Anxiety and Panic Attacks: Symptoms and Treatment
Introduction: Anxiety and Panic Attacks
You might have heard the terms “anxiety attack” and “panic attack” used interchangeably, but they are not the same condition. While there are some similarities, there are many differences, and it's important to have a correct diagnosis before treatment.
The main difference between anxiety and panic attacks is that anxiety is a chronic, ongoing and excessive level of worry. A panic attack occurs abruptly, for no apparent reason, and usually lasts for minutes or rarely up to one hour. A panic attack is regarded as a danger occurring at the moment, while chronic, ongoing anxiety and worry tend to focus on future events.
- Anxiety, or generalized anxiety disorder (GAD) is a chronic, ongoing condition with excessive worry over normal life events, whether minor or major.
- These ongoing feelings are usually more than the actual trouble you might encounter in your everyday life.
- When someone says they are having an anxiety attack, they are probably suffering from some extreme level of short-lived anxiety, not a true panic attack.
- Panic attacks can occur for no known reason and without warning.
- In a panic attack, you might feel terrified, anxious, worried, ear that you are going to die or that you need to escape.
- Your heart might start racing; some people mistake a panic attack for having a heart attack.
- A panic attack starts suddenly and may last for a few minutes or rarely up to an hour.
- After your panic attack is over, you may worry about when the next one will occur.
Symptoms of anxiety
Symptoms of anxiety (medically called generalized anxiety disorder) can include:
- frequent, ongoing and excessive feelings of worry, nervousness or anxiousness
- a rapid heart rate
- rapid breathing
- excessive perspiration and sweating
- feeling tense or having muscle aches
- trembling, quivering
- trouble concentrating
- headaches, stomach upset
- avoidance of circumstances that might trigger severe anxiety
Generalized anxiety disorder results in excessive worry over everyday situations and occurs over many months, or even years. General anxiety is not as abrupt and does not occur without warning like a panic attack, although anxiety can be severe.
Causes of anxiety
The exact causes of most anxiety disorders are not fully known. Researchers believe there are miscommunications between neurotransmitters and receptors in the brain that can worsen anxiety disorders. Anxiety disorders may also be caused by:
- traumatic life experiences
- difficult relationships
- your environment
- family history
Although the definition of panic attack and anxiety are different, treatments for these disorders are often the same and medications often come from similar drug classes.
Symptoms of a panic attack
The reaction from a true panic attack is different from anxiety. Panic attacks are often referred to as the “fight-or-flight” response. Doctors typically look for at least four of these signs of a panic attack to make a diagnosis:
- very fast heart rate
- quick breathing
- shortness of breath
- a feeling of choking
- chest pain or pressure
- lightheadedness or dizziness
- feeling shaky, trembling, numb or tingling
- nausea (sick to your stomach)
- sweating more than normal
- sudden flushing or chills
- feeling of doom
- fear of dying and feeling a need to escape
- an strong worry about when the next panic attack will occur
A panic attack leads to fear that is not normal and makes you uncomfortable. They are not dangerous or life-threatening. A panic attack typically lasts for short periods of time, usually peaking in about 10 minutes, but may rarely last up to an hour. They can occur several times daily, or people may go weeks or months between panic attacks.
Panic attacks can be treated by mental health professionals with talk therapy (psychotherapy) and medications.
Causes of a panic attack
A panic attack occurs when there's no obvious danger present. Panic attacks may start in response to a certain fear or situation without warning, and ongoing panic attacks may be brought on by these similar situations.
Like anxiety, the exact causes of panic attacks are not known, but may be due to:
- family history or genetics
- a life-changing event or major stress
- being more sensitive to stress or negative emotions
- biological changes in the brain
- if anxiety or panic runs in a family, it can be genetically inherited.
- caffeine can aggravate a panic attack
It is thought chronic anxiety begins in the brain where cells have difficulty communicating and processing fears. Medications used for anxiety and panic attacks are similar. Drugs that work in the brain, such as antidepressants and benzodiazepines, have been shown in clinical trials to help with both chronic anxiety and panic disorder.
