What is the appropriate short‑acting benzodiazepine (diazepam) dosing for an adult with an acute panic attack while awaiting psychiatric evaluation?

Diazepam Dosing for Acute Panic Attack Pending Psychiatric Evaluation

For an adult experiencing an acute panic attack while awaiting psychiatric evaluation, administer diazepam 2–10 mg orally as a single dose, with the option to repeat every 3–4 hours if needed, but limit use to a maximum of 1–3 days to avoid dependence. 1

Immediate Dosing Strategy

• Start with 5–10 mg orally for moderate to severe panic symptoms, as this range provides rapid anxiolytic effect within 30–60 minutes while minimizing excessive sedation 1, 2
• Use 2–5 mg orally for milder panic symptoms or in elderly/debilitated patients, as lower doses reduce risk of psychomotor impairment 1
• Repeat dosing every 3–4 hours only if panic symptoms persist, but avoid exceeding 3–4 doses in the first 24 hours 1

Duration and Discontinuation

• Limit diazepam to 1–7 days maximum for acute panic episodes, as short-term use (ideally under 2 weeks) prevents tolerance and dependence while maintaining efficacy 2, 3
• Single-dose or intermittent use (taking medication only when panic occurs rather than scheduled dosing) is preferred over continuous daily administration for episodic panic 2, 3
• Taper gradually if more than 3–5 consecutive days of use occurred, reducing by 25% of the initial dose daily to minimize withdrawal reactions 1, 4

Why Diazepam for Panic Disorder

• Diazepam is the drug of choice for acute stress reactions and episodic anxiety due to its rapid onset (30–60 minutes), long duration of action (20–80 hour half-life allowing single daily dosing), and established efficacy in panic disorder 2, 5, 3
• Comparable efficacy to alprazolam but with less severe discontinuation problems, as alprazolam's short half-life is associated with particularly difficult withdrawal and serious rebound symptoms 5
• More practical than short-acting benzodiazepines (lorazepam, oxazepam) for panic attacks because diazepam's longer half-life provides sustained anxiolytic coverage and reduces interdose rebound anxiety 2, 3

Critical Safety Considerations

• Psychomotor impairment risk is significant, especially in elderly patients—warn against driving or operating machinery for 6–8 hours after dosing 2
• Paradoxical excitement occurs occasionally (particularly in elderly or psychiatric patients), manifesting as increased agitation rather than sedation—if this occurs, discontinue immediately 2
• Dependence develops rapidly with daily use beyond 2–4 weeks, making benzodiazepines unsuitable for long-term panic disorder management without specialist supervision 2, 6

Bridging to Definitive Treatment

• Benzodiazepines provide rapid symptom control (within hours) while awaiting psychiatric evaluation, but definitive panic disorder treatment requires SSRIs or cognitive-behavioral therapy, which take 4–8 weeks to achieve full effect 2, 6
• Combine with psychological measures whenever possible, as benzodiazepines alone do not address underlying panic disorder pathology 2
• Psychiatric evaluation should occur within 1–2 weeks to initiate appropriate long-term treatment and avoid prolonged benzodiazepine dependence 2, 6

Common Pitfalls to Avoid

• Do not prescribe scheduled daily dosing for more than 2 weeks without specialist input, as this rapidly leads to tolerance and dependence 2, 3
• Do not use alprazolam as first-line despite its popularity in panic disorder, because discontinuation is particularly difficult with serious rebound/withdrawal symptoms 5
• Do not abruptly stop after more than 5–7 days of consecutive use—always taper gradually to prevent withdrawal seizures and severe rebound anxiety 1, 2
• Do not assume benzodiazepines are definitive treatment—they are a bridge to psychiatric care, not a standalone solution for panic disorder 2, 6