What is the recommended treatment for panic attacks?

Treatment of Panic Attack

Immediate Management of Acute Panic Attack

For an acute panic attack, implement psychological first aid with structured breathing techniques and reassurance, reserving benzodiazepines only for severe cases while avoiding them in patients with substance use history, respiratory disorders, or elderly patients. 1, 2

Environmental and Psychological Interventions

• Place the patient in a private room when possible to minimize anxiety-provoking stimuli. 1
• Guide the patient through box breathing (4-4-4-4 pattern: inhale 4 seconds, hold 4 seconds, exhale 4 seconds, hold 4 seconds) while seated upright with a slight forward lean. This mitigates hyperventilation-induced hypocapnia, stabilizes tidal volume, and stimulates vagal activity to reduce heart rate. 1
• Apply a cold compress or cool air to the face to reduce physiological arousal. 1
• Provide explicit reassurance that symptoms are not life-threatening and will resolve, as patients experiencing panic often fear they are dying or having a heart attack. 1
• Avoid rebreathing from a paper bag, as this may cause dangerous hypoxemia. 1

Pharmacological Management for Acute Episodes

• Administer a benzodiazepine only for rapid symptom relief in severe acute panic attacks. 2
• Benzodiazepines should be limited to short-term use (first few weeks only) while waiting for SSRI onset of action, then tapered and discontinued. 2
• Completely avoid benzodiazepines in patients with substance use history, respiratory disorders, or elderly patients due to risks of dependence, tolerance, and adverse outcomes. 2

Critical Differential Diagnosis

• Rule out acute coronary syndrome in patients over 30 years old or with cardiac risk factors, as the likelihood of angina increases dramatically with age (67% in men aged 30-39 to 94% in men aged 60-69). 1
• Key features distinguishing panic from cardiac causes include trembling, dizziness, de-realization, paresthesias, chills or hot flushes, and abrupt onset peaking within minutes. 1
• Pain affected by palpation, breathing, or body position argues against angina. 1

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Long-Term Treatment of Panic Disorder

Begin treatment with sertraline 25-50 mg daily or escitalopram 5-10 mg daily combined with cognitive behavioral therapy, as combination treatment demonstrates superior response rates and remission compared to monotherapy. 2, 3

First-Line Pharmacotherapy: SSRIs

• Start with sertraline or escitalopram due to superior evidence for efficacy and tolerability. 2
• Sertraline dosing: initiate at 25-50 mg daily, titrate by 25-50 mg every 1-2 weeks to target dose of 50-200 mg/day. 2, 4
• Escitalopram dosing: initiate at 5-10 mg daily, titrate by 5-10 mg every 1-2 weeks to target dose of 10-20 mg/day. 2
• Critical: begin with a subtherapeutic "test" dose to minimize initial anxiety or agitation that commonly occurs with SSRI initiation, as panic disorder patients are hypersensitive to physical sensations. 2, 3

Expected Timeline and Monitoring

• Statistically significant improvement may begin by week 2, with clinically significant improvement expected by week 4-6. 2
• Maximal therapeutic effect occurs by week 12; do not abandon treatment prematurely. 2
• Monitor closely for suicidal thinking and behavior, especially in the first months and after dose adjustments (pooled risk 1% vs 0.2% placebo; number needed to harm = 143). 2
• Assess treatment response at 4-6 weeks using standardized symptom rating scales. 2, 3

Second-Line Pharmacotherapy

• Switch to a different SSRI if inadequate response after 6-8 weeks at therapeutic dose. 2
• Consider venlafaxine extended-release 75-225 mg/day as an alternative first-line option for patients who fail or cannot tolerate SSRIs. 2, 3
• Venlafaxine requires blood pressure monitoring due to risk of sustained hypertension. 2

Medications to Avoid

• Avoid tricyclic antidepressants despite equal efficacy due to unfavorable risk-benefit profile, particularly cardiac toxicity. 2, 5
• Long-term benzodiazepines carry significant risks of dependence, tolerance, and withdrawal, with evidence showing 63% of trauma patients on benzodiazepines developed PTSD versus only 23% on placebo. 2
• Beta-blockers have limited evidence for panic disorder and should be reserved for performance anxiety only. 2

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Cognitive Behavioral Therapy Integration

Individual CBT following the Clark and Wells or Heimberg model should be offered as monotherapy or combined with medication, with combination treatment showing superior outcomes. 3, 2

Core CBT Components

• Education on anxiety mechanisms and the fight-or-flight response is fundamental. 2
• Cognitive restructuring to challenge catastrophic thinking patterns (catastrophizing, over-generalization, negative predictions, all-or-nothing thinking) is essential. 2, 6
• Graduated in vivo exposure to feared physical sensations and situations reduces avoidance behaviors and increases tolerance. 2
• Relaxation techniques including diaphragmatic breathing and progressive muscle relaxation reduce physiological tension. 2, 6
• Structured duration of 12-20 sessions is recommended. 2, 7

CBT Delivery Format

• Individual CBT is prioritized over group therapy due to superior clinical and health-economic effectiveness. 3
• If the patient refuses face-to-face CBT, offer self-help with support based on CBT principles. 3

Special Populations: Children and Adolescents

• For patients 6-18 years old with panic disorder, combination treatment (CBT plus SSRI) is preferentially recommended over monotherapy. 3
• Parental oversight of medication regimens is paramount in pediatric populations. 3

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Treatment Duration and Discontinuation

• Continue treatment for 9-12 months after recovery to prevent relapse. 2
• Taper gradually when discontinuing to avoid discontinuation syndrome (dizziness, fatigue, nausea, sensory disturbances, anxiety, irritability). 2, 3
• For shorter half-life SSRIs (sertraline, paroxetine, fluvoxamine): decrease by no more than 25-50% every 1-2 weeks. 2, 3
• For longer half-life SSRIs (fluoxetine): taper at approximately 3-4 week intervals. 3

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Post-Attack Management and Prevention

Develop a written action plan for managing future episodes, teaching patients to recognize early warning signs (racing heart, tight chest, sense of impending doom) so they can implement coping strategies before symptoms escalate. 1

Grounding and Coping Techniques

• Teach sensory grounding techniques for use at warning signs: noticing environmental details (colors, textures, sounds), cognitive distractions (word games, counting backwards), or sensory-based distractors (flicking rubber band on wrist). 1
• Practice diaphragmatic breathing techniques daily as a foundational skill that can abort panic attacks when warning signs appear. 6

Lifestyle Modifications

• Implement structured daily routines with regular aerobic exercise combined with daily breathing and relaxation techniques. 6
• Regular cardiovascular exercise helps manage physiological manifestations of anxiety and reduces panic attack frequency. 6
• Gradually reduce avoidance behaviors by creating a hierarchy of feared situations and approaching them in a stepwise manner. 6
• Avoid relying solely on avoidance as a coping strategy, as this perpetuates and worsens anxiety over time. 6

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Critical Pitfalls to Avoid

• Never recommend psychological debriefing (formal structured interventions where patients relive the trauma), as this may worsen outcomes. 1
• Do not provide oxygen therapy unless the patient is actually hypoxemic (oxygen saturation <90%), as patients with pure hyperventilation due to panic are unlikely to require oxygen. 1
• Avoid constant reassurance-seeking during panic episodes, as this reinforces anxiety. 6
• Do not stop anxiety management techniques once symptoms improve, as this leads to relapse. 6

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Comorbidity Considerations

• Screen for depression, as it occurs commonly with panic disorder and untreated depression can significantly influence outcomes and quality of life. 1