What are the treatment options for an anxiety attack?

Treatment of Anxiety Attack

For an acute anxiety attack, initiate slow-paced diaphragmatic breathing immediately (6 breaths per minute or slower) for at least 5 minutes, followed by cognitive behavioral therapy (CBT) as first-line treatment for ongoing anxiety management, with SSRIs (escitalopram 10-20 mg/day or sertraline 50-200 mg/day) reserved for moderate-to-severe symptoms or CBT failure. 1, 2

Immediate Management of Acute Anxiety Attack

Non-Pharmacological Intervention (First-Line)

• Implement slow-paced diaphragmatic breathing exercises immediately - this involves breathing at 6 breaths per minute or slower for a minimum of 5 minutes, which effectively reduces anxiety through modulation of autonomic nervous system activity 3, 4
• Slow breathing increases delta, theta, alpha, and beta band power on EEG and specifically decreases beta power during uncertain/anxious states, indicating reduced physiological arousal 3
• Sessions shorter than 5 minutes are associated with ineffective outcomes and should be avoided 4
• Human-guided training (in-person or video-guided) is more effective than written instructions alone 4

Acute Pharmacological Intervention (When Necessary)

• Alprazolam 0.25-0.5 mg orally can be used for immediate relief in patients with established anxiety disorders experiencing breakthrough panic attacks 5
• Dosing should not exceed 4 mg/day in divided doses, with increases at 3-4 day intervals if needed 5
• Critical caveat: Benzodiazepines carry significant dependence risk and should be reserved for acute situations only, not routine management 5

Ongoing Treatment After Initial Attack

First-Line: Cognitive Behavioral Therapy

• CBT should be initiated as the primary treatment approach with 12-20 structured sessions targeting anxiety-specific cognitive distortions, relaxation techniques, and gradual exposure when appropriate 1, 6
• CBT demonstrates large effect sizes (Hedges g = 1.01) for generalized anxiety disorder and is effective across anxiety subtypes 1
• Individual CBT is superior to group therapy in both clinical effectiveness and cost-effectiveness 1

Pharmacological Treatment Algorithm

When to Initiate Medication:

• Moderate-to-severe anxiety symptoms that impair function 6
• Inadequate response to CBT alone after 8 weeks 6
• Patient preference for pharmacotherapy 6
• History of positive medication response 6
• Severe symptoms or psychotic features 6

First-Line Medications:

• Start with escitalopram 5-10 mg daily or sertraline 25-50 mg daily - these are top-tier agents with superior efficacy, favorable side effect profiles, and lower discontinuation syndrome risk 1, 2
• Titrate escitalopram by 5-10 mg increments every 1-2 weeks to target dose of 10-20 mg/day 1
• Titrate sertraline by 25-50 mg increments every 1-2 weeks to target dose of 50-200 mg/day 1
• Start low to minimize initial anxiety/agitation that paradoxically occurs with SSRIs in the first 1-2 weeks 1, 2

Alternative First-Line Options:

• Fluoxetine 5-10 mg daily, titrated by 5-10 mg every 1-2 weeks to 20-40 mg/day - longer half-life beneficial for patients who miss doses occasionally 1, 7
• Venlafaxine XR 75-225 mg/day - effective but requires blood pressure monitoring due to hypertension risk 1, 2
• Duloxetine 60-120 mg/day - particularly useful with comorbid pain conditions 1

Medications to Avoid or Use Cautiously:

• Paroxetine has higher discontinuation syndrome risk and potentially increased suicidal thinking compared to other SSRIs - reserve for when first-tier agents fail 1, 2
• Fluvoxamine has greater drug-drug interaction potential 2
• Tricyclic antidepressants should be avoided due to cardiac toxicity risk 1

Response Monitoring and Adjustment

Timeline for Expected Response:

• Statistically significant improvement may begin by week 2 1
• Clinically significant improvement expected by week 6 1
• Maximal therapeutic benefit achieved by week 12 or later 1
• Do not abandon treatment prematurely - full response requires patience 1

Monitoring Schedule:

• Assess at weeks 4 and 8 using standardized anxiety rating scales (e.g., GAD-7, HAM-A) 6, 1
• Monitor for common SSRI/SNRI side effects: nausea, sexual dysfunction, headache, insomnia, dizziness 1
• Monitor closely for suicidal thinking, especially in first months and after dose changes (NNH = 143) 1

If Inadequate Response at 8 Weeks:

• Switch to a different SSRI (e.g., sertraline to escitalopram or vice versa) 6, 1
• Add CBT if not already implemented 6
• Consider switching to SNRI (venlafaxine or duloxetine) 1
• Consider adding pregabalin/gabapentin as second-line option, particularly with comorbid pain 1

Combined Treatment Approach

• Combination of medication plus CBT provides optimal outcomes and is preferred over monotherapy when moderate-to-severe symptoms are present 6, 2
• This approach addresses both immediate symptom relief (medication) and long-term coping skills (CBT) 6

Critical Pitfalls to Avoid

• Never escalate SSRI doses too quickly - allow 1-2 weeks between increases to assess tolerability and avoid overshooting therapeutic window 1
• Never abruptly discontinue SSRIs/SNRIs - taper gradually to avoid discontinuation syndrome (dizziness, fatigue, headaches, nausea, rebound anxiety) 2, 5
• Shorter half-life SSRIs (sertraline, paroxetine) require more gradual tapering than fluoxetine 2
• Do not use benzodiazepines as long-term treatment - dependence risk increases with dose and duration 5
• Avoid breathing exercises shorter than 5 minutes or fast-paced breathing, which are ineffective 4
• Do not use beta-blockers (atenolol, propranolol) for anxiety disorders - negative evidence for efficacy 1

Special Populations

Comorbid Depression and Anxiety:

• Prioritize treatment of depressive symptoms first, or use unified protocol combining CBT for both conditions 6

Cultural Considerations:

• For certain populations (e.g., Southeast Asian refugees), incorporate culturally adapted CBT including mindfulness, culturally appropriate visualization, and addressing somatic conceptualizations of anxiety (e.g., "blocked wind") 6

Cancer Patients:

• Provide psychoeducation about commonality of anxiety, symptoms, and when to contact medical team 6
• Alprazolam and fluoxetine have demonstrated efficacy in this population 6