Panic & Anxiety Attacks

Information About Panic Attacks

There are two classes of anti-panic medicines that are highly effective. They are:

Group 1 – Benzodiazepines:

Xanax (alprazolam), Klonopin (clonazepam), Ativan (lorazepam), Tranxene, Serax Valium, Librium, and others

Group 2 – Antidepressant anti-panic medicines:

  1. SSRI’s (Zoloft, Prozac, Paxil, Celexa, Lexapro, and Luvox)
  2. tricyclics (Tofranil, nortriptyline, protriptyline, Elavil, Sinequan, Surmontil, and others).

The most important difference between Group 1 and Group 2 is that medicines in Group 1 work much quicker, i.e. stop panic attacks in twenty minutes to a couple of weeks in worse cases. Group 2 requires 1-8 weeks to be effective. However, Group 1 can be physically addictive. Patients with substance abuse tendencies have a high risk of abusing these medicines and/or they may be a gateway substance leading to relapse on their drug of choice.

Group 2 medicines are just as likely to stop all panic attacks as Group 1 after a lag period. The lag period is 1-3 weeks to the onset of reducing the severity and frequency of attacks. It takes Group 2, 3-10 weeks to totally stop all panic attacks in 70% of patients. Since most people need to be on medicine for at least 1 year to significantly reduce the risk of relapse back into panic attacks soon after stopping the medicines, Group 2 are preferred for maintenance because of no risk of physical or psychological dependence and withdrawal. However, Group 2 medicines do need to be tapered somewhat when stopping to avoid some discontinuation symptoms, i.e. uncomfortable symptoms associated with stopping Group 2 meds abruptly.

Hence, if substance abuse is no issue, Dr. Darvin Hege starts most patients with a Group 1 medicine immediately and encourages starting a Group 2 drug as well. The purpose is to get immediate relief as soon as possible and to prepare to taper off the Group 1 medicine and rely on the Group 2 medicine alone after the lag period until Group 2 is fully in effect. This usually takes 1-3 months. In addition to having a faster onset, Xanax in some studies appears to have a little more early robust relief of panic attacks. The newer XR form of Xanax (Xanax XR or alprazolam XR) is generally much preferred for several reasons. It provides much more even blood levels over twenty-four hours after a single dose. Consequently, it provides more consistent reduction and protection against onset of new panic attacks and less severe attacks if they break through. Additionally, there is less sedation, impaired operation of vehicles, and abuse.

How do I know if I’m having a Panic Attack?

Criteria for Panic Attack – A person experiences a discrete period of intense fear or discomfort:

  • It occurs suddenly
  • It reaches a peak within 10 minutes

A person experiences four (or more) of the following 13 symptoms:

  1. Palpitations, pounding heart, or accelerated heart rate
  2. Sweating
  3. Trembling or shaking
  4. Sensations of shortness of breath or smothering
  5. Feeling of choking
  6. Chest pain or discomfort
  7. Nausea or abdominal distress
  8. Feeling dizzy, unsteady, lightheaded, or faint
  9. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
  10. Fear of losing control or going crazy
  11. Fear of dying
  12. Paresthesias (numbness or tingling sensations)
  13. Chills or hot flushes

Which medicine has the fewest side effects?

Both Group 1 and Group 2 have risks of side effects. Most patients do not have side effects to a significant extent. Those who do usually have side effects that are generally very mild and go away within a few days or weeks.

The most common side effects of Group 1 medicines occur in a minority of patients. They are drowsiness and/or incoordination, usually occurring if the initial dose is too high or the dose is increased too fast. The risk of developing physical and/or psychological dependence to Group 1 medicines is very low unless the person has a history of substance abuse.

Group 2 medicine side effects occur in only a minority of patients as well. Most common are nausea, dizziness, sedation, insomnia, sexual side effects, and/or increased appetite and weight gain. Seldom are there side effects from a succession of multiple medicine trials so that we can’t get panic attacks reduced or stopped in a few days or a week or two.

How long do I have to stay on the medicine?

Most evidence that we have suggests the majority of patients should stay on their medicines for at least one year after the panic attacks are stopped. If the medicine is stopped before one year, there is a higher incidence of relapse more quickly than for those who wait for at least a year. And our data shows that it is best to stay on the same dose that stopped the panic attack for the year unless there is an uncomfortable side effect. Most patients could be successfully and painlessly weaned off Group 1 medicines during this year and come to rely solely on the robust long-term effectiveness of a Group 2 medicine. Cognitive behavioral therapy (CBT) has proven effective to augment extinguishment of panic attacks and increases a patient’s likelihood of successfully weaning off all medicines. Dr. Hege has have a network of CBT therapists to whom he refers patients while focusing on medication management.

Why can’t I just have my primary physician administer these medicines?

There are many non-psychiatrist physicians who are quite skilled with these medicines. However, Dr. Hege sees ten or more patients each day in different stages of recovery from panic attacks. Dr. Hege has been practicing since 1978. If your PCP is uncomfortable treating panic attacks or reaches the limit of their skills, Dr. Hege has vast experience in evaluating for some other condition that may be underlying the panic attacks (depression, bipolar disorder, PTSD, ADHD). Sometimes a complicating condition develops after the onset of panic attacks such as depression or substance abuse. Addressing the core panic disorder or other condition with the vast selection of tools with which psychiatrists are familiar will likely result in relief and success.

For more information about treatment of panic attacks, call Dr. Hege today for the expertise and relief you need!