What is the treatment for panic and anxiety attacks?

Difference Between Panic Attack and Anxiety Attack

Panic attacks are a distinct clinical entity with specific diagnostic criteria (DSM-IV), while "anxiety attacks" is not a formal medical diagnosis but rather colloquial terminology for heightened anxiety symptoms. 1

Clinical Definition of Panic Attack

A panic attack is formally defined as a discrete period of intense fear or discomfort in which four or more of the following symptoms develop abruptly and reach a peak within 10 minutes: 1

• Palpitations, pounding heart, or accelerated heart rate 1
• Sweating 1
• Trembling or shaking 1
• Sensations of shortness of breath or smothering 1
• Feeling of choking 1
• Chest pain or discomfort 1
• Nausea or abdominal distress 1
• Feeling dizzy, unsteady, lightheaded, or faint 1
• Derealization (feelings of unreality) or depersonalization (being detached from oneself) 1
• Fear of losing control 1
• Fear of dying 1
• Paresthesias (numbness or tingling sensations) 1
• Chills or hot flushes 1

What People Call "Anxiety Attacks"

When patients describe "anxiety attacks," they typically refer to symptoms of generalized anxiety that may include: 1

• Unrealistic or excessive worry about multiple life circumstances 1
• Motor tension (trembling, muscle tension, restlessness, easy fatigability) 1
• Autonomic hyperactivity (shortness of breath, palpitations, sweating, dry mouth, dizziness, nausea) 1
• Vigilance and scanning (feeling keyed up or on edge, exaggerated startle response, difficulty concentrating, trouble sleeping, irritability) 1

The key distinction is that panic attacks have a sudden onset, reach peak intensity within 10 minutes, and require at least 4 specific symptoms, whereas generalized anxiety symptoms build more gradually and persist over longer periods. 1

Treatment Approach

For Panic Disorder (Recurrent Panic Attacks)

Combination treatment with cognitive-behavioral therapy (CBT) plus an SSRI provides superior outcomes compared to either treatment alone. 2, 3

First-line pharmacotherapy: 4, 3

• Sertraline: Start 25-50 mg daily, titrate by 25-50 mg every 1-2 weeks to target dose of 50-200 mg/day 4
• Escitalopram: Start 5-10 mg daily, titrate by 5-10 mg increments to target dose of 10-20 mg/day 4
• Fluoxetine: Start 5-10 mg daily, increase by 5-10 mg every 1-2 weeks to target dose of 20-40 mg/day 4

Expected timeline: Statistically significant improvement begins at week 2, clinically significant improvement by week 6, maximal benefit by week 12 or later 4

CBT components for panic disorder: 2, 3

• Education about the nature of panic disorder 3
• Cognitive restructuring to challenge catastrophic misinterpretations of bodily sensations 3
• Interoceptive exposure (deliberately inducing feared physical sensations in a controlled manner) 2
• Breathing retraining and relaxation techniques 3
• Gradual exposure to situations that trigger panic 3

For Generalized Anxiety Disorder

CBT is recommended as first-line treatment for mild to moderate presentations, with SSRIs/SNRIs as alternatives for more severe presentations or when quality CBT is unavailable. 5

First-line medications: 4

• Escitalopram or sertraline (SSRIs) 4
• Duloxetine 60-120 mg/day (SNRI) - particularly beneficial for comorbid pain conditions 4
• Venlafaxine extended-release 75-225 mg/day (SNRI) - requires blood pressure monitoring 4

CBT for GAD includes: 4

• Education on anxiety 4
• Cognitive restructuring to challenge distortions 4
• Relaxation techniques 4
• Gradual exposure when appropriate 4
• Structured duration of 12-20 sessions 4

Critical Monitoring and Safety Considerations

All SSRIs carry a boxed warning for suicidal thinking and behavior, with pooled absolute rates of 1% versus 0.2% for placebo. 4 Close monitoring is essential, especially in the first months and following dose adjustments. 4

Common SSRI/SNRI side effects that emerge within the first few weeks include nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, and dizziness. 4 Most resolve with continued treatment. 4

What to Avoid

Benzodiazepines (such as alprazolam) should be reserved for short-term use only due to risks of dependence, tolerance, and withdrawal. 4, 1 While alprazolam is FDA-approved for panic disorder and can provide rapid symptom relief, 1 the risk of dependence increases with dose and duration of treatment. 1 Abrupt discontinuation must be avoided - dosage should be decreased by no more than 0.5 mg every 3 days when discontinuing. 1

Tricyclic antidepressants should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity. 4

Treatment Duration

Medications should be continued for at least 12-24 months after remission, 6, 7 and in some cases indefinitely for panic disorder. 7 Discontinue gradually to avoid withdrawal symptoms, particularly with shorter half-life SSRIs. 4