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Panic Disorder Treatment

Treatment of Panic DisorderYou’ve just been diagnosed with panic disorder. Maybe you’ve also been diagnosed with agoraphobia, because you fear and avoid certain anxiety-provoking places and situations, such as using public transportation, being in open or enclosed spaces, or being by yourself outside of your house.

Living with anxiety is exhausting. You can easily feel hopeless and helpless, believing there’s nothing you can do. Thankfully, it’s not hopeless, and you’re not helpless. Effective treatment is available, and you can get better.

The National Institute for Health and Care Excellence, which provides evidence-based recommendations for health and care in England, recommends cognitive-behavioral therapy (CBT) as the first-line treatment for panic disorder. They recommend taking medication only when CBT doesn’t work.

However, other treatment guidelines note that which intervention you try depends on your preference, previous response to treatment, availability of treatment, and whether you have any co-occurring disorders (such as depression or bipolar disorder).

Psychotherapy for Panic Disorder

The first-line psychotherapy for panic disorder (with or without agoraphobia) is cognitive behavioral therapy (CBT). CBT typically consists of 12 sessions at 60 minutes each week. One of the best studied CBT manuals is panic control treatment protocol (PCT).

In CBT, you’ll begin by learning about panic disorder and agoraphobia (if you have the latter, as well). You’ll learn the causes of anxiety and how anxiety works (e.g., the fight-or-flight response). You also learn the facts behind common myths and beliefs (e.g., “I’m losing control!” “I’m having a heart attack!”).

You learn to closely monitor your symptoms and record panic attacks in a journal, which includes jotting down triggers, symptoms, thoughts, and behaviors. Your therapist will teach you how to practice relaxation techniques, such as progressive muscle relaxation. You’ll examine the validity of your cognitions, and change unhelpful or catastrophic beliefs (e.g., “I’m too weak to handle this”; “What if that horrible thing does happen?”).

In addition, your therapist will help you face uncomfortable sensations that normally trigger anxiety and cope with them. That is, you might spin around to trigger dizziness or breathe through a straw to trigger shortness of breath. Then you’ll replace thoughts like “I’m going to die” with more helpful, realistic thoughts, such as “It’s just a little dizziness. I can handle it.”

You’ll also gradually face anxiety-provoking situations—driving, going to the grocery store—because not facing them is what feeds your fear. You’ll reduce your safety behaviors, as well. These might be anything from needing to be with others to having your cell phone or medication with you.

Lastly, you and your therapist will develop a plan to manage setbacks and prevent relapse.

Not everyone responds to CBT, which is why other therapy options are important. Panic-focused psychodynamic psychotherapy (PFPP) and panic-focused psychodynamic psychotherapy extended range (PFPP-XR) appear to be effective for panic disorder and other anxiety disorders, though they’re less researched than CBT.

Based on psychoanalytic principles, PFPP-XR is a manualized treatment, and consists of 24 sessions, two times a week. It is divided into three phases; the content of these phases varies with each individual.

In the first phase, the clinician helps you to explore the origins of your anxiety and discover the meaning of your symptoms. Having a deeper understanding of your anxiety, and knowing the source leads to a reduction in anxiety and panic attacks. In the second phase, you and your therapist further identify the unconscious feelings and underlying conflicts of your anxiety symptoms. In the third phase, you and your therapist explore the conflicts and fears around ending therapy. (This journal article features an in-depth case example that illustrates how PFPP-XR works and connects the past to the present.)

Other promising treatments for panic disorder that require more research include acceptance and commitment therapy (ACT) and mindfulness-based stress reduction (MBSR), according to UpToDate.com.

Medications for Panic Disorder

Medication is used to prevent panic attacks or reduce their frequency and severity, and to decrease the associated anticipatory anxiety. The first-line treatment for panic disorder is selective serotonin reuptake inhibitors (SSRIs). The U.S. Food and Drug Administration (FDA) has approved fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) for treating panic disorder. But your doctor might prescribe another SSRI “off label.”

