NAMI HAMILTON COUNTY

What Are the Current Treatments for Panic Disorder?

We asked Mark H. Pollack, M.D., Associate Professor of Psychiatry, Harvard Medical School, and Director of the Anxiety Disorders Program at the Massachusetts General Hospital, Boston. 

The chief symptom of panic disorder is repeated bouts of intense fear or anxiety that come on suddenly and peak within 10 minutes. The episodes are accompanied by symptoms of physiological arousal— a racing heart, heavy breathing, and an urge to flee.  Patients often say that it is the most distressing experience they have ever had.  One common result is anticipatory anxiety — intense fear of further attacks or concern about the implications of the symptoms.  Many patients also develop agoraphobia, a tendency to avoid situations in which they have suffered panic attacks — and eventually any situation, such as traffic or a crowded room, in which help might be unavailable or escape difficult in the event of an attack. 

Panic disorder is common, affecting 3% to 4% of Americans (two-thirds to three-quarters of them women) at some time in their lives. The disorder is usually chronic and often occurs in people who were shy or anxious as children. It runs in families, and a genetic vulnerability is likely. 

This disorder is distressing and disabling, physically, psychologically, and socially. Patients may endure lengthy, expensive, and uncomfortable medical evaluations before they are diagnosed correctly. The effects on their social lives and ability to work can be disastrous. Patients of both sexes suffering from panic associated with depression are at increased risk of suicide, and men with panic disorder are at increased risk of dying prematurely of heart disease.

Fortunately, both medications and behavior therapy are effective. The preferred drugs are selective serotonin reuptake inhibitors (SSRIs), including paroxetine (Paxil), sertraline (Zoloft), fluoxetine (Prozac), citalopram (Celexa), and fluvoxamine (Luvox). They often relieve not only the panic attacks but also other accompanying conditions —depression, social anxiety, general anxiety, obsessional thoughts, compulsive acts, and posttraumatic stress. Side effects, especially nausea and loss of sexual functioning, may be a problem for some patients.

Tricyclic antidepressants such as  imipramine (Tofranil) and clomipramine (Anafranil) are also effective for panic disorder, although they generally have more serious side effects than SSRIs. They include dry mouth, blurred vision, a rapid heartbeat, lightheaded-ness, and weight gain. Another sometimes useful class of antidepressants, the monoamine oxidase inhibitors, includes phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan). These drugs can produce a dangerous rise in blood pressure when the patient eats certain foods or takes certain medications. As a result, they are usually not prescribed unless other approaches do not work. 

Benzodiazepines such as alprazolam (Xanax) and clonazepam (Klonopin) are also used to treat panic disorder, usually in combination with antidepressants.  They have the virtue of acting immediately (anti-depressants take two to four weeks), but they may cause drowsiness, intellectual impairment, and dizziness. Physical dependence may develop, in which case the dose must be reduced gradually to prevent a withdrawal reaction with symptoms that may include anxiety, jitteriness, and even seizures. Patients with a tendency to abuse illicit drugs or alcohol are also at some risk for benzodiazepine abuse. Some patients with panic disorder also benefit from anticonvulsants, and new medications are being developed.

Cognitive-behavioral therapy may be provided either alone or along with medication. It teaches patients how to manage anxiety (for example, by proper breathing) and how to correct anxiety-provoking thoughts. Their fear may be reduced by repeated exposure to anxiety-provoking situations or sensations. Patients who relapse when the treatment ends may benefit from maintenance medication, maintenance cognitive-behavioral therapy, or both.

Reprinted with permission from the Harvard Mental Health Letter, 164 Longwood Avenue, Boston, MA 02112