When panic attacks occur frequently, the person is said to have a panic disorder. This is one of many different types of anxiety disorders. Roughly 6 million Americans have panic disorder in any given year, and women experience panic disorder twice as often as men. Up to one-third of people may experience a panic attack in their lifetime, but only 10% of these go on to develop full panic disorder.
People who experience panic attacks may anticipate a future attack and avoid places or situations where the attack may reoccur; this is known as panic disorder with agoraphobia. Panic attacks can also occur without agoraphobia. Only about 30% of patients with panic disorder also have agoraphobia.
With agoraphobia, you have fear towards certain places and often avoid situations that might cause you to panic and make you feel trapped, helpless or embarrassed. A person who experiences panic disorder with agoraphobia may avoid normal routines like going to school or work, going to the grocery store, or driving.
How To Stop a Panic Attack
For panic attacks, it’s important that you are treated quickly by a medical professional. Do not start avoiding what triggered the attack. If you do not get treatment you may start avoiding the trigger and stay at home. This can negatively affect your work and social situations.
A panic attack is best treated with medicines and talk therapy with a specialist. Talk therapy can be either individual or in a group setting.
It may take a few weeks or longer for your therapy to reach its maximum effect, so it’s important to continue with your treatment. If you are having side effects, speak with your doctor about options.
Treatments for Anxiety and Panic Disorder
Treatment of anxiety or panic attacks often involve specific FDA-approved medications that act in the brain to reset neurotransmitters that are thought to be involved with fear. Your doctor may also decide to prescribe other medications “off-label”, meaning they are not specifically FDA-approved for these conditions, but have been used successfully in clinical treatment. Talk therapy is often combined with medications for both anxiety and panic disorders.
Many of the same classes of medications have been shown to be effective for both the treatment of generalized anxiety and panic disorder. These include:
- Selective serotonin reuptake inhibitors (SSRIs)
- Serotonin-norepinephrine reuptake inhibitors (SNRIs)
- Tricyclic antidepressants (TCAs)
- Benzodiazepines (BZDs)
Monoamine oxidase inhibitors (MAOIs) may infrequently be used for treatment of panic disorder as well.
Based on the American Psychiatric Association guidelines for the treatment of panic disorder, these drug classes have all been shown to have a comparable effect, but some are not as well-tolerated from a side effect standpoint. Others, such as the BZDs may be prone to abuse or addiction, especially in people who have a history of a substance use disorder.
For both anxiety and panic disorders, therapy may continue for a year or more after symptom control, but symptoms may reappear if drug treatment is discontinued. Many of these drugs need to be slowly stopped over several months to help prevent withdrawal symptoms such as worsened anxiety, agitation, difficulty sleeping (insomnia), fatigue, dizziness, and nausea.
Drug treatment for anxiety or panic disorder is an individual decision you and your doctor will make based on factors such as your previous treatments, drug side effects, drug interactions with your current medications, and other considerations like costs and availability.
SSRI and SNRI Antidepressants
SSRI (selective serotonin reuptake inhibitor) are a class of antidepressant medications. They are often recommended as the first choice to treat panic attack or anxiety due to safety, effectiveness, and a tolerable side effect profile.
Treatment selection is individualized for you and based on your past treatment history, side effect profile, possible drug interactions, and cost or other preferences. Most SSRIs are now available in a generic formulation, making them affordable. Not all SSRIs are FDA-approved for GAD or panic disorder, but are often used "off-label".
The average time for the treatment to start working can range from 2 to 4 weeks, but a full clinical effect can take 8 to 12 weeks. Your doctor will prescribe low doses at the beginning of therapy to lessen the stimulating effect that some of these medications can produce. Treatment may often be continued for a year or longer to help prevent a recurrence or relapse.
