What is the appropriate acute and short‑term management for a panic attack triggered by a physical or verbal altercation?

Acute Management of Panic Attack Following Physical or Verbal Altercation

For a panic attack triggered by a fight, immediately implement psychological first aid with structured breathing techniques and environmental modification, while explicitly avoiding benzodiazepines which worsen trauma-related outcomes. 1

Immediate Interventions (First 10-15 Minutes)

Environmental Control

• Move the patient to a private, quiet space away from the altercation scene to minimize anxiety-provoking stimuli and reduce physiological arousal. 2, 1
• Position the patient seated upright with slight forward lean ("coachman's seat") to optimize breathing mechanics. 1
• Apply cooling to the face using a cold compress or cool air to reduce sympathetic activation. 1

Structured Breathing Protocol

• Guide the patient through box breathing: inhale 4 seconds, hold 4 seconds, exhale 4 seconds, hold 4 seconds, repeating this cycle. 1
• This technique stabilizes tidal volume, prevents hyperventilation-induced hypocapnia, and stimulates vagal activity to reduce heart rate. 1
• Warn the patient they may initially experience "air hunger"—this sensation is benign and will pass with continued practice. 1
• Alternatively, use slow diaphragmatic breathing: breathe in through the nose, hold briefly, exhale slowly through pursed lips. 1

Reassurance and Grounding

• Repeatedly assure the patient that symptoms are not life-threatening and represent a normal stress response, not a medical emergency. 2, 1
• Deploy sensory grounding techniques: have the patient identify 5 things they can see, 4 they can touch, 3 they can hear, 2 they can smell, 1 they can taste. 2
• Use cognitive distraction such as counting backwards by 7s or naming categories (animals, cities). 2

Critical Differential Diagnosis

Rule Out Medical Emergencies

• In patients over 30 or with cardiac risk factors presenting with chest pain, rule out acute coronary syndrome before attributing symptoms solely to panic. 1
• Key features favoring panic over cardiac etiology: trembling, dizziness, derealization, paresthesias, chills/hot flushes, abrupt onset peaking within minutes. 1
• Pain worsened by palpation, breathing, or body position argues against angina. 1

Oxygen Therapy Considerations

• Do NOT administer oxygen unless oxygen saturation is documented <90%—pure hyperventilation from panic does not require oxygen. 1
• Avoid rebreathing from a paper bag as this may cause dangerous hypoxemia. 1

What NOT to Do

Benzodiazepines Are Contraindicated

• Do NOT prescribe benzodiazepines (alprazolam, clonazepam, lorazepam) for panic attacks following trauma—they increase PTSD chronicity from 23% to 63% at 6 months. 3, 4

Avoid Psychological Debriefing

• Do NOT conduct formal psychological debriefing where the patient is asked to ventilate emotions and relive the trauma—this worsens long-term outcomes. 1, 4

Short-Term Management (First 24-72 Hours)

Establish Safety and Routine

• Help the patient restore a sense of safety by identifying a safe environment and supportive people. 2
• Encourage return to normal routines (regular mealtimes, sleep schedule) to reduce the stress response after the unpredictability of the altercation. 2
• Prepare the patient for potential changes in routine to minimize additional stress triggers. 2

Sleep Management (If Needed)

• If insomnia develops, consider mirtazapine 15-30 mg at bedtime (minimum therapeutic dose 15 mg) rather than benzodiazepines. 3
• Trazodone 50-200 mg at bedtime is an alternative first-line option for trauma-related sleep disturbance. 3
• Short-acting non-benzodiazepine hypnotics (zolpidem 10 mg, eszopiclone 2-3 mg) may be used sparingly for sleep-onset insomnia only. 3

Psychological First Aid Principles

• Apply active listening without forcing the patient to discuss the traumatic event. 2, 4
• Provide practical assistance (transportation, contacting family, addressing immediate needs). 4
• Facilitate social connection with supportive individuals. 4

Follow-Up Plan (Within 2-3 Weeks)

Written Action Plan

• Develop a written crisis plan teaching the patient to recognize early warning signs (racing heart, tight chest, sense of impending doom) so they can implement box breathing and grounding before symptoms escalate. 1

Cognitive Behavioral Therapy Referral

• Refer for trauma-focused CBT starting 2-3 weeks post-incident, when acute stress reactions have stabilized. 4
• CBT should include 9-15 sessions combining prolonged exposure (imaginal and in vivo) with cognitive restructuring, achieving 40-87% remission. 4
• Starting CBT at approximately 2 weeks balances early intervention with allowing natural recovery processes. 4

Pharmacotherapy Consideration

• If anxiety persists beyond 2-3 weeks despite CBT, initiate an SSRI (sertraline up to 200 mg/day) or SNRI (venlafaxine extended-release), which show small-to-medium effect sizes for anxiety disorders. 4, 5
• Continue SSRI for 6-12 months after symptom remission due to high relapse rates (26-52%). 4
• Combine medication with trauma-focused CBT for optimal outcomes. 4

Common Pitfalls

• Mistaking panic for cardiac emergency: While cardiac workup may be appropriate in high-risk patients, recognize that panic attacks can produce intense chest pain and palpitations that are not dangerous. 1
• Prescribing benzodiazepines for "quick relief": This increases PTSD risk threefold and should be avoided despite patient requests. 3, 4
• Delaying CBT referral: Early trauma-focused therapy (2-3 weeks post-event) prevents chronicity better than waiting for "spontaneous recovery." 4
• Ignoring comorbid depression: Depression commonly co-occurs with panic disorder and requires concurrent treatment. 1

Monitoring and Reassessment

• Assess symptom trajectory weekly for the first 4 weeks. 3
• Screen for development of PTSD symptoms (intrusive memories, avoidance, negative mood changes, hyperarousal). 4
• Monitor for suicidal ideation, as panic disorder increases suicide risk. 6
• If symptoms persist or worsen beyond 3-4 weeks despite interventions, escalate to combined pharmacotherapy and intensive CBT. 4, 5