Panic disorder, characterized by recurrent and unexpected panic attacks, affects millions worldwide, severely impacting quality of life. Panic attacks involve sudden periods of intense fear or discomfort, accompanied by physical symptoms such as palpitations, sweating, trembling, shortness of breath, and feelings of impending doom. Effective management is crucial, and treatment typically involves a combination of psychotherapy, pharmacotherapy, and lifestyle modifications. This blog post explores the most effective, evidence-based treatments for panic disorder and panic attacks, grounded in psychiatric practice.
In last month’s article we discussed the epidemiology and pathogenesis of panic disorder and panic attacks. In this article, we’ll cover some of the most effective, evidence-based treatments for panic disorder. As you’ll see, there is no one-size- fits-all approach to treatment, but rather important elements that should be considered for each individual.
Cognitive-Behavioral Therapy (CBT)
Engaging in therapy is the most important first intervention for the majority of individuals diagnosed with panic disorder. Of the modalities, Cognitive-Behavioral Therapy (CBT) is the generally regarded as the gold standard approach. CBT attempts to identify and eradicate maladaptive thought processes and behaviors that have lead to the disorder and continue to propagate it. Research consistently shows that CBT is highly effective in reducing panic attack frequency and severity, with long-term benefits that often persist beyond the end of treatment. Core components of CBT for the treatment of panic disorder include, but are not limited to:
Psychoeducation: Simply understanding the origin and neurobiological basis of panic disorder often helps patients demystify the physical impact of panic disorder and can help reduce fear.
Cognitive Restructuring: Individuals can identify catastrophic thinking patterns and irrational beliefs that tend to exacerbate anxiety.
Exposure Therapy: By exposing individuals to the situations that often induce a panic attack, a skilled therapist can help build tolerance and coping mechanisms.
Relaxation Techniques: Utilizing mindfulness-based methods such as progressive relaxation and deep breathing can help patients manage acute panic symptoms.
Pharmacotherapy
In most cases, individuals with persistent panic-disorder will benefit from pharmacological interventions. These medications can be utilized either for short treatment courses or, in some cases, for longer time horizons. There are a number of potential agents that can be utilized, including:
Selective Serotonin Reuptake Inhibitors (SSRIs): SSRIs, such as sertraline, escitalopram, and fluoxetine, are typically the first-line pharmacological treatment. These medications are taken on a daily basis with the goal of lowering overall levels of anxiety. In individuals that are concurrently diagnosed with Generalized Anxiety Disorder (GAD) these medications are particularly helpful.
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): SNRIs, like duloxetine, venlafaxine, and desvenlafaxine, are also effective, particularly for patients who may not respond to SSRIs.
Benzodiazepines: In the past, these medications were often the first treatments given when an individual experienced a panic attack. However, benzodiazepines have a high risk of addiction and abuse and are now typically only reserved for short-term use in refractory cases. Shorter acting benzos such as alprazolam (Xanax) are more addictive than longer acting agents such as clonazepam (Klonopin) and diazepam (Valium).
Research has found that the combination of therapeutic interventions and pharmacological agents is more effective than treatment alone in the majority of cases.
A Deeper Dive into Pharmacological Treatments
While the above recommendations provide a helpful big-picture view of available treatments, an important study published in the British Journal of Medicine by Chawla and colleagues (2021) sheds light on how these pharmacological approaches compare in head-to-head studies. This study was a systematic review and network meta-analysis including 87 randomized controlled trials involving a total of 12,800 patients.
Overall anxiety level was most effectively treated by SSRIs plus beta blockers (97.5%), TCAs plus benzodiazepines (70.9%), and SSRIs alone (62.9%). SNRIs (31.6%) and buspirone (33%) were the least effective treatments. Importantly, dropout rates were the highest for MAOIs and buspirone while adverse effects were the highest for benzodiazepines and TCAs.
When considering the tolerability, safety, and efficacy of all treatments, SSRIs emerged at the top. Particularly, escitalopram and sertraline were the most effective within their class. Paroxetine, fluoxetine, and fluvoxamine were effective, but carried a higher associated risk of adverse effects. Citalopram was minimally effective and had a high risk of adverse effects.
As a whole, it seems that utilizing escitalopram or sertraline in combination with a beta blocker such as propranolol may be the most reasonable first-line choice for an individual diagnosed with panic disorder or suffering panic attacks in the context of comorbid GAD.
Lifestyle Modifications and Supportive Measures
While the above recommendations can be thought of as interventions originating outside of the patient, research has found that there are important lifestyle modifications that can make a big impact on reducing the severity and frequency of panic attacks.
Regular Exercise: Physical activity can help reduce anxiety levels and improve overall well-being.
Healthy Diet: A balanced diet supports overall mental health. Reducing caffeine and sugar intake can also mitigate anxiety symptoms.
Sleep Hygiene: Ensuring adequate and quality sleep is essential, as poor sleep can exacerbate anxiety.
Support Groups: Participating in support groups can provide emotional support and reduce feelings of isolation.
Conclusion
In conclusion, there is no cookie-cutter approach to treating panic disorder, but rather includes elements of therapeutic interventions, pharmacological agents, and lifestyle modifications tailored to each individual. Patients experiencing panic disorder are often diagnosed with other comorbid psychiatric conditions, requiring further consideration. Tailoring treatment to each patient’s needs is essential for effective long-term management and functioning.
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
Chawla, N., Anothaisintawee, T., Charoenrungrueangchai, K., Thaipisuttikul, P., McKay, G. J., Attia, J., & Thakkinstian, A. (2022). Drug treatment for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials. BMJ (Clinical research ed.), 376, e066084. https://doi.org/10.1136/bmj-2021-066084
Craske, M. G., & Barlow, D. H. (2007). Mastery of Your Anxiety and Panic: Workbook for Primary Care Settings (4th ed.).
Roy-Byrne, P. P., Craske, M. G., & Stein, M. B. (2006). “Panic Disorder.” The Lancet, 368(9540), 1023-1032.
J. Hennessy