Panic Disorder

Good News: Panic Disorder is a Well Known Medical Condition

The last thing that anyone wants is a medical problem about which no one knows anything. (If you go to your doctor with a case of Kuru *, you’re in real trouble. She won’t know what’s wrong with you.) But if you see your doctor for arthritis she will know what to do. And so it is with panic disorder. Every family doctor, general internist, psychiatrist, nurse practitioner, and physician’s assistant knows about panic disorder. It’s not new, it’s not rare, and it’s not fatal. And all of these doctors know a lot about what it is, how to treat it, what works well, and what doesn’t work.

More Good News: With Panic Disorder Treatment You Will Get Better

Okay, we’ll crank that back a little. We can’t guarantee that you’ll get better with panic disorder treatment. But panic disorder can be treated and the treatments are straightforward. The problem part with panic disorder is the first few panic attacks. They’re awful and they’re frightening. But after those first few you know what’s happening to you and you’re on the way to wellness. And with medication and therapy, as time goes by, you’re back in control.

Is Panic Disorder Treatment Really That Easy?

Well, no. Straightforward, yes, easy, no. The first task is finding you’re best doctor. Then you and your doctor need to work together to find the best medication for you. We have to offer this one statement of cheerleading and encouragement: don’t give up. It’s almost certain that something will work for you. It might not be a straight line from today to success. You might need to try several medications to find the best one. The same with therapists and therapies. Try several until you find the one therapist who’s on your side and the one therapy that works for you.

Being Generally Healthy Does Help with Controlling Panic Disorder

Good general health means that your body is well, you feel good, and you’re in control. When you’re healthy it’s easier to find the right medication and therapist. So if you’re not already in good physical shape, work to improve your health and protect it. Take care of yourself in every way that you can. Eat a healthy, balanced diet (fruits, vegetables, fish). Get at least minimal-to-moderate regular exercise (at least 20 minutes a day 5 days a week). Work with your schedule to get a good night’s sleep (7 hours) most nights.

A Reader Asks:

My wife has panic attacks. She takes a Xanax and the attack goes away. Why would she take anything different?

It could be that your wife is fine treating her panic disorder with Xanax® (alprazolam). It depends on how often and what dose she takes, how long she has used it, and how well it treats her panic attacks. If she takes a 0.5 mg tablet a couple times a month and it does the job, maybe fine. If she takes a 1 mg tablet four times a day, maybe not so fine. Alprazolam can be a helpful medication or a hellish addiction. It’s a topic for her and her doctor. Though alprazolam is FDA-approved for panic disorder, there probably are better solutions (see the information below). That said, we do need to add our usual caution. See our disclaimers under Legal. In short, we’re not able to be your wife’s doctor.

Fast (Medication) Plus Slow (Therapy) Means Sure and Steady Success

Taking medication without any therapy gives faster relief than therapy by itself. Therapy without using any medication will take longer to work. But with the therapy, when you stop, it keeps working because you’ve learned things. The best plan to follow, though, is to do both at once. Medication plus psychotherapy build on each other. The combination works far better than either one alone, and because of the medication you feel better sooner. The combo works better because each part, the medication and the therapy, helps in very different ways. In addition, the benefit lasts longer through your life because the therapy is an education that stays with you.

The Many Good Medications for Panic Disorder Treatment

There many good medications of several different types to overcome panic disorder and get control over the panic attacks. The question you need to answer for yourself is which of them, for you, works the best and has the fewest side effects.

Why Take Antidepressants for Panic Disorder?

Panic disorder is not depression. Panic disorder is a whole different medical condition from depression. So many people are upset (and offended?) when offered a medication usually used for depression to help treat their panic attacks. Many years ago people noticed, at first accidently, that these medications for depression did help treat panic disorder and lessen panic attacks. Later this question was rigorously studied and it proved to be true. Our brains are our most complex organ. There’s a lot we don’t understand so there are these occasional surprises.

The SSRIs for Panic Disorder Treatment

Most doctors treating panic attacks will first ask a person to try an SSRI (selective serotonin reuptake inhibitor) to see if it helps. In fact, three of them, sertraline (Zoloft®), fluoxetine (Prozac®), and paroxetine (Paxil®, Pexeva®) are actually FDA-approved for panic disorder. But there are several other SSRIs, and one or more of them might be useful. Your doctor can work with you to find the best one for you.