Your doctor also might prescribe a serotonin and norepinephrine reuptake inhibitor (SNRI). For instance, venlafaxine (Effexor XR) has been FDA-approved for panic disorder.

It takes about 4 to 6 weeks for patients to experience improvement with an SSRI or SNRI. If you’re unable to wait that long, your doctor might prescribe an additional medication: a benzodiazepine, such as clonazepam (Klonopin). Benzodiazepines are fast-acting—within hours—medications that reduce the frequency of panic attacks, anticipatory anxiety, and avoidance. However, because benzodiazepines can lead to abuse and addiction, they’re usually not prescribed if you have a substance use disorder or have struggled with substances in the past.

Instead, your doctor might prescribe another fast-acting medication, such as gabapentin (Neurontin), pregabalin (Lyrica), or mirtazapine (Remeron). Unlike benzodiazepines, these medications have a lower risk for abuse, addiction, and intense discontinuation syndrome (see below). These medications also can be used if you don’t respond to an SSRI or SNRI. UpToDate.com notes that gabapentin, pregabalin, and mirtazapine haven’t been well-studied in panic disorder, but the data that does exist and clinical experience seem to support their use for this condition.

Benzodiazepines can interfere with cognitive behavioral therapy (CBT), and are best used short term. They come with their own side effects, such as drowsiness, dizziness, confusion, and impaired coordination. People also have a hard time stopping benzodiazepines because discontinuing can spike anxiety and cause insomnia, tremors, and other adverse effects.

Tricyclic antidepressants (TCAs) also show efficacy in treating panic disorder. For instance, your doctor might prescribe nortriptyline (Pamelor), imipramine (Tofranil), or clomipramine (Anafranil). However, many people can’t tolerate the side effects of TCAs, which include dizziness, dry mouth, blurred vision, fatigue, weakness, weight gain, and sexual dysfunction. TCAs can cause cardiac problems, and thereby shouldn’t be prescribed to people with a history of cardiac disease.

Monoamine oxidase inhibitors (MAOIs) are effective for panic disorder, as well. But similar to TCAs, their side effects aren’t well-tolerated. They also require dietary restrictions and should never be combined with SSRIs, seizure medication, pain medication, and St. John’s Wort, among others.

Overall, before starting any medication, it’s critical to talk to your doctor about side effects, especially because people with panic disorder tend to be extra sensitive to physical reactions. For example, the widely-used SSRIs and SNRIs can cause nausea, headaches, dizziness, agitation, excessive sweating, and sexual dysfunction (e.g., decreased sexual desire, and inability to have an orgasm).

Make sure you also talk to your doctor about discontinuation syndrome, which can occur with SSRIs and SNRIs, too. Discontinuation syndrome produces withdrawal-like symptoms, such as dizziness, headache, irritability or agitation, nausea, and diarrhea. Plus, you can feel like you have the flu with symptoms such as tiredness, chills, and muscle aches. This is why you shouldn’t abruptly stop taking your medication (without first discussing it with your doctor). When you’re ready to stop taking your medication, it must be slowly decreased. And even this gradual process can still produce those adverse effects. In fact, discontinuation syndrome can be very difficult for many, many people.

Lastly, the decision to take medication, and which medication to take should be a thoughtful, collaborative process between you and your doctor. Be your own advocate, and bring up any concerns you have.

