Panic disorder

Panic disorder: just get treated already!

A friend wrote me recently to describe horrible discomfort from panic attacks, but also significant concerns about the medications his doctor had prescribed. Here’s my answer, in hopes that it may help others out there, too.

Dear [friend],

Thanks for being willing to reach out. Here are my thoughts.

  1. Yes, I know a lot about panic attacks. They are terribly uncomfortable. In fact, I’ve heard that people who’ve had both a heart attack and a panic attack felt the panic attack was more uncomfortable. The good news is that panic disorder is very treatable!
  2. You deserve care from an expert. The experts on panic attacks are psychiatrists. It’s generally better to be treated by somebody who’s not a personal friend, but I am happy to try to help you find somebody good. The easiest place to start is to find out who your insurance will pay.
  3. I see your doc prescribed alprazolam (Xanax®). That was the first medicine approved by the FDA to treat panic disorder. It can work, but some doctors tell people to take it every once in awhile as needed, and that’s a lousy strategy. One reason it’s a lousy strategy is that then you keep having the panic attacks! Furthermore, if you take it after a panic attack has started, you have to find the pill and take it, then it has to get to your stomach, then to your intestines, then to your bloodstream. That means it doesn’t kick in for 20-30 minutes after you take it, and by then the panic may have already improved somewhat and you’re left with just side effects. Also, alprazolam’s effects wear off in a matter of hours, so for it to really work without numerous cycles every day of sedation and withdrawal, it has to be taken four or more times a day. Every day! There are other, similar meds that last longer and hence work better. But for many people, this class of medicines is best as a temporary option.
  4. Your doc also prescribed fluoxetine (Prozac®). Prozac is a great choice. Like any medicine, there are pros and cons, and it has to be done right, but it works great for panic. Most people take 20 mg a day. However, most patients with panic do better if they work up to that dose, e.g. start at 5 mg every morning for a week, then 10 mg a day for a week, then 15, then 20. People with panic disorder are exceptionally sensitive to sensations in their body, so if you have any minor side effects like mild queasiness, you need to know that that’s nothing serious, it just shows that the medicine is getting into your body. To use an analogy, if you had pneumonia, Tylenol® would make you feel better right away—for a few hours, at least—but wouldn’t fix the problem. Penicillin by contrast will cure the pneumonia—but only if you take it every day for some longer period of time. In the meantime it might give you a tummy ache or something. That’s like taking as-needed alprazolam versus daily Prozac. The alprazolam helps briefly, but the Prozac, after about 4 to 6 weeks at a full dose, usually stops or reduces the severity of the panic. Prozac is not addictive, i.e. it’s not like alcohol or cocaine. Just take the stuff! Honestly, it’s much safer than Tylenol.
  5. The other treatment that is proven to help with panic disorder, other than medicines like Prozac, is cognitive-behavioral therapy (CBT). It is crucial for treating the avoidance that often comes with panic disorder, e.g. can’t get out of the house or can’t go to a store or can’t drive a car. It also helps reduce panic attack symptoms and of course it has no known side effects. CBT is not “tell me about your mother,” it’s a proven treatment that involves teaching you information and then having you do “homework” by practicing specific assigned thoughts and behaviors. The important thing is that it is proven to work. I usually recommend this be done by a psychologist. Again, don’t worry about it or argue about it, just do it! Where you have it done depends mostly on who your insurer will pay. While you’re waiting for your appointment with the psychologist, there’s a book you can check out of the library (or buy for $15-ish) that I strongly recommend. Using this book rather than meeting with a psychologist is kind of like watching the instructional video versus hiring a tennis coach: it’s not the same, but it will help. The book I like is Mind Over Mood (2nd edition). It covers panic attacks among several other topics. The book is organized so everyone works through the first 12 chapters, then you can pick and choose the subsequent chapter(s) that address your specific symptoms. This is not a book you read to “get it”; rather, it’s full of instructions to stop reading, do homework and then get back to the book. This is not some instant cure book from the supermarket checkout lane. It teaches a proven treatment for panic. (Note: I don’t have any connection to the book’s authors.)
  6. You mentioned thoughts of suicide when the panic attacks are at their worst. I’m glad they’re occasional and that you’re not planning to act on them, but thoughts of suicide are a big deal. Suicide is a permanent solution to a temporary problem. There’s always an alternative. For instance, nobody wants to be hospitalized, but it’s a way better option than suicide. Since you’ve been dealing with the panic attacks for a good while, and are not currently tempted to act on the suicidal thoughts, probably the steps above are better options to start with. But my point is that hospitalization is one of many alternatives to suicide that, after all, are much more likely to fix the problem and improve the quality of your life. The thoughts of suicide are another strong argument that you deserve expert care from a psychiatrist. Seriously, finding a psychiatrist is the first and most important step I recommend for everything you’ve discussed.

Keep me informed of how you’re doing, call if things get worse, and let me know if you have trouble finding a psychiatrist and psychologist.


Kevin J. Black 

NOTE: Treatment plans are individual, based on each person’s diagnosis, medical history, other medications, past treatment, etc. See your own doctor or other qualified professional for specific treatment recommendations.

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