What are the treatment options for a panic attack?

Treatment of Panic Attacks

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

Immediate Management During an Acute Panic Attack

When a patient is experiencing an active panic attack, implement these evidence-based interventions:

• Practice diaphragmatic breathing immediately when warning signs appear, as this can abort panic attacks and restore normal respiratory patterns 2, 3
• Use sensory grounding techniques to anchor the patient in the present moment and prevent dissociation 2
• Apply cognitive distraction to redirect attention away from catastrophic thoughts about physical sensations 2
• Avoid providing constant reassurance, as this reinforces the anxiety cycle 2

First-Line Treatment Algorithm

Psychotherapy as Primary Treatment

• Start with CBT specifically designed for panic disorder, which targets the catastrophic misinterpretation of physical sensations that drives the panic cycle 1, 4
• CBT should focus on eliminating anticipatory anxiety, breaking avoidance patterns, and normalizing physiological sensations 1
• If CBT-trained therapists are unavailable, implement problem-solving approaches based on CBT principles 1

Pharmacotherapy Initiation

When medication is indicated:

• Begin with sertraline 25-50 mg daily or escitalopram 10 mg daily due to their favorable efficacy and tolerability profiles 1
• Start 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 sertraline or escitalopram 1
• Expect 4-6 weeks for clinically significant improvement and up to 12 weeks for maximal therapeutic effect 1
• Paroxetine is FDA-approved for panic disorder and demonstrated efficacy in three 10-12 week trials, with long-term maintenance proven in a 3-month relapse prevention trial 5

Combination Therapy Strategy

• Preferentially recommend combination treatment (CBT plus SSRI) over monotherapy, as this approach shows superior response rates and remission compared to either treatment alone 1

Lifestyle and Behavioral Interventions

These form the foundation of non-pharmacological management:

• Implement structured daily routines with regular aerobic exercise, as cardiovascular activity reduces panic attack frequency 2
• Practice diaphragmatic breathing techniques daily, not just during panic episodes 2, 3
• Use progressive muscle relaxation as a regular practice to reduce physiological tension 2
• Establish consistent sleep-wake schedules as part of overall routine structure 2
• Create a hierarchy of feared situations and gradually approach them in a stepwise manner to reduce avoidance behaviors 2

Treatment-Resistant Cases

If inadequate response occurs:

• After 6-8 weeks at therapeutic SSRI dose, switch to a different SSRI or consider venlafaxine extended-release 1
• Venlafaxine can be offered for patients who fail or cannot tolerate SSRIs, with demonstrated efficacy across anxiety disorders including panic 1

Treatment Duration and Maintenance

• Continue antidepressant treatment for 9-12 months after recovery to prevent relapse 1
• Assess treatment response within 4-6 weeks of reaching therapeutic dose using standardized symptom rating scales 1
• Taper SSRIs gradually when discontinuing to avoid discontinuation syndrome (dizziness, fatigue, nausea, sensory disturbances, anxiety) 1

Role of Benzodiazepines

While alprazolam is FDA-approved for panic disorder with doses of 1-10 mg daily (mean 5-6 mg) showing efficacy 6:

• Avoid benzodiazepines entirely in patients with substance use history, respiratory disorders, or elderly patients 1
• If alprazolam is used, initiate at 0.5 mg three times daily and titrate slowly at 3-4 day intervals 6
• When discontinuing, reduce by no more than 0.5 mg every 3 days, as abrupt discontinuation causes dangerous withdrawal 6
• Recognize that benzodiazepines carry significant dependence risk that increases with dose and duration 6

Critical Pitfalls to Avoid

• 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 1
• Avoid relying solely on avoidance as a coping strategy, as this perpetuates and worsens anxiety over time 2
• Do not allow patients to stop practicing anxiety management techniques once symptoms improve, as this leads to relapse 2
• Monitor for serotonin syndrome, behavioral activation/agitation, and hypomania/mania during SSRI initiation and dose adjustments 1

Special Populations

For culturally diverse populations, particularly Southeast Asian refugees:

• Integrate cultural conceptualizations of anxiety and distress (such as "blocked wind" or chi) into treatment 7
• Use culturally appropriate visualization techniques, such as lotus blossom imagery for Asian populations 7
• Conduct treatment in culturally comfortable environments when possible 7
• Assess acculturation level, as those with lower acculturation benefit more from culturally adapted approaches 7