Other SSRIs are: citalopram (Celexa®, Cipramil®), escitalopram (Lexapro®, Cipralex®), and fluvoxamine (Luvox®, Faverin®).

The SNRIs

One of the SNRIs (serotonin–norepinephrine reuptake inhibitors), venlafaxine (Effexor XR®), is FDA-approved for panic disorder. But just as with the SSRIs, there are several other SNRIs that could work really well.

Other SNRIs are desvenlafaxine (Pristiq®), duloxetine (Cymbalta®), levomilnacipran (Fetzima®), and milnacipran (Ixel®, Savella®).

Bupropion – A Unique Medication

Then there’s bupropion (Wellbutrin®), a somewhat unique medication. Some think it is an odd one to choose to treat panic disorder. Odd because some think that bupropion might make “anxiety” worse. It doesn’t, or at least it only occasionally does as a side effect. Also, “anxiety” can mean many things. Panic disorder is a very specific medical condition. Some individuals find that bupropion is quite effective for panic disorder, lessening panic attacks with few side effects. For one thing, bupropion usually doesn’t ruin sexual interest, a problem with the SSRIs and SNRIs. If the SSRI or SNRI that you try first does not work for you or causes bad side effects, talk to your doctor about trying bupropion.

The Good Old Reliable Tricyclics

These grand old workhorse medications have been used by doctors for 60 years. They’re used less often now. One reason they’re less popular is just that they’re less popular. Everybody wants “that new one I saw on TV”. But they’re good medications and when they work, they often work really well. And, since cost at times does matter, they’re inexpensive. If none of the newer medications are right for you, talk to your doctor about trying a tricyclic. A good middle-of-the-road one that your doctor might suggest you try first is nortriptyline (Pamelor®). Here are the names of a few more of the tricyclics: amitriptyline (can be sedating), clomipramine (also can be sedating), doxepin, nortriptyline, and desipramine (can boost energy or be “activating”).

Benzodiazepines Tempting But Risky for Panic Disorder Treatment

Well, you see, there’s this dilemma, as we touched upon in the reader’s question above. Some people might feel that the benzodiazepines are the “magic bullets” for panic attacks. Because a “benzo” might calm a panic attack in a few minutes. All the other medications listed above are different. You have to take them every day and it takes a week or two or more for them to start working. In fact, two of the benzos, alprazolam (Xanax®) and clonazepam (Klonopin®), are FDA-approved to treat panic disorder. The other benzos might work as well.

There are too many benzos to list them all. A few others that your doctor might think about are chlordiazepoxide (Librium®), clorazepate (Tranxene®), and diazepam (Valium®).

The Trouble with Benzos

Here’s the dilemma. Benzos can be dangerous. It’s possible to become addicted to them and dependent on them. A benzo might work really well at first and then work less and less over time. Even if they seem to keep working, if used frequently and regularly for a long time they can start changing your emotions, making you a dull person. They can change your thinking, making you “feel stupid”, and can make your life feel gray, dull, and flat. Some people say that they can make a person act like a zombie. Benzos might even create a mental state that feels like depression.

How to Best Use Benzodiazepines

So, if the benzodiazepines are used at all, they are best used only now and then, as needed, as a rescue medication for a panic attack. They should be used along with a medication taken every day to lessen chance of a panic attack, like one of the medications mentioned above. And they should be used along with this daily medication and psychotherapy. Therapy will help you get control of the attacks so you’ll automatically need a benzodiazepine less often. Many people with panic disorder keep a benzodiazepine in reserve for rare use in specific situations. For example, a situation that you know might trigger an attack.

Therapy Works as a Panic Disorder Treatment

Therapy works, and usually works well, for panic attacks. There are many different therapies for panic disorder. As with trying different medications, try different therapists and therapies and find the one that you like best and that helps you the most.

Therapy As Education

Some of the therapies teach tips and tricks on seeing an attack coming and learning to control it. The nice thing about these is once you learn how to do it, you know how forever. Like riding a bicycle. You learn how to become master of your panic disorder, and to take over if you feel an attack starting. Also, you have a chance to learn how to avoid having panic attacks.

Cognitive Behavioral Therapy Makes Sense of Panic Disorder

Cognitive behavioral therapy (CBT) is a popular form of therapy that works and has a specific method. People who see themselves as reasonable and logical thinkers, who have a need to understand, seem to like CBT. CBT is a great way to understand panic disorder, panic attacks, what goes wrong, and how to conquer the panic.

