Panic disorder and agoraphobia: Australian treatment guide for consumers and carers, 2005

Effective treatments for panic disorder

Page last updated: June 2005

Panic disorder is a condition that we know a lot about. There has been a great deal of research to find out which treatments are effective, that is, which treatments will significantly help someone with panic disorder.

The aims of treatment for panic disorder are:

  • To help you cope with and stop panic attacks
  • To become aware of and stop fear-driven avoidance
  • To reduce the vulnerability to future panics.
It is important to remember though that even if treatment has been helpful, you will probably still experience symptoms of anxiety during your recovery.

The major treatments for panic disorder are:
  • Cognitive Behavioural Therapy
  • Antidepressant medication
  • Benzodiazepine medication.
Each of these treatments will be briefly described with the potential advantages and disadvantages listed. Your choice of treatment may depend on the skill of the therapist, cost or other considerations.

You do not need to be afraid of anxiety. You have skills to deal with it.

Is there a recommended treatment?

Research suggests that Cognitive Behavioural Therapy (CBT) is the preferred treatment but Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants are also commonly used. However, effective treatment should include behavioural treatment to limit avoidance. Each treatment must be considered for its suitability in your particular case. Both psychological and medication options will now be discussed.
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Psychological treatments

Cognitive Behavioural Therapy

CBT for panic disorder involves treatments that change the behaviour (exposure and anxiety management such as slow-breathing) and those that change anxiety-provoking and worrying thoughts (i.e. cognitive therapy). The goal is to help you develop a less upsetting understanding of physical changes that occur when you are anxious.

There is evidence that CBT is more effective than medication in both the short and long term. One advantage of CBT over medication is that it has been shown to be helpful in the long-term, i.e. several months to several years after short-term treatment has finished.

Education about the disorder

Following assessment, a therapist will teach you about anxiety in general, and panic disorder specifically. This will involve talking about the 'fight or flight' response and details of how this affects the body. Education will involve dispelling fears that people commonly have about this disorder such as that they are going crazy or will die as a result of the symptoms.

Cognitive therapy

This part of treatment involves identifying triggers for panic attacks and understanding the fears you have about the symptoms of panic. Triggers might be a thought or situation or a slight physical change such as faster heartbeat. People are taught to be more realistic in their interpretation of panic symptoms and feared situations.

Interoceptive and in vivo exposure

Interoceptive exposure involves becoming less frightened of the symptoms of panic in a controlled manner. For instance, it might involve jogging on the spot in the therapist’s office to become more familiar with the meaning of certain symptoms such as rapid heartbeat and shortness of breath. Alternatively, it may involve drinking cups of coffee or sitting in a hot room.

For those who avoid situations for fear of having a panic attack it will be important to face feared places. In vivo exposure involves breaking a fearful situation down into achievable steps and doing them one at a time until the most difficult step is achieved. For example, if a person is fearful of train journeys, the treatment may include going on trains, then going on trains with an increasing number of stops and with increasingly large crowds and so on.

Relaxation and breathing techniques

Panic can be made worse by overbreathing. Slowing one's breathing rate can be effective for some people to help deal with a panic attack and also to prevent a full-blown attack from occurring. Relaxation is probably more useful as a general strategy for dealing with anxiety but has been shown to be helpful for some people with panic disorder. Relaxation and slow-breathing alone have not generally been shown to effectively treat panic disorder, although there is some evidence that a form of relaxation called 'applied relaxation' can be helpful.
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Medications for panic disorder

Antidepressants

There are many different types of antidepressant medications that have been found to be effective in treating panic disorder. Each type works slightly differently and with your doctor you will be able to decide which works best for you, while causing the least amount of side effects.

Most medications will be started at a low dose and increased to an effective level. It is important that you take the medication as suggested by your doctor and do not make changes without his/her knowledge. If you experience unpleasant side effects, let your doctor know so that you can be advised whether they are normal or not. Some side effects are quite common and your doctor will help you to understand what to expect. See Appendix 1 for a list of possible questions for your prescribing doctor. Currently there is no evidence that the benefits of medications will continue once the medication is stopped.

Tricyclic antidepressants

Tricyclic antidepressants (TCAs) are an older class of drugs known for helping depression. They are also effective in treating anxiety. Imipramine has been shown in many good studies to be an effective treatment for panic disorder.

These drugs tend to have a number of unpleasant side effects including a dry mouth, dizziness and nausea, which means that some people find it difficult to take the medication even though it may help them.

Selective Serotonin Re-uptake Inhibitors

In recent years, there has been a lot of talk about drugs in this class of antidepressants as they are as effective as the older types of antidepressants but are associated with fewer side effects. The most well known is probably Prozac (fluoxetine) but now there are a range of other SSRIs, many which have been shown to help people with panic disorder (i.e. Cipramil / citalopram, Aropax / paroxetine, Zoloft / sertraline and Luvox / fluvoxamine).

Side effects, while less frequent, still occur and include headaches, nausea, insomnia and difficulties with sexual intercourse. Symptoms can also occur when you try to stop the SSRI medication.

Benzodiazepines

These drugs are designed to reduce tension and increase relaxation without causing sleep. There are side effects associated with these drugs which should be discussed with your doctor. Benzodiazepines such as alprazolam (Xanax) have been found to be effective in treating panic disorder. Disadvantages of this class of medication include the addictive quality and problems with withdrawal when you stop taking the drug. Long-term use is associated with dependence, increased risk of motor accidents and memory problems.

Other medications have been studied for panic disorder but there is not sufficient information at this stage to recommend their use.
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How do I choose a treatment?

The number needed to treat (NNT) is a statistic that is popular and informative. It means that the clinician must treat a certain number of people with a disorder for one person to become 'cured' (for panic disorder this means free of panic attacks).

The number of people your clinician would need to treat for one person to be panic free varies with different treatments.

Cognitive behaviour therapy: need to treat 3 people
Benzodiazepines: need to treat 5 people
Tricyclic antidepressants: need to treat 6 people
SSRIs: need to treat 6 people

How long until I feel better?

Improvements will not be seen instantly with any type of treatment so it is important to be patient and work hard towards recovery. Any treatment you choose will require your active involvement.

Generally with most antidepressant medications results will take three to four weeks to be seen. If after six weeks on a certain medication you do not see any improvement it is important to discuss with a health professional what other options are available.

Improvement will often be gradual with CBT and not instantaneous. It is important to give the treatment a chance. Treatment often involves 8 to 12 sessions of 60 to 90 minutes. As with medication, if you have not seen any improvement after six to eight sessions you may need to consider other treatments.

With CBT, you are required to be an active participant in treatment. If you have practised the techniques and done homework between sessions and are still finding that you are not better, then a change in treatment could be advised. Research about long-term outcome suggests that cognitive behavioural techniques have lasting benefits that continue after treatment has finished.

Keep an open mind and if you feel that the therapist you have chosen is not the right choice for you, take action and either seek a second opinion or change therapists altogether. It is important to fully participate in treatment and to be assertive regarding treatment recommendations and decisions. You should work with your doctor - not simply 'do as your doctor says'.