Treatment of panic attacks and panic disorder

Summary of treatment options
Your general practitioner should recognise and diagnose panic attacks or panic disorder and may give you some of the advice listed in the topic on Living with panic attacks and panic disorder. If problems are more serious, some of the following components either together, or separately, may be recommended as treatment.

The most effective treatment for serious panic problems is a combination of psychological therapy and medication.

Psychosocial treatments

Psychological therapy (often referred to as therapy or psychotherapy) involves a trained professional who uses clinically researched techniques, usually talking therapies, to assess and help people understand what has happened to them and to make positive changes in their lives.

Cognitive-behavioural therapy (CBT) - a psychological therapy which largely focuses on overcoming unhelpful beliefs - has been proven to work well with panic disorder. CBT may include specific therapy for hyperventilation and the teaching of relaxation skills; these may be taught separately or in a group.

Psychotherapy other than cognitive-behavioural therapy may treat the underlying causes of panic symptoms. Counselling may include some techniques used in psychological therapies, but is mainly based on supportive listening, practical problem-solving and information giving.

Medication

Medication can be effective in the treatment of panic disorder, especially if you live in an area where psychological therapy is not available or are so anxious that it is hard for you to consider psychological treatment as a first option. There are two types of medicines that are used for panic disorder - antidepressants and benzodiazepines (tranquillisers).

Even if you are not depressed, some antidepressants are useful in treating panic symptoms. A major problem with using medications to treat panic disorder is relapse. If you are using medication as the only form of treatment, there is a very high risk that the panic will come back when you stop taking the medication. This highlights the importance of using additional treatments, such as psychological therapy for this condition.

If you are prescribed medication, you are entitled to know the names of the medicines; what symptoms they are supposed to treat; how long it will be before they take effect; how long you will have to take them for and what their side effects (short and long-term) are.

If you are pregnant or breast-feeding no medication is entirely safe. Before making any decisions about taking medication at this time you should talk with your doctor about the potential benefits and problems associated with each particular type of medication in pregnancy.

Complementary therapies

Complementary therapies which enhance the person's life may be used in addition to psychological treatments and prescription medicines. Meditation can be useful in the treatment of panic disorder.

Psychosocial treatments

Cognitive-behavioural therapy (CBT)

This therapy looks at your cognitions or thoughts, and your behaviour. The most common cognitive or thinking problem in panic is unrealistic, catastrophic thoughts. The most common behavioural problem is avoidance of situations because of fear of panic. CBT provides a detailed and systematic way of understanding and changing these thoughts and actions.

This type of therapy is often done during eight to 12 weekly sessions. It can be done in groups, though more often it is individual. There will be some explanation of how anxiety and panic is caused and what triggers it for you. This includes any thoughts which can trigger attacks. Unhelpful thoughts are dealt with by recognising that they are distorted or biased and replacing them with other more helpful ones.

Avoidance of places may be keeping the problem going and making it hard to recover. For some people the agoraphobic avoidance becomes the major problem. In therapy, plans are made to overcome avoidance, usually by gradually going back into situations you have avoided and slowly rebuilding your confidence. CBT depends on you being able and willing to tolerate some anxiety.

Psychologists or other therapists using CBT may also teach relaxation and breathing techniques to help you become less frightened by your own physical symptoms and sensations. (Sometimes therapy for over-breathing is enough to help those who have milder symptoms and may be taught by a nurse-therapist or physiotherapist.)

CBT is very effective for most people - 70 to 80 percent of people with panic disorder will have very good results which will last for many years. Unfortunately most general practitioners do not have the time or the training to do CBT themselves, and most specialist community mental health services run by hospitals deal with only the most severe cases. Treatment there is free of charge.

At a number of community service agencies, charges are based on your ability to pay. Private therapists' fees may range from $60 to $200 per session, although some operate on a sliding scale. Fees for group therapy (where such groups are available) are cheaper.

Other psychotherapies and counselling

There are many types of psychotherapy in which you may explore your past or your current life. Some deal mainly with thinking patterns, others with emotions. Many come from the tradition of psychoanalysis.

This type of therapy does not deal with particular problems such as panic attacks but analyses and looks for deeper reasons, usually in your past, for emotional problems and conflicts. It tries to help people understand themselves better. This can include aspects of yourself that you do not usually talk about, like your dreams, fantasies, and sexual relationships.