Table 1: SSRIs Commonly Used for Generalized Anxiety Disorder or Panic Disorder
|Generic Name||Brand Name(s)||FDA-Approval|
|fluvoxamine||Luvox, Luvox CR||N/A*|
|paroxetine||Paxil, Paxil CR, Pexeva||Anxiety, Panic disorder|
*N/A: not FDA approved for anxiety or panic disorder, but might be used off-label
Paroxetine (Paxil) has a higher risk of withdrawal symptoms than fluoxetine (Prozac) due to a shorter half-life, but the onset of action of fluoxetine may be delayed for weeks. Paroxetine can be more sedating and may be useful for patients with insomnia.
Fluoxetine (Prozac) and sertraline (Zoloft) may be more stimulating causing anxiety and and interfering with sleep. Sertraline has the highest risk for stomach complaints and diarrhea.
Citalopram (Celexa) and escitalopram (Lexapro) may have fewer drug interactions than other SSRIs.
In general, side effects with SSRIs may include:
- irritability or agitation
- stomach upset (nausea or diarrhea)
- dry mouth
- QTc prolongation (abnormal heart rhythm)
- sexual dysfunction
- possible weight gain
- withdrawal syndrome with rapid discontinuation
- increased suicide risk
All antidepressants, including the SSRI and SNRI class have Boxed Warnings in their product insert detailing the risk of suicidality (thinking and behavior) in children, adolescents and young adults under 25 years of age. Patients of all ages should be closely observed and monitored for clinical worsening, suicidality, or unusual changes in behavior, especially with SSRI or SNRI dose increases or changes.
Venlafaxine ER (Effexor ER), a serotonin-norepinephrine reuptake inhibitor (SNRI) has been shown in clinical trials to be effective for treatment of panic disorder and is FDA-approved for this use. Randomized trials of other SNRIs in panic disorder are lacking. Use of the immediate-release venlafaxine for panic disorder is not recommended as it is associated with more side effects than the extended-release product. Dosing should start at the low end and slowly titrated up at roughly 1 to 2 week intervals.
Table 2: SNRIs Commonly Used for Generalized Anxiety Disorder or Panic Disorder
|Generic Name||Brand Name(s)||FDA-Approval|
|venlafaxine extended release (ER)||Effexor ER||Anxiety and panic disorder (ER form only)|
Both venlafaxine and duloxetine can worsen agitation or insomnia and may have significant withdrawal symptoms if not tapered slowly. Venlafaxine may be associated with fewer drug interactions than duloxetine.
Both duloxetine and venlafaxine ER can be found in generic formulations.
Side effects with SNRIs may include:
- dry mouth
- stomach pain
- QTc prolongation (abnormal heart rhythm)
- elevated blood pressure
- loss of appetite, weight loss
- excessive sweating
- sexual dysfunction
- withdrawal syndrome with rapid discontinuation
- increased suicide risk
Doses of SSRIs and SNRIs should be started at the low end of the therapeutic range and titrated up over 2 to 6 weeks. When stopping SSRI or SNRI treatment for panic disorder or generalized anxiety disorder, avoid an abrupt discontinuation. A slow taper over several months is generally recommended to avoid withdrawal symptoms.
In general, SSRIs and SNRIs have been shown to be roughly 60 to 70%% effective in the treatment of generalized anxiety disorder when compared to placebo.
Tricyclic Antidepressants (TCAs)
Certain tricyclic antidepressants have been shown effective for panic disorder; however, many patients may not be able to tolerate the side effects of this class. The elderly especially may be vulnerable to anticholinergic side effects like constipation, drowsiness, blurred vision, and urinary retention. Based on the 2019 Beers Criteria, this class is considered potentially inappropriate for adults 65 years and older due to these effects.
As with the SSRIs and SNRIs, treatment effect may not be seen until after 4 weeks with TCAs, and may take up to 12 weeks for full treatment effect.
