To panic is normal and sometimes, even necessary to get things done. However, if you have been experiencing recurrent and frequent episodes of panic called panic attacks, you may be suffering from an anxiety disorder, known as panic disorder.
A panic attack is a sudden, intense, fearful response to an unknown cause, lasting for a few minutes to hours. It can present with physical signs, such as increased heart rate, sweating and chest pain, often mimicking other health conditions, like cardiovascular disorders and thyroid disorders.
Panic attacks and panic disorder are different and the difference lies in the frequency and severity of the condition. Usually, panic attacks occur once or twice in a lifetime, with no major implications. However, recurrent panic attacks with a fear of another attack is suggestive of a panic disorder. To be specific, if you had at least two panic attacks for no apparent reason, followed by at least one month of constant fear of the next attack, you most likely have a panic disorder.
Panic disorder can be a tormenting condition to live with. However, it is not a fatal condition and is completely treatable. Through medical intervention and psychotherapy, you can lead a good quality life. But, if left untreated, it can lead to development of phobia, such as agoraphobia (fear of places or situations that might evoke panic attack), thus causing severe disruption of social and work-life.
Symptoms
According to the Anxiety and Depression Association of America, panic attack is a sudden onset of discomfort or fear that reaches peak within minutes and has at least four of the following symptoms.[1]
- Pounding heart, or rapid heart rate (medically known as palpitations)
- Sweating
- Trembling
- Difficulty in breathing
- A choking sensation
- Chest pain
- Abdominal discomfort or nausea
- Feeling giddy or light-headed
- Chills or hot flashes
- Paresthesia (a medical term for tingling sensation or numbness)
- Derealization i.e. an unreal feeling, or depersonalization i.e. feeling detached from oneself
- Feeling “crazy” due to loss of control
- A dying feeling
However, some individuals may not experience four of these symptoms, but have a full-blown panic attack. This condition is known as “limited-symptom panic attack”.
Panic attacks may also occur due to some other mental health condition, such as ADHD, Generalized anxiety disorder, OCD, social anxiety disorder, PTSD, etc.
Treatment
Treatment of panic disorder is aimed at reducing the frequency of panic attacks and providing symptomatic relief.
Cognitive Behavioral Therapy (CBT) forms the mainstay of treatment of panic disorder. CBT is a type of psychotherapy (also known as Talk therapy). During a CBT, your therapist may ask you questions regarding your feelings at the time of panic attack. By doing so, therapist targets your negative thoughts and try to amend them. For instance, your therapist may teach you some relaxation breathing technique, which can relieve your symptoms during a panic attack.
Based on the severity of your symptoms, your doctor may also prescribe you certain medications to complement the symptom-relieving effects of psychotherapy. Anti-depressants, including first-generation anti-depressants, second-generation anti-depressants and monoamine oxidase inhibitors form the major drugs used in the treatment of panic disorder. However, benzodiazepines and beta blockers may also be prescribed for symptomatic relief.
These medications are described below.
1. Anti-depressants
Anti-depressants are used as first-line medications in the treatment of panic disorder. This group of drug acts on a biological process, known as neurotransmission. It is a fundamental process that carries information from brain to the concerned organ, gland or muscle. This process is facilitated by the release of brain chemicals, known as neurotransmitters.
An interesting fact here is that in order to send a new information, the released brain chemicals have to be taken back by the brain cells. This phenomenon of reabsorption of neurotransmitter is known as “re-uptake”.
Anti-depressants inhibit the re-uptake of specific neurotransmitters, thus prolonging the stay of these neurotransmitters in the blood stream and relieving the symptoms of panic disorder.
The anti-depressants used in the treatment of panic disorder are as follows.
I. Second Generation Anti-depressants
These constitute the newly developed anti-depressants, with lesser side-effects as compared to the first-generation anti-depressants.
A. Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs have a mood elevating property. They selectively block a transporter on the nerve cell membrane, known as Serotonin Transporter (SERT). This transporter is responsible for re-uptake of a specific neurotransmitter, i.e. serotonin.
Researchers believe that low serotonin level can lead to a depressed mood. Thus, by inhibiting the re-uptake of serotonin, SSRIs make more serotonin available, hence potentiating its mood enhancing ability.
Available as: Oral preparations
i) Fluoxetine
US-FDA Status: Approved for panic disorder
Availability: Prescription only
Generic name: fluoxetine
Brand name: Prozac capsule
Side-effects: Hives, skin rash, restlessness, inability to sit still
Indicated in pregnancy: Only if benefit outweighs fetal risk
Alcohol content: Absent
ii) Paroxetine
US-FDA Status: Approved for panic disorder
Availability: Prescription only
Generic name: paroxetine hydrochloride
Brand name: Paxil tablet
Side-effects: Constipation, diarrhea, dizziness, drowsiness, headache, nausea, insomnia
Indicated in pregnancy: Contraindicated
Alcohol content: Absent
iii) Sertraline
US-FDA Status: Approved for panic disorder
Availability: Prescription only
Generic name: sertraline hydrochloride
Brand name: Zoloft tablet
Side-effects: Fatigue, dizziness, diarrhea, drowsiness, insomnia, decreased libido
Indicated in pregnancy: Only if benefit outweighs fetal risk
Alcohol content: Absent
However, every patient may respond differently to each SSRI and it may take 4 to 6 weeks to produce beneficial effects.