Relaxation and Meditation because It’s Hard to Panic When Relaxed

There are several relaxation methods that work to fight against panic attacks, make them come less often and make them milder if they happen. In the same way, there are styles of meditation that help. If practiced twice a day as is recommended, they help and are useful. Another way to beat panic disorder is with specific slow, deep-breathing exercises. These work best when learned from a skilled coach and then practiced regularly. These exercises are then a tool in your toolbox. They can then be used in any high anxiety situation for calm and a relaxed body.

More Ways to Beat Panic with Relaxation

The skill of relaxing your body with “progressive muscle relaxation” is another that can be learned. You learn about your body, where it’s tense and tight. Tension is a setup for a panic attack. Knowing how to get yourself to relax and “let it go” when a panic attack starts helps. There are others relaxation methods. Find one that works for you.

Group Therapy for Panic Disorder Treatment

Your doctor or therapist might refer you to supportive group therapy, usually run by a skilled licensed clinical psychologist. There’s a of people and conversation that works best. The psychologist has to be well-trained, skilled, and experienced. The other members of the group need to be screened by the psychologist and carefully chosen to fit together well and help each other. The psychologist will lead the conversation in the right direction so that each group member can lessen their panic attacks.

Individual Psychotherapy

Some individuals cannot “warm up” to the idea of sitting in a group and discussing their panic attacks. They might do better in individual “interpersonal psychotherapy”. The same caution is true for individual therapy as for group therapy. Find a skilled licensed clinical psychologist. Good person-to-person chemistry between you and the psychologist is really important here. You need to work with someone that you can trust and that is “with you” in your battle against panic disorder. You don’t need a “magical” therapist. The magic needs to be in the mixture, the combination of the two of you. If you feel you cannot “connect” emotionally with your therapist, pay attention to these feelings. Be good to yourself and seek out a different therapist.

Helpful links:

Clinical Studies Recruiting for Panic Disorder at Clinical Trials.gov

National Institute of Mental Health – Panic Disorder: When Fear Overwhelms

Anxiety and Depression Association of America – Understand the Facts: Panic Disorder

Mayo Clinic on Panic attacks and panic disorder

American Family Physician on Treatment of Panic Disorder

* Kuru has no known treatment. Prevention is straightforward; don’t eat dead relatives in New Guinea. It was discovered by Daniel Carleton Gajdusek, and in 1976 he won the Nobel Prize in Physiology or Medication for his research. Kuru’s a rare, incurable disorder found in the Fore people of Papua New Guinea. It’s transmitted by funerary cannibalism. When a family member died, their spirit is said to be set free by having the deceased cooked and eaten. An epidemic was started in the 1950s when a villager died of Creutzfeldt–Jakob disease, a fatal brain disease. When the villagers ate the brain, they contracted the disease. When they died, it was spread to other villagers who ate their infected brains. Kuru causes a person’s nervous system to fall apart, with headaches, tremors, muscle jerks, arm and leg pain, difficulty walking and swallowing, and severe, progressive loss of coordination.

The Good News About Panic Disorder

The current information about panic disorder is all good news. A panic disorder diagnosis is not a mystery. A person who starts having panic attacks can go to any emergency department, or urgent care clinic, or the neighborhood physician down the street. Almost any capable clinician will be able to make the diagnosis of panic disorder and start talking about treatment. They might refer you onward to someone more experienced in treating panic disorder, but the solution is in progress. 

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The Reasons Why Treating Panic Disorder Is So Straightforward

Both the approach to stop a panic attack and treatments to prevent panic attacks are well known. The medications we have now are good and getting better. Therapies for panic disorder help a lot, so much so that one or another type of therapy is now built into any treatment plan. So whether your panic attacks are new or you’ve had them for a while, be encouraged. All is getting better. As always, we are continually vigilant for anything new, and we’ll praise what works, debunk anything that doesn’t work, and encourage you to better health and better health care. So read on about panic disorder.

One of our readers (whose geographic location is unknown) commented:

I’m better now, but when I first started having panic attacks it was really bad. I’d have a panic attack and think I was dying right then and then my wife starts yelling at me asking why I’m doing that as though I can control it. I lost a friend because I had a panic attack right after our handball game. He said later he doesn’t believe in panic attacks and can’t put up with that nonsense. Why is it when a person has a panic attack other people get mad at them?