Table 3: TCAs Commonly Used for Panic Disorder (off-label use)
Side effects with TCAs may include:
- anticholinergic effects like dry mouth, blurred vision, and constipation
- excessive sweating
- difficulty sleeping
- fainting or dizziness upon standing
- fatigue and weakness
- weight gain
- sexual dysfunction
- cardiac problems or high blood pressure
A cardiac evaluation, including an electrocardiogram (ECG) should be assessed at baseline and with TCA dose increases. This is especially important in older adults, with high doses, and/or in patients with preexisting or family history of cardiovascular disease. Monitor the blood pressure and pulse rate before and when starting TCA therapy.
Benzodiazepines for GAD or Panic Disorder
Benzodiazepines have also been shown in clinical trials to be effective for generalized anxiety disorder and panic disorders. These agents work on specific brain GABA receptors to lower stimulation and exert a calming effect. These drugs are central nervous system depressants and can cause sedation.
When possible, this class of drug should be used only in the short-term and with extreme caution because they can cause sedation, judgment problems, memory impairment, dependence, and addiction. Avoid use in patients with a history of substance use disorder, including alcohol, due to the potential for misuse.
Benzodiazepines (BZDs) may have a place at the outset of therapy in patients with severe symptoms while antidepressants or other longer-term agents take effect. They can also be combined with SSRIs or SNRIs for breakthrough symptoms. Although all agents in this class are effective for panic disorder, only alprazolam and clonazepam are FDA-approved for panic disorder.
Table 4: Benzodiazepines Commonly Used for GAD or Panic Disorder
|Generic Name||Brand Name(s)||FDA-Approved Uses|
|alprazolam||Xanax, Xanax XR, Niravam||Anxiety, Panic disorder|
Side effects with benzodiazepines may include:
- addiction, dependence
- amnesia (forgetting recent events)
- drowsiness, somnolence, fatigue (use caution when operating vehicles)
- memory impairment
- withdrawal symptoms (anxiety, restlessness, rebound insomnia, tremor, seizures)
These drugs differ in how quickly they act based on their half-life, but in general are rapid with effects seen in the first 1 to 2 weeks. Discontinuation of this class should be slowly tapered, typically no more than lowering 1/10th of the dose every 2 to 3 weeks. It may takes several months to completely withdrawal therapy. A slow taper helps to avoid withdrawal symptoms such as worsened anxiety, insomnia, irritability, tremor, sweating and nausea and vomiting.
Flumazenil (Romazicon), an antidote for BZD overdose and to reverse BZD surgical sedation, may lead to acute withdrawal in patients receiving long-term benzodiazepine therapy.
Several benzodiazepine are excreted through the liver and can have significant drug interactions with CYP450 enzymes. Oxazepam and lorazepam are cleared primarily by the kidney and have fewer drug interactions.
Monoamine oxidase inhibitors (MAOIs) for panic disorder
Certain monoamine oxidase inhibitors (MAOIs) have been shown to be more effective than placebo for treatment of panic disorder; however, they are not specifically FDA-approved for this use. Due to food restrictions, risk for severe high blood pressure (hypertensive crisis), and severe drug interactions, MAOIs are rarely used to treat panic disorder. MAOIs should not be used with serotonin-modulating antidepressants such a SSRIs or SNRIs due to the risk for serotonin syndrome.
Any patient who is treated with a MAOI should have a drug interaction screen performed by their doctor or pharmacist any time a medication, over-the-counter product, herbal, vitamin or dietary supplement is added to their treatment. Learn more about MAOIs, dietary restrictions and drug interactions here.
Table 5: MAOIs Used for Panic Disorder (off-label use)
Side effects with MAOIs can include:
- anxiety, restlessness
- dizziness, orthostatic hypotension
- dry mouth
- erectile dysfunction, anorgasmia
- loss of appetite
- Mirtazapine, a tetracyclic antidepressant, has been shown in some open-label clinical trials to be effective for panic disorder, and might be option for 2nd or 3rd line treatment. It can be used as monotherapy or as an adjunct to SSRIs. It's use is off-label for panic disorder treatment.
