What is the first line management for a panic attack?

First-Line Management for Panic Attack

Cognitive-behavioral therapy (CBT) is the first-line treatment for panic attacks, either as monotherapy or in combination with an SSRI (sertraline or escitalopram), with combination therapy demonstrating superior remission rates compared to either treatment alone. 1

Immediate Acute Management

When a patient presents with an active panic attack, implement the following interventions:

• Apply psychological first aid principles including reassurance that symptoms are not life-threatening, despite their intensity 2
• Guide controlled breathing: Instruct the patient to take slow, deep breaths through the nose, hold briefly, and exhale slowly through pursed lips to interrupt catastrophic thinking 2
• Position the patient comfortably in a seated position with upper body elevated (the "coachman's seat" position optimizes breathing) 2
• Apply cooling to the face using a cold compress or cool air to reduce physiological arousal 2

Critical caveat: First rule out medical emergencies that mimic panic attacks, particularly cardiac events, before attributing symptoms to panic disorder 2

Long-Term Treatment Algorithm

First-Line: CBT-Based Interventions

CBT specifically designed for panic disorder is the gold standard, focusing on eliminating catastrophic misinterpretations of physical sensations and breaking the cycle of anticipatory anxiety, panic, and avoidance 1, 3

• CBT typically consists of 12-15 sessions delivered in individual or group format 3
• If CBT-trained therapists are unavailable, use problem-solving approaches based on CBT principles for patients concerned about prior panic attacks 1
• CBT offers particular cost-effectiveness relative to pharmacotherapy alone or combined treatment 4

First-Line: Pharmacotherapy Options

When initiating medication treatment:

• Start with sertraline 25-50 mg daily or escitalopram 10 mg daily due to favorable efficacy and tolerability profiles 1, 5
• Begin with a subtherapeutic "test" dose to minimize initial anxiety or agitation, as panic patients are hypersensitive to physical sensations 1
• Titrate slowly: at 1-2 week intervals for shorter half-life SSRIs (sertraline, escitalopram) or 3-4 week intervals for fluoxetine 1
• Expect 4-6 weeks for clinically significant improvement and up to 12 weeks for maximal therapeutic effect 1
• Monitor for serotonin syndrome, behavioral activation/agitation, and hypomania/mania during SSRI initiation and dose adjustments 1

Optimal Strategy: Combination Therapy

Combination treatment (CBT plus SSRI) is preferentially recommended over monotherapy, showing superior response rates and remission compared to either treatment alone 1, 4

Second-Line Options

If patients fail or cannot tolerate SSRIs:

• Venlafaxine extended-release can be offered, with demonstrated efficacy across anxiety disorders including panic 1
• Assess treatment response within 4-6 weeks of reaching therapeutic dose using standardized symptom rating scales 1
• If inadequate response after 6-8 weeks at therapeutic dose, switch to a different SSRI or consider SNRI (venlafaxine) 1

Treatment Duration and Maintenance

• Continue antidepressant treatment for 9-12 months after recovery to prevent relapse 1
• Taper SSRIs gradually when discontinuing to avoid discontinuation syndrome (dizziness, fatigue, nausea, sensory disturbances, anxiety) 1

Critical Pitfalls to Avoid

• Do not use benzodiazepines entirely in patients with substance use history, respiratory disorders, or elderly patients 1
• Do not stop antidepressants before 9-12 months after recovery, as relapse is frequent 1
• Do not use psychological debriefing for recent traumatic events, as it does not reduce panic, anxiety, or PTSD symptoms and may worsen outcomes 6, 2
• Do not overlook that most primary care patients prefer psychological treatments over pharmacotherapy for anxiety 6

Patient Education Components

• Educate patients that panic attacks are benign despite intense physical symptoms 2
• Develop a written plan for managing future episodes and teach patients to recognize early warning signs so they can implement coping strategies before symptoms escalate 2
• Consider referral for CBT which has strong evidence for treating panic disorder 2, 7