This is not a common problem, but, it’s not uncommon, either. The person having the attack is terribly frightened. Having anger focused on them not only doesn’t help, the lack of support can make it worse. It’s worth trying to discuss it when everyone is calm. Some people get angry when they don’t understand. Others get angry when they’re frustrated because they want to help but don’t know what to do. If they’re good people and you explain the attacks when you’re both calm, they might come to understand. If you can coach them on what to do and what not to do, maybe they’ll respond better next time. But if the other person is abrasive and doesn’t want to help and doesn’t believe in brain-based medical conditions, it might be just as well to have them out of your life. It’s just not worth the hassle.

Before We Start On Definitions…

Here’s a Story About Someone’s First Panic Attack

A healthy and relatively calm woman is walking quickly down the stairs to the subway. Relatively calm, but she has just been through a tense and upsetting interview for a new job. Suddenly she has a severe pain in her chest and feels dizzy. She grabs the metal stair rail, feeling nauseated, and then her vision goes strange. Everything seems to look small and far away then everything starts to go black. She can’t catch her breath and starts to fall despite her death grip on the metal handrail. Thinking to herself as she sinks to the ground, “Oh, God, what’s happening, I must be dying, I must be having a heart attack, I’m dying of a heart attack”. She tries to fumble in her purse for her cell phone but can’t think and can’t see what she’s doing.

What Might Happen Next

One of the people coming down the stairs sees her struggling, breathing hard, and sweating profusely. This Good Samaritan calls 911 and stays with her. Her chest pain has eased a bit but she says she can’t catch her breath. She’s still confused when the paramedics arrive. They get her into the ambulance and rush off to the Emergency Department. There the medical tests begin. Three hours later she’s feeling better though still upset and shaken by the whole experience. The emergency department physician comes in to talk with her. She says that the tests were all normal. She smiles at the woman and says, “You’ve had a panic attack.”

What Are The Symptoms of a Panic Attack and Panic Disorder?

The story above about the woman having her first panic attack provides a good description. A person having a panic attack is suddenly overcome with overwhelming anxiety and fear, unbelievably overwhelmed. Usually the attacks come “out of the blue” with no warning and no obvious reason for being anxious. If there is some stress that might have caused it (in her case, maybe the job interview) it doesn’t feel like it directly caused the attack. That stress feels like it’s just in the past, not something that would cause a big problem right now. The person feels like they have lost all control of themselves. Sometimes people feel terrified that they are going insane, completely out of their mind, right now. Or, more common, the person might think they’re dying, that they’ll be dead in a few moments. The terror might be worse during the first several attacks.

The Panic Attacks Become Just Annoying Rather Than Terrifying As Time Goes By

Often when the individual thinks back on the panic attack it doesn’t make sense. How did this happen, why did it happen? Perhaps they might even feel a bit silly. Winding up in the Emergency Department over panicking. They don’t panic, they’re always fine. But, in that moment of frightening terror it feels as if insanity or death or something else is real and is right now. Then, surviving the first few, the next big fear is the worry that there’ll be another attack. With medication and therapy one learns how to manage through a panic attack. Over time, as they come under better control and understanding, they can start to feel more annoying than terrifying. Until, finally, they might just go away.

Physically, What Is Panic Disorder? What Are Panic Attacks?

There was a famous scientist in the 1920s, W. B. Cannon, that studied what a person’s (or an animal’s) body does when it’s frightened and braces itself to fight an enemy or run away. He called it the fight or run response. (Journalists have changed it to the “fight or flight” response. You know, because that rhymes.) When threatened and needing to choose between fighting for their life or running away, stress hormones are blasted into the blood stream. Heart rate speeds up, the heart pounds, and breathing is fast. The body slows blood flow to the gut for digestion in order to instead push all the blood to the large muscles. The body is readied almost instantly for a maximal burst of physical energy. Just as with exercise, all this muscle tension makes heat. So the body sweats to get rid of the excess heat.

A Panic Attack Readies You to Fight or Run from a Threat That’s Not There

A panic attack seems to be a burst of all the energy that goes into W. B. Cannon’s fight or run, or fight or flight, response. But, it happens without a real, physical, life-threatening enemy in front of you. The feeling of threat rises from somewhere deep within your brain, and then boom, the attack hits. Often the person is not aware of the source of this feeling of threat, just overwhelmed by the panic attack reaction. Likely the sense of threat was from some previous time. And the threat feeling, for whatever reason, stayed buried until it surged up later as a panic attack.