Self-Help Strategies for Panic

  • Participate in aerobic exercise. Research has found that engaging in aerobic exercise can decrease symptoms of anxiety in individuals with panic disorder. Different studies used different exercise programs, so there’s no consensus on which one is best. Start with whatever aerobic exercises you enjoy, such as running, walking, swimming, riding your bike, or taking a group fitness class. Or consider experimenting with different exercise routines. Try to aim for about 20 minutes for each session.
  • Practice relaxation techniques, such as progressive muscle relaxation. You can find many guided practices online, such as this audio exercise, or download an app on your phone, like Calm.
  • Read self-help books. There are many excellent books written by anxiety experts that can help you better understand anxiety and panic, and cope with them. For instance, you might check out When Panic Attacks by David D. Burns, or Mastery of your Anxiety and Panic: Workbook by David H. Barlow and Michelle G. Craske.
  • Focus on taking good care of yourself. This includes getting enough sleep, taking restorative breaks throughout the day, and limiting anxiety-provoking substances (e.g., caffeine, tobacco, alcohol). For instance, to get enough sleep, you might create a calming bedtime routine, and make sure your bedroom is a soothing, decluttered space. To take restorative breaks, you might listen to a 5-minute guided meditation on your app, stretch your body, or simply breathe deeply for a few minutes.
  • Be kind to yourself. When you struggle with panic attacks, you might despise your anxiety, and become furious with yourself. You might think you’re being weak and ridiculous by avoiding certain places and situations. And you might wish you were “normal.” This is when it’s especially important to be kind, patient, and gentle with yourself—even though you want to do the opposite. Remind yourself that you’re not alone, and others struggle, too. Remind yourself that you’re OK, even though you feel incredibly uncomfortable. Remind yourself that this isn’t permanent, and the symptoms will pass. Remind yourself that you can get through this. Because you can.

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Andrews, G., Bell, C., Boyce, P., Gale, C., Lampe, L., Marwat, O., … Wilkins, G. (2018). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalized anxiety disorder. Australian & New Zealand Journal of Psychiatry, 52, 12, 1109-1172. https://doi.org/10.1177/0004867418799453.
Busch, F.N., Milrod, B.L. (2013). Panic-focused psychodynamic psychotherapy–extended range. Psychoanalytic Inquiry, 33,6, 584-594. DOI:10.1080/07351690.2013.835166.
Craske, M. (2019, March 14). Psychotherapy for panic disorder with or without agoraphobia in adults. UpToDate.com.
https://www.uptodate.com/contents/psychotherapy-for-panic-disorder-with-or-without-agoraphobia-in-adults.

Hofmann, S.G. (2017). Panic disorder and agoraphobia. Reference Module in Neuroscience and Biobehavioral Psychology, 1-5. DOI: http://dx.doi.org/10.1016/B978-0-12-809324-5.05372-4.

Roy-Byrne, P.P. (2019, February 15). Pharmacotherapy for panic disorder with or without agoraphobia in adults. UpToDate.com. Retrieved from https://www.uptodate.com/contents/pharmacotherapy-for-panic-disorder-with-or-without-agoraphobia-in-adults.

 


Margarita Tartakovsky, MS & John M. Grohol, Psy.D.

Margarita Tartakovsky, M.S. is an Associate Editor and regular contributor at Psych Central. She blogs regularly about body and self-image issues on her blog, Weightless, and about creativity on her second blog Make a Mess.

Dr. John Grohol is the founder, Editor-in-Chief & CEO of Psych Central. He is an author, researcher and expert in mental health online, and has been writing about online behavior, mental health and psychology issues -- as well as the intersection of technology and human behavior -- since 1992. Dr. Grohol sits on the editorial board of the journal Computers in Human Behavior and is a founding board member and treasurer of the Society for Participatory Medicine. He writes regularly and extensively on mental health concerns, the intersection of technology and psychology, and advocating for greater acceptance of the importance and value of mental health in today's society. You can learn more about Dr. John Grohol here.

APA Reference
John M. Grohol, M. (2019). Panic Disorder Treatment. Psych Central. Retrieved on September 20, 2019, from https://psychcentral.com/anxiety/panic-disorder-treatment/
Scientifically Reviewed
Last updated: 25 Jun 2019
Last reviewed: By a member of our scientific advisory board on 25 Jun 2019
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