What is the first line of treatment for a patient experiencing a panic attack?

First-Line Treatment for Acute Panic Attack

For a patient experiencing an acute panic attack, provide immediate reassurance and implement calming techniques (controlled breathing, grounding exercises), while short-acting benzodiazepines can be used for rapid symptom relief if non-pharmacological measures are insufficient. 1

Immediate Non-Pharmacological Management

Non-pharmacological interventions should be the first approach and include:

• Reassurance and education about the self-limited nature of panic attacks 1
• Controlled breathing techniques to prevent hyperventilation 1
• Grounding exercises to reduce dissociative symptoms 1
• Environmental modifications such as moving to a quiet space, opening windows for fresh air, or using a fan to cool the face 1
• Relaxation training to improve emotional control and prevent escalation to full panic 1

These techniques reduce helplessness and anxiety while preventing the development of a full panic attack 1.

Pharmacological Management for Acute Episodes

When non-pharmacological measures are insufficient:

Short-acting benzodiazepines provide rapid relief for acute panic symptoms 1, 2:

• Alprazolam 0.25-0.5 mg orally is the most commonly used agent for acute panic attacks 2
• Onset of action occurs within 30-60 minutes 2
• Use should be limited to acute situations only, not as routine treatment, due to significant dependence risk 3

Critical caveat: Benzodiazepines carry substantial risk of dependence and should not be used as ongoing treatment for panic disorder 3. They are appropriate only for acute symptom management while longer-term treatments are initiated.

Transition to Long-Term Management

After stabilizing the acute episode, initiate definitive treatment:

First-Line Pharmacotherapy for Panic Disorder

SSRIs are the first-line pharmacological treatment for ongoing panic disorder 1, 3, 4:

• Sertraline 50-200 mg/day demonstrates significant efficacy with favorable tolerability 5, 6, 7
• Escitalopram 10-20 mg/day offers superior efficacy and lower discontinuation rates 3
• Paroxetine is FDA-approved for panic disorder 4, 8

Expected timeline: Improvement begins by week 2, becomes clinically significant by week 6, with maximal benefit by week 12 or later 3. Treatment should not be abandoned prematurely.

Psychological Treatment

Cognitive behavioral therapy (CBT) based on panic-specific protocols should be initiated 1:

• CBT principles including graded self-exposure are recommended for patients concerned about prior panic attacks 1
• Combining CBT with medication provides superior outcomes compared to either treatment alone 1, 3
• Individual CBT demonstrates large effect sizes (Hedges g = 1.01) 3

Treatment Algorithm

1. Acute episode: Non-pharmacological calming techniques first 1
2. If insufficient: Consider single dose of short-acting benzodiazepine (alprazolam 0.25-0.5 mg) 2
3. Within 24-48 hours: Initiate SSRI therapy (sertraline or escitalopram) 3, 4, 7
4. Concurrent: Refer for CBT 1, 3
5. Monitor: Assess for suicidal ideation, especially in first months of SSRI treatment 3

Medications to Avoid

Do not use benzodiazepines as routine replacement therapy due to dependence risk 3. Beta blockers (atenolol, propranolol) are deprecated based on negative evidence 1, 3.

Common Pitfalls

• Prescribing benzodiazepines for chronic use rather than limiting to acute episodes 3
• Discontinuing SSRIs prematurely before 12 weeks when full response has not yet occurred 3
• Failing to combine pharmacotherapy with CBT, which provides additive benefit 1, 3
• Not monitoring for treatment-emergent suicidal ideation in the first months of SSRI therapy 3