These analytical therapies depend on forming a strong, trusting relationship with your therapist and may take many months or even years. You will be expected to do most of the work yourself and will not be given much direct advice.

You might consider a longer type of analytical therapy if you are aware of more complicated emotional problems through your life. The main risk is that you devote a long time to therapy without getting rid of your panic symptoms.

It is important that you agree with your doctor or therapist what type of therapy you are having and how long it will take.

Counselling is based on supportive listening and problem solving. You may enjoy talking to someone about your problems and life in a general way. There is no evidence that general counselling will help you with the specific problem of panic attacks.

What types of medication are used?

Antidepressants

If panic disorder is severe and difficult to change with psychological therapy, then medications can be used. Antidepressants have an effect on panic disorder even if you are not depressed. They are effective for about 70 percent of people with panic disorder.

A major problem with using medication to treat panic disorder is relapse. If you are using medication as the only form of treatment, there is a high risk that the problem will flare up again when you stop taking the tablets. This highlights the importance of using additional treatments such as psychological therapy.

Antidepressants have no immediate effect and start working after two to three weeks. Their effect can increase over several more weeks. They are usually taken for three to 12 months to block the anxiety associated with panic disorder. This time can be used to try to build up your confidence.

Antidepressants are not addictive, but there may be a small rebound effect of anxiety and insomnia if you stop taking them very suddenly. They are usually given for three to six months. If you have had more than one episode of panic disorder (multiple panic attacks over a period of time) you may be advised to stay on them longer than this. Almost all are in tablet or capsule form, taken once a day.

Antidepressants have a number of side effects depending on which type of antidepressant it is. These side effects differ from person to person and, although they can be quite severe for some people, they usually fade away after two to three weeks. You may need to try different antidepressants before you find one which suits you.

Antidepressants affect brain chemicals, mainly noradrenaline and serotonin.

The Tricyclic Antidepressants (tricyclics/TCAs) and the Monoamine Oxidase Inhibitors (MAOIs) are the oldest antidepressants and have been useful in the treatment of panic disorder. However, the antidepressants generally prescribed first these days are newer Selective Serotonin Re-uptake Inhibitors (SSRIs).

Another antidepressant called a Reversible Inhibitor of Monoamine Oxiadase A (RIMA) is a safer version of the old MAOIs and can also be effective in treating panic disorder for some people. These newer antidepressants generally have fewer side effects than the older antidepressants.

Selective serotonin re-uptake inhibitors (SSRIs)

Over the past decade the Selective Serotonin Re-uptake Inhibitors (SSRI) antidepressants have become available. SSRIs have their effect specifically on serotonin, and can often be started at the usual effective dose from day one, although the therapeutic effect may take some weeks to occur.

As some people experience a slight increase in anxiety when starting at the full dose it is often useful to start at a smaller dose and build up gradually.

Side effects of SSRIs can include:

• nausea and weight loss or weight gain
• headache
• trouble sleeping
• agitated or jittery feelings (occurs less if starting dose is low and increases gradually)
• rash (not common, but means the drug should be stopped)
• sexual problems.

SSRI-like antidepressants

The newest "SSRI-like" generations of antidepressants target serotonin and noradrenaline neurotransmitter systems with less effect on other neurotransmitter systems, therefore fewer side effects. Overseas studies have found they may also be useful in treating panic disorder.

These newer drugs may not be subsidised, and therefore the full cost of treatment would have to be paid by the patient. Although more expensive, these newer types of medications are equal in effectiveness to the tricyclics and have less troublesome side effects.

RIMAs

MAOIs are an older group of antidepressants which have been shown to be effective in the treatment of panic disorder however, due to potentially dangerous interactions with some foods and medicines they are rarely used nowadays. A safer form has been developed called a Reversible Inhibitor of Monoamine oxidase A (RIMA).
 
Tricyclics/TCAs

Tricyclics can be very effective at treating panic disorder and may be useful for those who have found little benefit from SSRIs or have been unable to tolerate that type of medication. Each TCA has a different pattern of side effects, so when one is not tolerated there is likely to be another that causes less of that side effect.

Because of these side effects, it is necessary to start on a low dose and increase slowly over two weeks or more to reach the effective dose (usually about 150mg per day).

Common side effects of tricyclics:

• drowsiness (which can be beneficial if sleep problems exist)
• blurred vision
• dry mouth
• constipation
• dizziness
• trouble urinating (mostly a problem for older men)
• increased sweating
• weight gain
• problems with sexual function such as impotence, reduced sex drive, or lack of orgasm
• heart problems, in people who already have heart problems or are elderly. (Some of this group of drugs are safer for people with heart problems).

