How should I evaluate and manage an acute panic attack, including immediate treatment, follow‑up, and long‑term therapy?

Management of Acute Panic Attack

For an acute panic attack, immediately move the patient to a private, quiet space, guide them through box breathing (4-second inhale, 4-second hold, 4-second exhale, 4-second hold), provide firm reassurance that symptoms are not life-threatening, and avoid benzodiazepines unless symptoms are severe and refractory to non-pharmacologic measures. 1

Immediate Evaluation: Rule Out Medical Emergencies First

Before diagnosing panic, you must exclude life-threatening conditions that mimic panic attacks:

• Check for acute coronary syndrome in any patient over 30 years old or with cardiac risk factors presenting with chest pain—the likelihood of angina increases from 67% in men aged 30-39 to 94% in men aged 60-69. 1
• Key features that distinguish panic from cardiac causes: trembling, dizziness, derealization, paresthesias, chills/hot flushes, and abrupt onset peaking within minutes all favor panic. 1
• Pain worsened by palpation, breathing, or body position argues against angina and supports a benign cause. 1
• Order TSH to rule out thyroid dysfunction, which commonly presents with anxiety symptoms. 2
• Assess for substance use (stimulants, caffeine excess, or withdrawal states) that can mimic or exacerbate panic. 2

Acute Management: Non-Pharmacologic First-Line

Environmental Control

• Place the patient in a private room to minimize anxiety-provoking stimuli and create a calming environment. 1
• Position the patient seated with upper body elevated in a "coachman's seat" position to optimize breathing mechanics. 1

Box Breathing Technique (Most Effective Immediate Intervention)

Guide the patient through structured box breathing: inhale for 4 seconds, hold for 4 seconds, exhale for 4 seconds, hold for 4 seconds, and repeat. 1

• This technique prevents hyperventilation-induced hypocapnia and cerebral vasoconstriction, addressing the physiological trigger of "air hunger" that escalates panic. 1
• The rhythmic pattern diverts attention from catastrophic thoughts and provides a tangible sense of control. 1
• Warn patients they may initially feel "air hunger"—this is benign and will pass; explicit reassurance improves adherence. 1

Additional Physical Interventions

• Apply a cold compress or cool air to the face to reduce physiological arousal. 1
• Use small ventilators or fans to help with breathlessness. 1
• Avoid rebreathing from a paper bag—this outdated practice may cause dangerous hypoxemia. 1

Reassurance and Education

• Provide firm, explicit reassurance that symptoms are not life-threatening despite their intensity—this is a core component of psychological first aid. 1
• Explain that panic attacks are self-limited and typically peak within 10 minutes. 1

Pharmacologic Management: Use Sparingly

• Benzodiazepines may be administered for rapid symptom relief in severe, refractory cases but should be reserved for short-term use only (first few weeks while awaiting SSRI onset). 3
• Avoid benzodiazepines entirely in patients with substance use history, respiratory disorders, or elderly patients. 3
• Long-term benzodiazepine use worsens outcomes—one study found 63% of trauma patients on benzodiazepines developed PTSD versus only 23% on placebo. 3
• Do not provide oxygen therapy unless the patient is actually hypoxemic (SpO₂ <90%)—pure hyperventilation from panic does not require oxygen. 1

Post-Attack Management: Critical for Preventing Recurrence

Immediate Follow-Up (Same Visit)

• Assess suicide risk immediately—any suicidal ideation requires emergency psychiatric evaluation. 2
• Screen with GAD-7: scores 10-14 indicate moderate-to-severe symptoms; scores ≥15 require immediate mental health referral. 2
• Develop a written action plan for managing future episodes, teaching patients to recognize early warning signs (racing heart, tight chest, sense of impending doom). 1

Teach Sensory Grounding Techniques for Future Episodes

• Instruct patients to notice environmental details (colors, textures, sounds), use cognitive distractions (word games, counting backwards), or sensory-based distractors (flicking rubber band on wrist) at the first sign of panic. 1

What NOT to Do

• Never use psychological debriefing (formal structured interventions asking patients to ventilate emotions and relive the trauma)—this may worsen outcomes. 1

Long-Term Treatment: Start Immediately

First-Line Pharmacotherapy

Initiate sertraline 25-50 mg daily or escitalopram 5-10 mg daily in combination with cognitive-behavioral therapy (CBT)—combination therapy yields higher response and remission rates than either modality alone. 3

• Begin with a subtherapeutic "test" dose to minimize the initial anxiety or agitation that commonly occurs with SSRI initiation in panic patients who are hypersensitive to physical sensations. 3
• Titrate sertraline by 25-50 mg every 1-2 weeks to target dose of 50-200 mg/day. 3
• Titrate escitalopram by 5-10 mg every 1-2 weeks to target dose of 10-20 mg/day. 3
• Expect statistically significant improvement by week 2, clinically meaningful change by weeks 4-6, and maximal effect by week 12—do not abandon treatment prematurely. 3
• Monitor closely for suicidal thoughts or behaviors, especially during the first months and after dose adjustments (pooled risk 1% vs 0.2% placebo; number needed to harm = 143). 3

Second-Line Options

• If inadequate response after 6-8 weeks at therapeutic SSRI dose, switch to a different SSRI. 3
• Venlafaxine extended-release 75-225 mg/day is an evidence-supported alternative for patients who fail or cannot tolerate SSRIs; monitor blood pressure due to risk of sustained hypertension. 3

Cognitive-Behavioral Therapy (Essential Component)

Refer for individual CBT immediately—it is as effective as medication and combination treatment is superior to either alone. 3

CBT should include:

• Education on anxiety mechanisms and the fight-or-flight response. 3
• Cognitive restructuring to challenge catastrophic thinking patterns. 3
• Graduated exposure to feared physical sensations (interoceptive exposure) and avoided situations (in vivo exposure). 3
• Relaxation techniques, including breathing retraining and progressive muscle relaxation. 3
• Structured duration of 12-20 sessions. 3

Prioritize individual CBT over group formats due to superior clinical effectiveness and better health-economic value. 3

Treatment Duration

• Continue effective treatment for 9-12 months after remission to reduce relapse risk. 3
• When discontinuing an SSRI, taper gradually to avoid discontinuation syndrome (dizziness, fatigue, nausea, sensory disturbances, anxiety). 3
• For short-half-life SSRIs (sertraline, paroxetine), reduce dose by no more than 25-50% every 1-2 weeks. 3

Common Pitfalls to Avoid

• Do not miss comorbid depression—crying spells, anhedonia, or persistent low mood signal depression, which affects treatment duration and may require longer therapy beyond the standard 12-24 months. 2
• Do not prescribe tricyclic antidepressants despite equal efficacy—they have an unfavorable risk-benefit profile due to cardiac toxicity. 3
• Do not use beta-blockers for panic disorder—they have limited evidence (may be used only for performance anxiety). 3
• Do not provide long-term benzodiazepines—they carry significant risks of dependence, tolerance, and withdrawal. 3

Special Populations

Children and Adolescents (Ages 6-18)

• Combined CBT + SSRI therapy is preferred over monotherapy in pediatric panic disorder. 3
• Ensure parental oversight of medication administration and adherence. 3