What is the recommended acute and long‑term management of a panic attack, including evaluation, medication, and psychotherapy?

Management of Panic Attack

Immediate Acute Management

For an acute panic attack, immediately implement psychological first aid with structured breathing control—specifically "box breathing" (4-second inhale, 4-second hold, 4-second exhale, 4-second hold)—combined with reassurance that symptoms are not life-threatening. 1

Environmental and Positioning Interventions

• Place the patient in a private room to minimize anxiety-provoking stimuli 1
• Position the patient seated upright with slight forward lean (coachman's seat position) to optimize ventilatory capacity 1
• Apply cooling to the face (cold compress or cool air) to reduce physiological arousal 1

Breathing Techniques

• Guide slow diaphragmatic breathing: inhale through nose, hold briefly, exhale slowly through pursed lips 1
• The 4-4-4-4 box breathing pattern stabilizes tidal volume and respiratory rate, preventing hyperventilation-induced hypocapnia and cerebral vasoconstriction 1
• Warn patients about initial "air hunger" sensations before starting breathing exercises; explicit reassurance that these sensations are benign improves adherence 1

Cognitive Interventions

• Provide immediate reassurance that symptoms, despite their intensity, are not medically dangerous 1
• Use sensory grounding techniques: notice environmental details (colors, textures, sounds), cognitive distractions (counting backwards), or sensory-based distractors (flicking rubber band on wrist) 1
• The rhythmic breathing pattern diverts attention from bodily sensations, interrupting the catastrophic-thought cycle 1

Critical Differential Diagnosis

Rule out acute coronary syndrome in patients over 30 years old or with cardiac risk factors—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: 1

• Panic-specific symptoms: trembling, dizziness, derealization, paresthesias, chills/hot flushes, abrupt onset peaking within minutes
• Against angina: pain affected by palpation, breathing, turning/twisting, or pain from multiple sites

Oxygen Therapy Considerations

• Do NOT provide oxygen therapy unless oxygen saturation is documented <90% 1
• Patients with pure hyperventilation from panic do not require oxygen 1
• Avoid rebreathing from paper bags—this may cause dangerous hypoxemia 1

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Pharmacological Management for Acute Episodes

Administer a benzodiazepine (e.g., lorazepam) for rapid symptom relief during the acute attack, but limit use to short-term only (first few weeks) while awaiting SSRI onset. 2

Benzodiazepine Guidelines

• Use only for the first few weeks while waiting for SSRI therapeutic effect, then taper and discontinue 2
• Absolutely avoid in patients with substance use history, respiratory disorders, or elderly patients 2
• Long-term benzodiazepine use worsens outcomes: 63% of trauma patients on benzodiazepines developed PTSD versus 23% on placebo 2

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Long-Term Pharmacotherapy

Initiate sertraline 25-50 mg daily or escitalopram 5-10 mg daily combined with cognitive-behavioral therapy; combination therapy yields superior response and remission rates compared to either modality alone. 2

SSRI Initiation Protocol

• Start with sub-therapeutic "test" dose to minimize initial anxiety/agitation that commonly occurs in panic disorder patients hypersensitive to physical sensations 2
• Sertraline: start 25-50 mg daily, titrate by 25-50 mg every 1-2 weeks to target 50-200 mg/day 2
• Escitalopram: start 5-10 mg daily, titrate by 5-10 mg every 1-2 weeks to target 10-20 mg/day 2

Expected Timeline

• Statistically significant improvement by week 2 2
• Clinically meaningful improvement by weeks 4-6 2
• Maximal therapeutic effect by week 12—do not abandon treatment prematurely 2

Monitoring Requirements

• Assess treatment response at 4-6 weeks using standardized panic-symptom rating scales 2
• Monitor closely for suicidal ideation, especially during first months and after dose adjustments (pooled risk 1% vs 0.2% placebo; number needed to harm = 143) 2
• Monitor for serotonin syndrome, behavioral activation/agitation, and hypomania/mania 2

Second-Line Options

• Switch to a different SSRI if inadequate response after 6-8 weeks at therapeutic dose 2
• Venlafaxine extended-release 75-225 mg/day is an evidence-supported alternative for patients who fail or cannot tolerate SSRIs 2
• Venlafaxine requires blood pressure monitoring due to risk of sustained hypertension 2

Medications to Avoid

• Tricyclic antidepressants: avoid due to unfavorable risk-benefit profile, particularly cardiac toxicity 2
• Beta-blockers: limited evidence for panic disorder (may be used for performance anxiety only) 2
• Long-term benzodiazepines: significant risks of dependence, tolerance, and withdrawal 2

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Cognitive-Behavioral Therapy (CBT)

Offer individual CBT based on structured protocols, either as monotherapy or combined with medication; prioritize individual over group formats due to superior clinical effectiveness. 2

Core CBT Components

• Education on anxiety mechanisms and fight-or-flight response 2
• Cognitive restructuring to challenge catastrophic thinking patterns 2
• Graduated exposure to feared physical sensations (interoceptive exposure) and avoided situations (in vivo exposure) 2
• Relaxation techniques: breathing retraining and progressive muscle relaxation 2

Treatment Structure

• 12-20 structured sessions recommended 2
• When patients decline face-to-face CBT, provide structured self-help program with therapist support following core CBT principles 2

Cultural Considerations

• Extended psychoeducation phase, emphasis on in vivo exposure, discussion of cultural stressors, and cultural sensitivity improve outcomes in diverse populations 2

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Post-Attack Management Plan

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

• Teach sensory grounding techniques for use at warning signs 1
• Box breathing can be incorporated as interoceptive exposure within CBT, allowing patients to experience and tolerate mild breath-linked sensations without catastrophic outcomes 1

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Treatment Duration and Discontinuation

Continue effective pharmacologic or CBT treatment for 9-12 months after remission to reduce relapse risk. 2

Tapering Protocol

• Taper gradually to avoid discontinuation syndrome (dizziness, fatigue, nausea, sensory disturbances, anxiety) 2
• Short half-life SSRIs (sertraline, paroxetine): reduce dose by no more than 25-50% every 1-2 weeks 2
• Long half-life SSRIs (fluoxetine): taper at intervals of approximately 3-4 weeks 2

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Special Populations

Pediatric Patients (Ages 6-18)

Combined CBT + SSRI therapy is preferred over monotherapy in children and adolescents with panic disorder. 2

• Use sertraline or escitalopram as first-line agents 2
• Ensure parental oversight of medication administration and adherence 2

Elderly Patients

• SSRIs are recommended as initial choice in older patients 3
• Start at low dosage to avoid initial exacerbation of anxiety, then gradually increase to therapeutic range 3
• Avoid benzodiazepines in elderly due to fall risk, cognitive impairment, and dependence 2
• Conduct careful search for depressive disorder, physical illness, or drugs contributing to panic attacks that begin in late life 3

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Comorbidity Considerations

Depression occurs commonly with panic disorder; untreated depression can influence end-of-life preferences and overall outcomes. 1

• Screen for and treat concurrent substance use disorders 4
• Assess for other anxiety disorders: social phobia, generalized anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder 5

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Critical Pitfalls to Avoid

• Never perform psychological debriefing (formal structured interventions where patients ventilate emotions and relive trauma)—this may worsen outcomes 1
• Never use paper bag rebreathing—risk of hypoxemia 1
• Never provide oxygen unless documented hypoxemia (SpO₂ <90%) 1
• Never continue benzodiazepines long-term—risk of dependence and worse outcomes 2
• Never start SSRIs at full therapeutic dose—begin with sub-therapeutic test dose to prevent initial anxiety exacerbation 2