Panic disorder - Treating panic disorder

The main aim in treating panic disorder is to reduce the number of panic attacks and ease the severity of symptoms.

Psychological therapy and medication are the two main types of treatment for panic disorder.

Depending on your individual circumstances, you may need one of these treatment types or a combination of the two.

If you're offered psychological therapy, it will probably be in the form of cognitive behavioural therapy (CBT, see below). If this doesn't work, medication may be recommended.

Before starting any form of treatment, your GP will discuss all of the options with you, outlining the advantages of each type and making you aware of any possible risks or side effects.

No single treatment works for everyone and you may need to try a number of treatments before finding one that works for you. The treatment that's recommended will depend on your general level of health, the severity of your condition and your personal preferences.

It's important you understand what your treatment will involve. If you don't understand something your GP has told you, ask them to explain it in more detail.

Cognitive behavioural therapy

Psychological therapy has proven long-term benefits and it's recommended for treating panic disorder. It will usually take the form of cognitive behavioural therapy (CBT).

CBT is thought to be one of the most effective psychological treatments for panic disorder. It involves having regular sessions with a therapist.

The therapist may discuss with you how you react when you have a panic attack and what you think about when you're experiencing an attack.

Once you and your therapist have identified any negative thoughts and beliefs, you can work on replacing them with more realistic and balanced ones. Your therapist can also teach you ways of changing your behaviour, making it easier for you to deal with future panic attacks.

For example, they may be able to show you breathing techniques that can be used to help keep you calm during a panic attack.

The National Institute for Health and Care Excellence (NICE) recommends a total of seven to 14 hours of CBT to be completed within a four month period. Treatment will usually involve having a weekly one to two hour session.

NICE also recommends that in certain situations a shorter programme of CBT may be appropriate. This can involve a reduced number of hours of CBT with ‘homework’ being set between sessions so that you can practice what you've learnt after each session.

You should visit your GP regularly while you're having CBT so that they can assess your progress and see how you're doing.

Support groups

Support groups can provide useful information and advice about how you can effectively manage your panic disorder. They're also a good way of meeting other people who've had similar experiences of the condition.

Panic attacks can sometimes be frightening and isolating, so it can be helpful to know that other people are experiencing the same feelings and emotions as you.

Anxiety UK and Triumph Over Phobia (TOP UK) are UK-based charities that provide information and support for people with anxiety disorders.

Support groups often involve face-to-face meetings where you can talk about your problems and difficulties with others. Many can also provide support and guidance over the telephone or in writing.

Ask your GP about support groups for panic disorder near you. You can also use the services directory to find anxiety services in your area.

Antidepressants

Antidepressants are often associated with depression, but they can also be used to treat a number of other psychological conditions.

Antidepressants can take two to four weeks before becoming effective. It's therefore important to continue taking them, even if you feel they're not working. You should only ever stop taking prescribed medication if your GP specifically advises you to do so.

Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants are two types of antidepressants that are often recommended for treating panic disorder.

When starting a new type of medication, you should be regularly assessed by your GP at two, four, six and 12 week intervals. This will allow you to discuss any issues that you have with your medication, and enables your GP to assess which treatment is most effective. It will also provide you with the opportunity to try a different type of medication if you want to.

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressant that work by increasing the level of a chemical called serotonin in your brain.

They're the most commonly prescribed type of antidepressant for treating panic disorder. They're usually started at a low dose before gradually being increased as your body adjusts to the medicine.

Common side effects of SSRIs include:

nausea
headaches
low sex drive (loss of libido)
blurred vision
diarrhoea or constipation
dizziness
dry mouth
loss of appetite
sweating
feeling agitated
insomnia (sleep problems)
abdominal pain

When you first start taking SSRIs, your feelings of anxiety and panic may get slightly worse. In most cases, this is temporary and your symptoms will start to return to normal levels within a few days of taking the medicine.

Speak to your GP if you feel that your symptoms have got worse and that they're not showing signs of returning to normal levels after a few days.

After you start to take a SSRI, you should visit your GP after two, four, six, and 12 weeks so that they can check on your progress and see whether you're responding to the medicine. Not everyone responds well to antidepressant medicines, so it's important that your progress is carefully monitored.

If your GP feels it necessary, you may require regular blood tests or blood pressure checks when taking antidepressants. If after 12 weeks of taking the medication you don't show any signs of improvement, your GP may prescribe an alternative SSRI to see if it has any effect.

