Good News: Panic Disorder is a Well Known Medical Condition
The last thing that anyone would want is a medical problem that no physician can diagnose or treat. (If you go to your primary care physician with a case of Kuru *, you’re in real trouble. He won’t have a clue about what’s wrong.) But if you see your physician for arthritis she’ll know what it is and how to treat it. Similarly with panic disorder, every family physician, general internist, psychiatrist, nurse practitioner, and physician’s assistant knows about panic disorder. It’s not new, it’s not rare, it’s not a mystery, and it’s not fatal. And almost all physicians know about panic disorder and what works to treat it.
More Good News: With Panic Disorder Treatment You Have a Great Chance to Get Better
It’s true, with panic disorder you have a great chance to get better. While we can’t guarantee that everyone will quickly and easily conquer their panic disorder, we can say that panic disorder can be treated and the treatments are straightforward. The dilemma with panic disorder is not the treatment plan, it’s those first few panic attacks. They’re awful. But with capable medical care and appropriate treatment, after those first few you will start to understand what’s happening to you and you’re on the way to wellness. And with medication and therapy, pretty quickly, you’re back in control.
Panic Disorder Treatment Is Straightforward But Now Always Easy
There’s a difference between straightforward and easy. The steps to wellness that one needs to take are clear but walking up those known stairs takes some effort. The first task is finding your own best physician as a partner in your treatment. Then you and your chosen physician need to work together to find the best medication for you, meaning the medicine that works the best but also has the fewest side effects. 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 trial-and-error is there with therapists and therapies. Try several until you find the one therapist who’s most on your side and the one therapy that works the best for you.
Being Generally Healthy Does Help with Controlling Panic Disorder
If your body is, by and large, healthy, that makes it easier for the panic disorder treatments to work. Good general health means that your body is well, the for the most part you feel good, and you’re feeling relatively in control. When you’re healthy it’s even easier to find the right medication and your best 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 twenty minutes a day five days a week). Work with your schedule to get a good night’s sleep (at least seven 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 she takes it 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, fine. Maybe even a 1 mg tablet twice a day would be fine if it works well, continues to work well, and doesn’t cause any problem side effects. If she takes a 1 mg tablet four times a day and feels she needs more, that’s not good. Alprazolam can be a helpful medication or a hellish addiction. It’s a topic for your wife and her physician. Though alprazolam is FDA-approved for panic disorder, there might be better solutions (see the information below).
Fast (Medication) Plus Slow (Therapy) Means Sure and Steady Toward Success
Taking medication without any therapy (therapy is educational among other benefits) gives faster relief than therapy by itself. Therapy without using any medication will take longer to work but might work eventually. But when you’ve been in therapy long enough and then 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, reinforce 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 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, different medication families, that help greatly 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. It will take some trial-and-error work between you and your physician, which is no fun, but we guarantee it will, in the long run, be well worth the effort.
It Seems Odd to 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 physicians 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 of them might be useful. Your physician can work with you to find is one works well for you.
Other SSRIs are:
- citalopram (Celexa®, Cipramil®)
- escitalopram (Lexapro® Cipralex®)
- fluvoxamine (Luvox®, Faverin®)
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.
Other SNRIs are:
- desvenlafaxine (Pristiq®)
- duloxetine (Cymbalta®)
- levomilnacipran (Fetzima®)
- milnacipran (Ixel®, Savella®)
Bupropion – A Unique Medication
Then there’s bupropion (Wellbutrin®), a somewhat unique medication. Some think it’s an odd one to choose to treat panic disorder because for some people bupropion might make “anxiety” worse. But for many people bupropion doesn’t make anxiety worse. Or it might increase nervous feelings only occasionally 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 and not worsening any feelings of anxiety or nervousness. It’s also noteworthy that bupropion usually doesn’t ruin sexual interest, a problem with the SSRIs and SNRIs. If the SSRI or SNRI that you try first doesn’t work for you or causes bad side effects, talk to your physician about trying bupropion.
The Good Old Reliable Tricyclics
These grand old workhorse medications have been used by physicians for 60 years. They’re used less often now. One reason that 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 physician about trying a tricyclic. A good middle-of-the-road one that your physician 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)
- desipramine (can boost energy or be “activating”)
Benzodiazepines – the “Use with Caution” 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 benzodiazepines, alprazolam (Xanax®) and clonazepam (Klonopin®), are FDA-approved to treat panic disorder. Any of the other benzodiazepines might work as well. There are too many benzodiazepines to list them all.
A few others that your physician might think about are:
- chlordiazepoxide (Librium®)
- clorazepate (Tranxene®)
- diazepam (Valium®)
Why Benzodiazepines Present a Dilemma to Both Patient and Physician
Here’s the dilemma. Benzodiazepines can be dangerous. It’s possible to become addicted to them and dependent on them. For some people it’s really easy to become addicted. A benzodiazepine might work really well at first and then work less and less well as time goes by. Even if they seem to keep working, if they’re used frequently and regularly for a long time they can start changing your emotions, making life a bit dull for you. They can change your thinking, making you “feel stupid”, and can make your life feel gray, sad, and flat. Some people say that benzodiazepines can make a person act like a zombie. They 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 in their pocket or purse for rare use in specific situations. For example, a situation that you know might trigger an attack. The exception might be for treatment-resistant panic disorder. If you’re a subscriber to our stie, see our page on Treatment-Resistant Panic Disorder.
Therapy Is Part of the Panic Disorder Treatment Plan
Panic disorder is a condition in which therapy tends to work. A few therapy techniques are more typically recommended for panic disorder more than others, as we discuss below. As with trying different medications, try different therapists and different 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 how to notice that an attack is coming and learning how to control it. One convenient point about these tips and tricks is that once you learn how to do it, you know how forever. It’s 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 the opportunity to learn how to avoid having panic attacks.
Cognitive Behavioral Therapy Makes Sense of Panic Disorder
Cognitive behavioral therapy is a popular form of therapy that works and follows a specific plan to learn about and lessen the impact of panic disorder. Individuals who view themselves as reasonable and logical thinkers, who have a need to understand, seem to like cognitive behavioral therapy. It’s a really good therapy for learning to understand panic disorder, panic attacks, what goes wrong, and how to calm 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 the attacks come less often, and make them milder if they happen. In the same way, there are styles of meditation that can 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 technique that can be learned. You learn about the various muscle groups in your body and how to determine which muscles are tense and tight. Increased muscle tension and feeling stressed is a setup for a panic attack. Knowing how to get yourself to relax and “let it go” when a panic attack first starts helps keep the attack from overwhelming you. There are other relaxation methods. Find the one that works for you.
Group Therapy for Panic Disorder
Your physician or therapist might refer you to supportive group therapy, usually run by a skilled and licensed clinical psychologist. There’s a known mix 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 so that the ability is there to help each other. The psychologist will lead the conversation in the right direction so that each group member can learn to lessen their panic attacks.
Some individuals cannot “warm up” to the idea of sitting in a group and discussing their panic attacks, especially when they’re new to psychotherapy. They might do better in individual “interpersonal psychotherapy”, or in “panic-focused psychodynamic psychotherapy”. The same caution is true for individual therapy as for group therapy. Find an experienced psychiatrist or a skilled and licensed clinical psychologist. Good person-to-person chemistry between you and the psychiatrist or 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” in an emotionally comfortable way with your therapist, pay attention to these feelings. Be good to yourself and seek out a different therapist.
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 deceased relatives in New Guinea. Kuru 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 dies, 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, leading to death.