery to prevent relapse 1
• For patients on alprazolam doses >4 mg/day, periodic reassessment and consideration of dose reduction is advised 4
• Patients in controlled trials were able to taper to 50% of maintenance dose after 3 months without loss of clinical benefit 4

Stopping treatment prematurely is a common pitfall—relapse rates increase significantly when treatment is discontinued before 9-12 months 1.

Differential Diagnosis Considerations

Rule out medical conditions that mimic panic attacks:

• In primary care settings with acute chest pain, look for pain affected by palpation, breathing, or movement (suggests non-cardiac origin) 2
• Panic attacks have sudden onset, build to peak rapidly, and include trembling, dizziness, derealization, paresthesias, and chills or hot flushes 2
• Failing to differentiate panic disorder from medical conditions is a critical pitfall that can delay appropriate treatment 1