Combining drug treatment with psychotherapy is usually the most effective strategy for treating panic disorder. If symptoms are recurrent, medication treatment is a first-line intervention for panic disorder. Several drugs have been shown to be effective, including antidepressant medicines such as the selective serotonin reuptake inhibitors (SSRIs; e.g., Prozac, Zoloft), serotonin-norepinephrine reuptake inhibitors (SNRIs; e.g., Cymbalta, Effexor), and tricyclic antidepressants (e.g., Pamelor, Tofranil). Antianxiety medicines such as benzodiazepines also reduce symptoms in severe cases. Unfortunately, anywhere from 20 to 60 percent of panic disorder patients in clinical trials do not respond adequately to their initial medication treatment.
MEDICATIONS FOR TREATMENT OF PANIC ATTACKS
- Antidepressants include the following:
- Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitor (SNRIs) are first-line treatments and may take weeks or months to become effective. Tricyclic antidepressants are also effective in many cases. Monoamine oxidase inhibitors (MAOIs) are effective but require dietary restrictions to avoid serious side effects. Examples include citalopram (Celexa), fluvoxamine (Luvox), paroxetine (Paxil), imipramine (Tofranil), venlafaxine (Effexor), and phenelzine (Nardil).
- Minor tranquilizers or benzodiazepines can help reduce the anxiety and feelings of fear associated with panic. They can become habit-forming, however, and they may cause side effects when used with alcohol. These medicines need to be used with caution and only when symptoms are incapacitating. Examples include alprazolam (Xanax), clonazepam (Klonopin), diazepam (Valium), and lorazepam (Ativan).
A recent meta-analysis of previous clinical trials for panic disorder identified three important findings: longer duration of illness was associated with poorer outcomes, older age was associated with more dropouts from treatment, and longer duration of treatment led to higher rates of treatment success. The bottom line is that individuals with panic disorder need to be patient because the initial medication might not work. It may need to be switched to another one from either the same class or a different class of medication, or it could take weeks or months to become effective. It is important to work closely with your doctor so your medication treatment can be personalized for optimal effectiveness.
DID YOU KNOW?
- Some people get panic attacks while sound asleep. These episodes are similar to usual panic attacks during the day and may include shortness of breath and chest pain.
- Although people naturally try to avoid situations they believe will cause their attacks, such avoidance behavior actually increases fearfulness and restricts daily functioning.
- About one in every four patients who present to their doctor with chest pain actually has panic disorder.
Despite its dramatic and debilitating consequences, panic disorder and agoraphobia respond well to antidepressants and cognitive behavioral therapy (CBT), such as desensitization psychotherapy. The medication helps eliminate the panic attacks and the therapy helps the patient gradually overcome their phobia of the outside world.
Psychotherapy can also be effective in reducing panic symptoms. Panic-focused CBT, through individual or group sessions, can be delivered weekly and can reduce symptoms within months. Many patients find psychodynamic psychotherapy useful in helping them avoid maladaptive behaviors that complicate their symptoms and functioning. Other approaches, such as family therapy and supportive psychotherapy, can help patients deal with interpersonal and other psychological stressors that contribute to symptoms.
Patients with accompanying agoraphobia often benefit from desensitization psychotherapy, which gradually teaches patients to remain calm in perceived stressful situations. Patients make lists of places and situations that trigger their fear reaction and then rank those different situations according to the degree of anxiety experienced with each. The therapist begins with the least disturbing scenario and teaches the patient relaxation exercises to use in order to tolerate these anxiety-provoking situations.
Numerous positive randomized controlled trials have demonstrated the effectiveness of individual or group CBT for panic disorder. Desensitization or exposure therapy has also been shown to be effective in several investigations.
Sandy responded well to an antidepressant medication and desensitization therapy. Over time, she became more comfortable leaving the house and going out to public places. She gradually got back to living normally, and after six months of treatment, Sandy finally took that vacation in Europe with her husband.
ALTERNATIVE STRATEGIES FOR PANIC
Some clinicians have used psychodynamic therapy in patients with panic disorder, but systematic evidence for its effectiveness is limited. One controlled study did show that panic-focused psychodynamic psychotherapy was effective in relieving symptoms.
Other treatments, such as eye movement desensitization and reprocessing, have not been formally tested for panic disorder or have been shown to be ineffective or less effective than standard treatments like CBT. Even without systematic data demonstrating effectiveness, many clinicians recommend a variety of stress-reducing interventions that can lower anxiety levels and thus reduce symptoms associated with panic attacks and related feelings of fear as well as associated phobias. Some herbal remedies that help calm people may also temporarily reduce symptoms in some patients, although systematic studies of these in panic disorder are limited. Many alternative panic disorder interventions have been used successfully to augment the benefits of conventional treatments.
ALTERNATIVE PANIC DISORDER INTERVENTIONS
- dietary and herbal supplements
- inositol, kava, l-lysine/l-arginine combination
- biofeedback and neurofeedback
- massage, acupuncture, acupressure
- other approaches
- exercise, meditation, yoga, music, pets, volunteering
Studies have shown that regular exercise can reduce symptoms of anxiety, and many patients with panic symptoms report feeling better when they remain physically active. Proper nutrition may also reduce the frequency and degree of symptoms. Excessive amounts of caffeine, alcohol, or even monosodium glutamate (MSG) may increase symptoms of anxiety and worsen panic attacks.
Knowledge of the condition and its effective treatments is comforting for many patients who no longer have to fear that they are losing control. Many feel reassured when they understand that brain changes are driving their symptoms and that those symptoms will pass if they wait them out.