The length of time that you'll have to take a SSRI for will vary depending on how well you respond to the treatment. Even if you feel that your panic disorder has been successfully treated, it's likely that you'll need to keep taking the medication for at least six to 12 months.

If you stop taking your medication before this time, the risk of your symptoms recurring may be increased. Some people may have to take SSRIs for longer than the usual six to 12 month period.

When you and your GP decide that it's appropriate for you to stop taking SSRIs, you will gradually be weaned off them by slowly reducing your dosage. As with antidepressants, you should never stop taking SSRIs unless your GP specifically advises you to.

Stopping your medication straight away without being weaned off, or without seeking advice from your GP, may result in withdrawal symptoms such as:

dizziness
numbness and tingling
nausea and vomiting
headache
anxiety
sleep disturbances
sweating

These symptoms can also occur if you miss a dose of medication, or if your dose is reduced. The symptoms are usually mild, but they can be severe if the medication is stopped suddenly.

For some people, this means having to take SSRIs on a long-term basis. For others, a course of CBT can help to reduce the risk of their symptoms recurring.

Contact your GP if you experience troublesome side effects that don't ease.

Tricyclic antidepressants

If SSRIs aren't suitable, or if your symptoms don't improve after a 12 week course of SSRIs, your GP may try prescribing a different type of antidepressant.

Tricyclic antidepressants work in a similar way to SSRIs. They regulate the levels of the chemicals noradrenaline and serotonin in your brain, which has a positive effect on your feelings and mood.

Imipramine and clomipramine are two tricyclic antidepressants that are often prescribed to treat panic disorder. Tricyclic antidepressants aren't addictive.

SSRIs are usually prescribed before tricyclic antidepressants because they have fewer side effects. Common side effects of tricyclic antidepressants include:

constipation
difficulty urinating
blurred vision
dry mouth
weight gain or weight loss
drowsiness
sweating
lightheadedness
skin rash

The side effects should ease after seven to 10 days as your body starts to get used to the medication. However, see your GP if they become troublesome and don't ease.

Pregabalin

Pregabalin is another medication that’s often used to treat panic disorder. It’s an anticonvulsant that's also used to treat epilepsy (a condition that causes repeated seizures). However, it's also been found to be beneficial in treating anxiety.

Side effects of pregabalin can include:

drowsiness
dizziness
increased appetite and weight gain
blurred vision
headaches
dry mouth
vertigo – the sensation that you, or the environment around you, are moving or spinning

Pregabalin is less likely to cause nausea or a low sex drive than SSRIs.

Clonazepam

Clonazepam is another medication that’s often used to treat epilepsy and is also sometimes prescribed for panic disorder.

It can cause a wide variety of side effects including lethargy (lack of energy), abnormal eye movement (nystagmus), confusion and allergic reactions.

Read more about the side effects of clonazepam.

Referral

You may be referred to a mental health specialist if treatments such as attending a support group, CBT and medication don't improve your symptoms of panic disorder.

A mental health specialist will carry out an overall reassessment of your condition. They'll ask you about your previous treatment and how effective you found it. They may also ask you about things in your life that may be affecting your condition, or how much support you get from family and friends.

The specialist will be able to devise a treatment plan for you, which will aim to effectively treat your symptoms.

The type of mental health specialist that you'll be referred to will depend on your individual situation. For example, you may be referred to a:

psychiatrist – a trained medical doctor who specialises in mental health; a psychiatrist is one of the only mental health specialists who is able to prescribe medication
clinical psychologist – who is trained in the scientific study of human behaviour and mental processes and focuses solely on the assessment and treatment of mental health conditions; a clinical psychologist will help you to find ways of effectively managing your anxiety and panic attacks

Glossary
Benzodiazepine: Benzodiazepines are a group of medicines used to help sleep, reduce anxiety and as a muscle relaxant. For example, temazepam.
Psychotherapy: Psychotherapy is the treatment of mental and emotional health conditions, using talking and listening.
Anxiety: Anxiety is an unpleasant feeling when you feel worried, uneasy or distressed about something that may or may not be about to happen.
Antidepressants: Antidepressant medicine is used to treat depression. For example fluoxetine, paroxetine.
Doses: Dose is a measured quantity of a medicine to be taken at any one time, such as a specified amount of medication.
Depression: Depression is when you have feelings of extreme sadness, despair or inadequacy that last for a long time.