SSRIs are also used to treat several other conditions, such as social phobia, OCD, bulimia nervosa, PTSD, Premenstrual dysphoric disorder (PMDD), etc.
B. Serotonin and Noradrenaline Reuptake Inhibitors (SNRIs)
It also belongs to a second-generation anti-depressant class of drugs. Unlike SSRI, it blocks two types of transporters on the nerve cell membrane, namely SERT (Serotonin Transporter) and NET (Noradrenaline Transporter), thus inhibting the reuptake of both serotonin and noradrenaline. Therefore, SNRIs are also known as dual re-uptake inhibitors or dual-acting anti-depressants. Potentiated action of serotonin and noradrenaline elevates the mood.
Available as: Oral preparations
i) Venlafaxine
US-FDA Status: Approved for panic disorder
Availability: Prescription only
Generic name: venlafaxine
Brand name: Effexor
Side-effects: Insomnia, constipation, dizziness, nervousness, nausea, dry mouth
Indicated in pregnancy: Only if benefit outweighs fetal risk
Alcohol content: Absent
ii) Duloxetine
US-FDA Status: Approved for panic disorder
Availability: Prescription only
Generic name: duloxetine hydrochloride
Brand name: Cymbalta capsule
Side-effects: Constipation, dizziness, fatigue, drowsiness, headache, nausea, insomnia, xerostomia (dry mouth)
Indicated in pregnancy: Only if benefit outweighs fetal risk
Alcohol content: Absent
SNRIs are also used in certain other conditions, such as diabetic neuropathic pain, fibromyalgia, stress urinary incontinence in women, etc.
II. First Generation Anti-depressants
These include earlier developed anti-depressants.
A. Tricyclic Anti-depressants (TCAs)
Like second-generation anti-depressants, TCAs also inhibit Serotonin transporter (SERT) and Noradrenaline transporter (NET), thus potentiating the mood-elevating action of serotonin and noradrenaline. These also have a direct action on certain other receptors of the nervous system, such as adrenergic, cholinergic and histaminergic receptors. All these effects together alleviate the mood changes seen in panic disorder.
However, first generation anti-depressants lack the selective inhibitory action on neurotransmitters. Also, these are less effective and bear more side-effects as compared to second-generation anti-depressants. Therefore, second-generation anti-depressants are preferred in panic disorder.
Available as: Oral preparations
i) Clomipramine
US-FDA Status: Approved for panic disorder
Availability: Prescription only
Generic name: clomipramine hydrochloride
Brand name: Anafranil capsule
Side-effects: Drowsiness, headache, dizziness, constipation, ejaculatory disorder, nausea, fatigue, insomnia
Indicated in pregnancy: Only if benefit outweighs fetal risk
Alcohol content: Absent
ii) Imipramine
US-FDA Status: Approved for panic disorder
Availability: Prescription only
Generic name: imipramine pamoate
Brand name: Tofranil tablet
Side-effects: Blurred vision, agitation, abdominal pain, clay colored stools, chest pain
Indicated in pregnancy: Only if benefit outweighs fetal risk
Alcohol content: Absent
iii) Desipramine
US-FDA Status: Approved for panic disorder
Availability: Prescription only
Generic name: desipramine hydrochloride
Brand name: Norpramin tablet
Side-effects: Abdominal pain, blurred vision, anxiety, black tarry stools, anxiety, chest pain
Indicated in pregnancy: Only if benefit outweighs fetal risk
Alcohol content: Absent
B. Monoamine Oxidase (MAO) Inhibitors
The brain chemicals (i.e. neurotransmitters), namely serotonin, noradrenaline and dopamine are metabolized by an enzyme, known as Monoamine oxidase. MAO inhibitors block the action of this enzyme thus, prevent the degradation of these neurotransmitters.
Potentiated action of these neurotransmitters elevates the mood and combats the symptoms of panic disorder.
Available as: Oral preparations
i) Isocarboxazid
US-FDA Status: Approved for panic disorder
Availability: Prescription only
Generic name: isocarboxazid
Brand name: Marplan tablet
Side-effects: Confusion, chills, numbness, cold sweats, dizziness, difficulty urination
Indicated in pregnancy: Only if benefit outweighs fetal risk
Alcohol content: Absent
ii) Phenelzine
US-FDA Status: Approved for panic disorder
Availability: Prescription only
Generic name: phenelzine
Brand name: Nardil tablet
Side-effects: Chills, cold sweats, confusion, dizziness, trembling
Indicated in pregnancy: Only if benefit outweighs fetal risk
Alcohol content: Absent
iii) Tranylcypromine
US-FDA Status: Approved for panic disorder
Availability: Prescription only
Generic name: tranylcypromine sulfate
Brand name: Parnate tablet
Side-effects: Anxiety, uncontrolled action, agitation, bleeding gums, black tarry stools
Indicated in pregnancy: Only if benefit outweighs fetal risk
Alcohol content: Absent
2. Anti-anxiety drugs
Other than the second-generation anti-depressants, there are some other medications that may be prescribed by your doctor to relieve the symptoms of panic attacks. These are mostly anti-anxiety drugs which are an ill-defined group of drugs with mild depressant effect on the central nervous system. These are used on a short-term basis, to relieve the anxiety associated with the disorder, without interfering with the normal physical and mental functions of the body. Various anti-anxiety drugs used in the treatment of panic disorder are as follows.