- It is classified as a alpha2-adrenergic antagonist which causes an increase in norepinephrine and serotonin release. It also has potent antagonist action at 5-HT2 and 5-HT3 serotonin receptors and H1 histamine receptors.
- This is a sedating antidepressant and may be better tolerated by patients who have worsening anxiety or stimulation due to SSRI treatment. Doses are typically given at bedtime. Other side effects include weight gain, constipation, dry mouth, and increased hunger.
- Buspirone is an FDA-approved agent for generalized anxiety disorder that appears to work by blocking serotonin (5HT1A and 5HT2) receptors without effect on the benzodiazepine-GABA receptors. It is not a controlled substance.
- It may be used alone or as adjunctive treatment for anxiety. The length of time for adequate response may take up to 4 weeks.
- Common side effects include insomnia, nausea, and agitation.
- Pregabalin has been shown to be an effective option for generalized anxiety disorder from several clinical trials. Its mechanism of action in GAD is not known.
- Side effects may include dizziness, sedation, withdrawal and dependence. Pregabalin is not approved in the U.S for the treatment of anxiety, but is approved in other countries.
- Although several herbal treatments have been marketed for treatment of anxiety disorders, more research is required. Products such as kava kava, valerian and St. John's Wort are often sold over-the-counter for stress and anxiety relief and to help with sleep. Studies have not proven these products as helpful and side effects such as liver damage can occur.
- Herbal and dietary supplements are not reviewed by the FDA for effectiveness, and may cause serious side effects or drug interactions. Always check with your doctor or pharmacist before using any natural remedy or over-the-counter product for panic attacks or anxiety.
Psychotherapy or Talk Therapy
Psychotherapy is a well-established and effective treatment often used for generalized anxiety and panic disorders. In psychotherapy, or sometimes called talk therapy, you can talk with a trained mental health professional about your feelings, concerns, and impact on your life. You can learn new ways of thinking and new skills to help lessen your symptoms of panic or anxiety. A goal of treatment in panic disorder is to learn to manage it successfully, yet realize all anxiety may not be completely eliminated.
Cognitive behavioral therapy (CBT) helps patients identify and change thoughts or behaviors that contribute to anxiety or panic. Therapy can lessen the panic sensations and help patients to overcome fear that may lead them to avoiding places or situations. CBT teaches you different ways of thinking and reacting to the feelings that come on with a panic attack. Attacks can begin to disappear once you learn to react differently to the physical sensations of anxiety and fear that occur during panic attacks. Sessions are usually attended once weekly for 3 to 4 months.
Patient support groups for anxiety may be helpful for some patients. Patients have the opportunity to learn that they are not unique in experiencing excessive worry, anxiety, or panic attacks. Support groups are not a substitute for effective treatment, but they can be a helpful addition to it.
Preventing Panic Attacks and Lowering Anxiety
Panic attacks may occur without warning and there's no guaranteed way to prevent a first panic attack. While anxiety may be ongoing, there are ways to help lessen the effect by maintaining a healthful and lower-stress lifestyle.
If you’ve had a panic attack or deal with anxiety that affects you on a continuing basis, it’s important to get medical advice as soon as possible. Early treatment will help to prevent worsening of your disorder. The following lifestyle changes may help to decrease a recurrence of panic attacks and ease anxiety in your life:
- take your medications as directed, avoiding caffeine, and other stimulants.
- avoid alcohol, illicit drugs, excess caffeine and smoking, which can trigger or worsen your symptoms.
- maintain a regular exercise program to lessen stress and anxiety.
- eat a healthy diet and don’t skip meals.
- attend talk therapy (psychotherapy) if prescribed by your doctor or join a medically recommended support group.
- consider yoga, meditation, deep breathing or relaxation techniques.
- learn breathing exercises to help lower stress and sudden anxiety.
- keep a daily log of triggers that worsen your symptoms, and try to manage these triggers.
- have your doctor or pharmacist review your medicines to be sure you are not taking any that can worsen your symptoms.
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