Panic Attacks and Medication
Dr Jonathan Haverkampf
Panic attacks have a sudden onset. Often there is the sense of losing control, physically as well as psychologically. A panic attack leads into a vicious cycle, where the anxiety of losing even further control makes the panic attack worse. Breathing is often rapid and shallow, which further contributes to the panic attack by altering the blood gas levels. Panic attacks seem to occur out of the blue at first, but a closer look in psychotherapeutic sessions often leads to underlying thoughts, emotions and situations that can trigger or maintain them. While psychotherapy is the preferred long-term treatment, medication has a place in reducing symptoms rapidly and working effectively against the symptoms in the medium- and long-term.
The sudden onset seems to require medication that is taken preemptively. However, this is often not the case. Many patients report that merely having a tablet of an anxiolytic, such as lorazepam or alprazolam in their pocket and immediately available, effectively prevents panic attacks and reduces the need for medication. The knowledge that one has something that helps quickly, can make one less anxious about becoming anxious.
In the medium- to long-term usually an antidepressant with anti-anxiety properties is used, particularly substances from the group of selective serotonin reuptake inhibitors (SSRIs). They are generally held to be non-addictive and their side-effect profiles, especially of the newer ones, are usually relatively benign. The serotonin syndrome, a potentially fatal side-effect, can occur in some drug combinations, but is otherwise a very rare occurrence. The most dangerous combination with monoamine-oxidase (MAO) inhibitors, a functional group of antidepressants, is more an academic consideration, because the latter should not be used anymore in treating anxiety.
The usual strategy is to prescribe an anxiolytic, such as lorazepam or alprazolam, as a fast-acting substance. Lorazepam in the sublingual form, placed underneath the tongue, often works the fastest, although the maximum effect can take as long as the oral form (swallowing it). Parallel, a longer-term medication with an SSRI can be started, which can take several weeks to show an effect. But SSRIs are usually quite effective in reducing panic attacks and anxiety, while, unlike the benzodiazepines, they are considered to be non-addictive. Sometimes a switch to another SSRI may be necessary, but one should not switch unless an SSRI has been tried for six to eight weeks at a higher dose.
Other antidepressants which directly influence also the norepinephrine transmitter system, such as the serotonin-norepinephrine reuptake inhibitor (SNRI) Venlafaxine (Effexor®), are probably better avoided in the first-line treatment of panic attacks because they can make them worse in the early phase of treatment. However, sometimes if two or three SSRIs have not worked satisfactorily, one may have to resort to different functional groups or, depending on one’s level of desperation, even combinations.
© 2012, 2016 Dr Christian Jonathan Haverkampf. All rights reserved.
Psychotherapy & Counselling, Communication, Medicine (Psychiatry); Dublin, Ireland
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This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition.
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