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 Anxiety  Holistic-online.com

Panic Disorder
Conventional Medical Treatment - Drug Therapy

In pharmacotherapy, a prescription medication is used both to prevent panic attacks or reduce their frequency and severity, and to decrease the associated anticipatory anxiety.

The three groups of medications most commonly used are the tricyclic antidepressants, the high-potency benzodiazepines, and the monoamine oxidase inhibitors (MAOIs). Determination of which drug to use is based on considerations of safety, efficacy, and the personal needs and preferences of the patient.

A significant proportion of patients do not easily tolerate certain of the tricyclics, whereas benzodiazepines are better accepted. Patients who tolerate tricyclics show significant improvement, with a reduced number of panic attacks during the period of treatment, ranging from 8 to 32 weeks in controlled trials. Benzodiazepines have a rapid onset of action with immediate reduction of panic symptoms, whereas antidepressants require 3 to 6 weeks to achieve therapeutic effect. Benzodiazepines reduce anxiety between attacks.

Meta-analysis of the pharmacotherapy interventions using benzodiazepines vs antidepressants showed that both benzodiazepines and antidepressants were more effective than placebo.

Panic-free rates was slightly higher when using benzodiazepines (61 %) compared to antidepressants (58%)

Dropout rates was significantly higher for antidepressants (25.4%) compared to benzodiazepines (13.1%)

Ineffective Medications

The following drugs were found to be ineffective in treating panic disorders:

Nonbenzodiazepine anxiolytic

Atypical antidepressants

Effective Medications

The most effective drugs for the treatment of panic disorders are imipramine (Tofranil), clonazepam, alprazolam (Xanax) and fluoxetine (Prozac).

High-Potency Benzodiazepine Therapy

The high-potency benzodiazepines are a class of medications that effectively reduce anxiety. Some examples are alprazolam, lorazepam and clonazepam. Alprazolam (trade name Xanax) is the most thoroughly studied of this group.


bulletPrompt onset of therapeutic action
bulletFavorable side-effect profile
bulletReduced anticipatory anxiety


bulletPotential for abuse or dependency or both -Risk of rebound on withdrawal
bulletCNS (Central Nervous System) side effects (sedation, disturbed memory)

Benzodiazepines have a rapid onset of action. They can be used to treat surges of anticipatory anxiety or panic. They have few bothersome side effects, and are well tolerated by the majority of patients.

Risks of benzodiazepines include sedation and psychomotor impairment. Benzodiazepines will interact with alcohol if it is not restricted. Although some of these adverse side effects largely subside after 4 to 6 weeks of treatment, subjective cloudiness may remain. The most serious risk with this class of medication is that of physical dependence, especially those who have had problems with alcohol or drug dependency.

Generally, the physician prescribing one of these drugs starts the patient on a low dose and gradually increases it until panic attacks cease. This procedure minimizes side effects.

Treatment with high-potency benzodiazepines is usually continued for 6 months to a year. Scientific evidence shows surprisingly low rates of abuse of this and other medicines in persons with panic disorder. Physical dependence can develop with such medicines at larger dosages. The person who chooses such medicine for this disorder should accept the fact that they may require higher doses and may therefore be physically dependent on the medicine. They must not abruptly cease taking their medicine. Doing so would result in withdrawal symptoms such as malaise, weakness, and other unpleasant effects. One does not abruptly stop such medicine. When it comes time to go off medicine it is decreased gradually by tiny reductions every one to three weeks). There may also be a recurrence of panic attacks after the medication is withdrawn.

Monoamine Oxidase Inhibitor (MAOI) Therapy

Of the MAOIs, a class of antidepressants which have been shown to be effective against panic disorder, phenelzine is the most commonly used. Treatment with phenelzine usually starts with a relatively low daily dosage that is increased gradually until panic attacks cease or the patient reaches a maximum dosage of about 100 milligrams a day.


bulletMinimal abuse potential
bulletNo physiologic dependency
bulletRare anticholinergic side effects
bulletProphylaxis against depression


bulletDiet and drug restrictions
bulletPostural hypotension
bulletDisturbed sexual function, sleep
bulletDelayed onset of therapeutic action

The benefits of MAO inhibitors include, as with the tricyclics, an antidepressant effect and a low risk of dependence. However, the anticholinergic effects may be lower than for the tricyclics. Sexual difficulties, particularly problems in orgasm, may occur as do hypotension and weight gain. One added complication, which may be difficult for some patients, is the need to follow a low tyramine diet. This can interact with the MAOI to cause a sudden, dangerous rise in blood pressure. All patients who are taking MAOIs should obtain their physician's guidance concerning dietary restrictions and should consult with their physician before using any over-the-counter or prescription medications.

Treatment with phenelzine or another MAOI generally lasts 6 months to a year. At the conclusion of the treatment period, the medication is gradually tapered.

More Information on MAOI - drug interactions

Selective Serotonin Reuptake Inhibitor (SSRI) Therapy

Newly available antidepressants such as fluoxetine (one of a class of new agents called serotonin reuptake (SSRI) inhibitors) appear to be effective in selected cases of panic disorder. As with other anti-panic medications, it is important to start with very small doses and gradually increase the dosage. 


bulletMinimal abuse potential
bulletLittle physiologic dependency
bulletFavorable side-effect profile


bulletInitial increased anxiety
bulletDisturbed GI and sexual function, sleep
bulletDelayed onset of therapeutic action

More Information on SSRI - drug interactions

Tricyclic Antidepressant (TCA) Therapy

Tricyclic antidepressants offer the benefit of once-a-day dosing, a low risk of dependence, and no dietary restrictions. They also have a concomitant antidepressant effect that is frequently helpful. 


bulletMinimal abuse potential
bulletNo significant dependency
bulletProphylaxis against depression


bulletSide effects (anticholinergic, antiadrenergic, sedative, sexual)
bulletWeight gain
bulletDelayed onset of therapeutic action
bulletDangerous/fatal in overdose

Imipramine is the tricyclic most commonly used for this condition. When imipramine is prescribed, the patient usually starts with small daily doses that are increased every few days until an effective dosage is reached. The slow introduction of imipramine helps minimize side effects. Adverse effects include anticholinergic side effects, low blood pressure, overstimulation, dry mouth, constipation, blurred vision and weight gain.

People with panic disorder, who are inclined to be hypervigilant about physical sensations, often find these side effects disturbing at the outset. Taken together, these effects may cause up to 35 percent of patients to discontinue treatment before therapeutic benefits occur. Side effects usually fade after the patient has been on the medication a few weeks.

It usually takes several weeks for imipramine to have a beneficial effect on panic disorder. Most patients treated with imipramine will be panic-free within a few weeks or months. Treatment generally lasts from 6 to 12 months. Treatment for a shorter period of time is possible, but there is substantial risk that when imipramine is stopped, panic attacks will recur. Extending the period of treatment to 6 months to a year may reduce this risk of a relapse. When the treatment period is complete, the dosage of imipramine is tapered over a period of several weeks.

More Information on TCA - drug interactions

Combination Treatment

Many believe that a combination of medication and cognitive-behavioral therapy represents the best alternative for the treatment of panic disorder. The combined approach is said to offer rapid relief, high effectiveness, and a low relapse rate. The combination may be particularly helpful for patients with agoraphobia. 

Few studies have examined combined behavioral and pharmacologic methods. There is some evidence that a combination of tricyclics and exposure therapy may have additive effects in the short term. Research is being carried out to determine the optimum strategy for management of panic disorder.

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