Panic Disorder and Panic Attacks are Remarkably Frightening and Upsetting

Here’s the odd thing about panic disorder. It’s almost not possible to believe that the experience of a panic attack doesn’t hurt you. How can it feel so terrifying in the moment and yet medically not do any damage? The episode is so ghastly that people are not comforted to learn that a panic attack won’t kill you. Or, even harm you. But it’s true that, frightening as they are, especially the first few attacks, one can eventually learn to control them and tolerate them. And it’s also true, and good news, that they are not medically dangerous. Once a person understands the panic attacks and experiences a few attacks they can become less frightening. Each attack does go away at some point without any help. Even though you might go to an Emergency Department with the first few.

Well, Okay, Yes, But… They Scare Me to Death!

Well, yes, it’s unfortunate, but it’s not so simple as, “Okay, now I get it.” Despite a person having had panic attacks and knowing what’s happening, no one wants to have one. Most certainly no one wants to have one in a public place or while driving. And, as our reader described above, even at home around people who know you, they might just get angry with you and your attacks. These facts means that a person with untreated panic disorder tends to go out less, to socialize less, and starts to become a loner. They might narrow life to only going to work or school. Other joys of social life might shrink. Without proper treatment having panic disorder can easily become socially crippling.

Official Diagnosis of Panic Disorder

US-based physicians use the DSM 5 TR as the guide to diagnose panic disorder. (DSM 5 TR is the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revisions). In DSM 5 TR panic disorder has the diagnosis code number 300.01.  Here’s a link to a Mayo Clinic page that lists the specific signs and symptoms used diagnose it.

How Panic Disorder Is Usually Treated

The silver lining to this panic disorder thundercloud is that there are many good treatments for panic disorder. (For a more complete discussion see our free page on Panic Disorder Treatment.) There are a whole variety of therapies that don’t involve medications and several good medications that help a lot. There are a few medications that people can carry with them in case they feel an attack coming on or they have an actual panic attack. But just a medication by itself is not that helpful in the long run. The best treatment is a good physician-prescribed medication along with being in involved in one of the really good therapies.

The Medications for Panic Disorder

The medications typically tried first are from a family of medications that usually come to mind for treating depression, the SSRIs (selective serotonin reuptake inhibitors). Panic disorder is not depression and most people with panic disorder are not depressed. It just so happens that these medications work for both. Another family of medications that was originally developed for depression, the “tricyclics” or TCAs, also at times work well for panic disorder. Finding the best medication depends both on how well a medication works and its side effects. The unfortunate part of this situation is that a period of trial-and-error is needed for you to find the best fit of good benefit and fewest side effects. Everyone hates trial-and-error but it is definitely worth the effort.

More Medications for Panic Disorder

There’s also a group of medications that immediately come to mind for anxiety. These are popular medications with familiar names (like Valium, Xanax, and Ativan) that are used just to relieve here-and-now anxiety. But here’s the problem. They usually don’t work that well long-term, the benefit wears off. And they’re not that safe to take for a long time. There is a real risk of abuse and addiction. There are some people who become badly trapped by needing to use these medications. They’re trapped in that the drug doesn’t help that much anymore but if they stop using it the withdrawal side effects are totally awful.

Educational Therapy – Psychotherapy – Behavioral Therapy

Many People Like the Therapies

All sorts of excellent therapies are available to help treat panic disorder. Over time these therapies help people to have fewer and fewer, and less and less severe, panic attacks.  And, when they do feel a bit of a panic, the panic attack is milder. There are “tricks and tips”, special ways of doing things, that when learned, practiced, and used can be really helpful to make panic attacks less frequent and less severe, and certainly less frightening. One popular therapy is CBT, or Cognitive Behavioral Therapy. It’s popular because it often works well and is easy to follow. It’s a therapy that’s makes rational sense to many people who see themselves as reasonable and logical and don’t want “psychotherapy”. Then there are relaxation skills, supportive group therapy, and individual interpersonal psychotherapy. Try more than one method, find what helps you the most, and make it yours.

Helpful links:

National Institute of Mental Health on Panic Disorder

Medline Plus on Panic Disorder  

Anxiety and Depression Association of America on Panic Disorder

The Mayo Clinic on Panic Attacks and Panic Disorder

American Psychological Association with Answers to Your Questions about Panic Disorder