Management of New Panic Attacks After Assault
Begin trauma-focused psychotherapy immediately without delay, as early psychological intervention prevents chronic PTSD development, and avoid benzodiazepines entirely—they triple PTSD risk compared to placebo. 1
Immediate Safety and Psychological First Aid
Conduct a thorough safety assessment including screening for suicidal ideation, self-harm behaviors, and ensuring the patient is in a physically safe environment away from the perpetrator. 2, 3
Implement Psychological First Aid (PFA) focusing on four core elements: promoting safety, calmness, self-efficacy, and connectedness through active listening, rapport building, and non-directive emotional support. 2
Use grounding techniques immediately including breathing retraining, progressive muscle relaxation, or mindfulness practice to address acute panic symptoms and agitation. 2
Normalize the stress response by explaining that panic attacks are common reactions to trauma (occurring in 53-90% of trauma survivors) and typically resolve with appropriate treatment. 4
Trauma-Focused Psychotherapy: First-Line Treatment
Initiate trauma-focused cognitive behavioral therapy (TF-CBT), Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), or EMDR as soon as possible—do not delay treatment by requiring a prolonged "stabilization phase." 1
These evidence-based therapies achieve 40-87% remission rates for PTSD after 9-15 sessions and directly address both panic symptoms and underlying trauma. 1, 5
Delaying trauma-focused treatment is iatrogenic, potentially reducing self-confidence and treatment motivation by inadvertently communicating the patient cannot handle their traumatic memories. 1
Problem-solving treatment and behavioral activation can be considered as adjunct approaches for patients in substantial distress. 2
Pharmacotherapy Considerations
What to AVOID:
Never prescribe benzodiazepines for panic attacks or anxiety following trauma. 1
63% of patients receiving benzodiazepines developed PTSD at 6 months compared to only 23% receiving placebo—this represents a tripling of PTSD risk. 1
Despite their ranking as most effective for acute panic symptoms in general panic disorder, benzodiazepines are contraindicated in the post-trauma context. 6
When to Consider SSRIs:
For moderate to severe panic symptoms that persist despite psychotherapy, consider FDA-approved SSRIs: paroxetine 10-40 mg/day or sertraline (equivalent dosing). 2, 1, 6
SSRIs show 53-85% response rates in panic disorder and should be continued for at least 9-12 months after symptom remission to prevent relapse. 2, 1
Psychotherapy should be attempted first; medication is an adjunct, not a replacement for trauma-focused treatment. 5
Paroxetine and fluoxetine have stronger evidence of efficacy than sertraline for panic symptoms specifically. 6
Practical Assistance and Connectedness
Provide concrete problem-solving assistance for immediate practical concerns (safety planning, housing, legal resources, medical care) to promote self-efficacy. 2
Facilitate connection with social support by encouraging the patient to reach out to trusted friends, family, or support groups while respecting their autonomy about disclosure. 2
Arrange prompt mental health follow-up with professionals experienced in trauma treatment, ideally through a "warm handoff" rather than simply providing referral information. 5
Follow-Up and Monitoring
Schedule follow-up within 1-2 weeks to assess treatment response, medication adherence if prescribed, and ensure psychotherapy has been initiated. 7, 5
Monitor for comorbid conditions including depression (using PHQ-9), substance use, and ongoing suicidal ideation, as panic disorder increases suicide risk. 2, 5, 8
Continue trauma-focused psychotherapy for the full 9-15 session course even if panic symptoms improve earlier, as this prevents PTSD development. 1
Critical Pitfalls to Avoid
Do not label the patient as "too complex" for standard trauma-focused therapy—this has iatrogenic effects suggesting treatments will be ineffective. 1
Do not insist on extended stabilization before trauma processing—evidence does not support this approach and delays effective treatment. 1
Do not use psychological debriefing within 24-72 hours post-trauma—this approach is not supported by evidence and may be harmful. 2, 5
Do not prescribe benzodiazepines even though they are effective for general panic disorder—the post-trauma context fundamentally changes the risk-benefit calculation. 1, 6
Recognize that 77% of trauma survivors experience panic attacks during trauma and 47% report recurrent attacks afterward—this is expected, not a sign of treatment failure. 4