Because of their effects on the heart these drugs are very dangerous in overdose.

Benzodiazepines (tranquillisers)

Benzodiazepines (the Valium type of medicines) can be used to treat anxiety symptoms. They increase the activity of a chemical in the brain called GABA (gamma amino butyric acid) which regulates alertness. This lessens anxiety, induces sleepiness, and makes the muscles relax.

To stop panic, benzodiazepines need to be taken in higher doses than for ordinary anxiety. Some benzodiazepines have a higher potency and may be more effective.

There are two ways of taking benzodiazepines. One is for very short periods to relieve great distress or allow you to cope with some important event you cannot avoid. The other less common way is to take them regularly for weeks or months to prevent panic occurring. If you take them regularly you are likely to develop some dependency which is why they are usually only prescribed for short periods of time. If you have trouble with addictions they are best avoided.

Because benzodiazepines are known to be addictive, stopping them needs to be done gradually. Sudden stopping may produce withdrawal symptoms such as anxiety, insomnia, nausea, headaches and dizziness and occasionally, may induce epileptic seizures.

People with epilepsy must be careful as withdrawal can also make seizures more likely. The effects of sudden stopping may be similar to your original symptoms of anxiety, so it is hard to tell if you have withdrawal or not.

Benzodiazepines work almost immediately and have few side effects. The main side effect of drowsiness or fatigue usually wears off.
 
People taking benzodiazepines need to know that they may become too drowsy or relaxed to drive or operate machinery. Muscle relaxation can be a risk for older people whose muscles may be weak and this increases their risk of falling. Older people may also become confused.

People with severe breathing problems need to be careful as benzodiazepines can reduce breathing a little. Benzodiazepines are not advised in pregnancy, especially near birth, as they can affect the baby and some get into breast milk.

Benzodiazepines are safe with almost all other medicines. The effects of alcohol are magnified by them, so people taking benzodiazepines should avoid using alcohol.

Medicine interactions

Most psychiatric medicines tend to react with each other when taken in combination. Their sedative effect in particular may make you feel sleepy. Your doctor will, where possible, limit the number of medications prescribed. You should be told what effects you may notice from the medication and receive clear instructions about how you should take them and what precautions are necessary.

You should not mix different types of antidepressants unless instructed by your doctor, as this could be very dangerous.

The effects of alcohol and many illegal drugs will also be heightened, so they should be avoided. It is important the doctor knows all the medications (including any herbal medicines such as St John's Wort) you are taking, as some taken together can be dangerous.

Complementary therapies

The term complementary therapy is generally used to indicate therapies and treatments which differ from conventional Western medicine and which may be used to complement, support or sometimes replace it. There is an ever-growing awareness that it is vital to treat the whole person and assist them to find ways to address the causes of mental health problems rather than merely alleviating the symptoms. This is often referred to as an holistic approach.

Complementary therapies often support an holistic approach and are seen as a way to address physical, nutritional, environmental, emotional, social, spiritual and lifestyle needs.
 
Many cultures have their own treatment and care practices which many people find helpful and which can often provide additional benefits to health and wellbeing.  Rongoa Maori is the indigenous health and healing practice of New Zealand.  Tohunga Puna Ora is a traditional healing practitioner. Traditional healing for many Pacific Islands' people involves massage, herbal remedies and spiritual healers.

In general, meditation, hypnotherapy, yoga, exercise, relaxation, massage, mirimiri and aromatherapy have all been shown to have some effect in alleviating mental distress. Complementary therapies can include using a number of herbal and other medicinal preparations to treat particular conditions.

It is recommended that care is taken as prescription medicines, herbal and medicinal preparations can interact with each other. When considering taking any supplement, herbal or medicinal preparation we recommend that you consult a doctor to make sure it is safe and will not harm your health.

Women who may be pregnant or breastfeeding are advised to take extra care and to consult a doctor about any supplements, herbal or medicinal preparations they are considering using, to make sure they are safe and that they will not harm their own or their baby's health.

See also: Panic attacks/disorder; Panic attacks/disorder - living with

Support groups

See the support organisations (which include helplines) under Further information and support below.

Original material provided by the Mental Health Foundation of New Zealand, 2002. Edited by everybody, May 2005.