I. Benzodiazepines (BZDs)
These are primarily used as an anti-convulsant in the treatment of epilepsy. However, they are used as a second-line drug (after anti-depressants) in panic disorder.
Understanding the mechanism of action of BZDs, requires a prior understanding of a specific neurotransmitter, known as gamma-Aminobutyric acid (GABA). GABA is the most common neurotransmitter, present throughout the central nervous system. It is an inhibitory neurotransmitter, i.e. it relaxes the brain. The action of GABA is mediated through three receptors, designated as A,B and C. BZDs act on GABA-A receptor and enhance the relaxing effect of GABA neurotransmitter. The end result is an anti-anxiety effect of BZDs that is used in treatment of panic disorder. Other effects produced by BZDs include sedative, hypnotic (sleep-inducing) and muscle relaxation effect.
Available as: Oral preparations and Injectable preparations
A. Lorazepam
US-FDA Status: Approved for panic disorder
Availability: Prescription only
Generic name: lorazepam
Brand name: Ativan tablet
Side-effects: Drowsiness, abdominal pain, agitation, bleeding gums, agitation
Indicated in pregnancy: Only if benefit outweighs fetal risk
Alcohol content: Absent
B. Diazepam
Diazepam oral
US-FDA Status: Approved for panic disorder
Availability: Prescription only
Generic name: diazepam
Brand name: Valium tablet
Side-effects: Trembling, agitation, unsteadiness, black tarry stools
Indicated in pregnancy: Usually contraindicated
Alcohol content: Absent
Diazepam Injection
US-FDA Status: Unapproved for panic disorder
Generic name: diazepam (injection)
Brand name: Valium
Side-effects: Same as seen with oral diazepam
Indicated in Pregnancy: Usually contraindicated
Alcohol Content: Absent
C. Alprazolam
US-FDA Status: Approved for panic disorder
Availability: Prescription only
Generic name: alprazolam
Brand name: Xanax tablet
Side-effects: Difficulty in urination, constipation, cognitive dysfunction, fatigue, rash
Indicated in pregnancy: Only if absolutely indicated
Alcohol content: Absent
D. Chlordiazepoxide
Chlordiazepoxide Oral
US-FDA Status: Approved for panic disorder
Availability: Prescription only
Generic name: chlordiazepoxide hydrochloride (oral)
Brand name: Librium capsule
Side-effects: Difficulty in coordinating muscle, fainting, mood changes, unsteadiness
Indicated in Pregnancy: Not indicated in first trimester as it can cause congenital fetal malformation
Alcohol Content: Absent
Chlordiazepoxide Injection
US-FDA Status: Unapproved for panic disorder
Generic name: chlordiazepoxide hydrochloride (injection)
Brand name: Librium
Side-effects: Same as seen with oral chlordiazepoxide
Indicated in Pregnancy: Not indicated in first trimester as it can cause congenital fetal malformation
Alcohol Content: Absent
E. Oxazepam
US-FDA Status: Unapproved for panic disorder
Generic name: oxazepam (oral)
Brand name: Oxazepam capsule
Side-effects: Fainting, black tarry stools, dark urine, chest pains, abdominal pain
Indicated in Pregnancy: Usually contraindicated
Alcohol Content: Absent
BZDs are used as a first-line treatment for certain mental health disorders, such as generalized anxiety disorder. However, BZDs are prescribed for a short-term basis only as they may produce mild tolerance and dependence.
II. Non-selective Beta-blockers
This group of drugs does not directly act on brain cells. However, these may be prescribed to relieve physical signs of panic attack. These block the beta receptors present in the heart, thus reducing the heart rate and producing an anti-anxiety effect. Therefore, it relieves symptoms, such as palpitations and tremors, associated with panic disorder.
Available as: Oral preparations
A. Propranolol
US-FDA Status: Approved for panic disorder
Availability: Prescription only
Generic name: propranolol hydrochloride
Brand name: Hemangeol oral solution
Side-effects: Chest tightness, cough with muscous, trouble breathing
Indicated in Pregnancy: Only if benefit outweighs fetal risk
Alcohol Content: Absent
However, this drug is used only for short-term as it produces some major side-effects.
OTC
All the drugs used in panic disorder act on the nervous system and alter the brain chemicals. Hence, they pose serious side-effects, if taken unsupervised. Therefore, all the drugs used in panic disorder are available on prescription only and there are no over-the-counter drugs for panic disorder.
Thus, a medical consultation must be sought to effectively manage the condition.
