Editing Panic attack (section)

==Treatment==
Panic disorder is usually effectively managed with a variety of interventions, including psychological therapies and pharmacological treatment with medication.<ref>{{Cite web |title=Panic disorder: MedlinePlus Medical Encyclopedia |url=https://medlineplus.gov/ency/article/000924.htm |access-date=12 March 2023 |website=medlineplus.gov |language=en |archive-date=8 June 2023 |archive-url=https://web.archive.org/web/20230608055731/https://medlineplus.gov/ency/article/000924.htm |url-status=live }}</ref><ref name=Bourne2005/> The focus on management of panic disorder involves reducing the frequency and intensity of panic attacks, reducing anticipatory anxiety and agoraphobia, and achieving full remission.<ref name=":8">{{Cite journal |last1=Manjunatha |first1=Narayana |last2=Ram |first2=Dushad |date=March 2022 |title=Panic disorder in general medical practice- A narrative review |journal=Journal of Family Medicine and Primary Care |language=en-US |volume=11 |issue=3 |pages=861–869 |doi=10.4103/jfmpc.jfmpc_888_21 |doi-access=free |pmid=35495823 |pmc=9051703 |issn=2249-4863}}</ref>

Most panic attacks will resolve spontaneously within a course of 20 to 30 minutes without interference.{{cn|date=November 2024}} However, [[Benzodiazepine|benzodiazepines]], specifically [[alprazolam]] and [[clonazepam]], are frequently prescribed for panic disorder due to their quick onset of action and good tolerability and can thus be used as a way to end a current, on-going attack.<ref>{{Cite journal |last1=Susman |first1=Jeffrey |last2=Klee |first2=Brian |date=2005-02-15 |title=The Role of High-Potency Benzodiazepines in the Treatment of Panic Disorder |url=https://www.psychiatrist.com/pcc/role-high-potency-benzodiazepines-treatment-panic |journal=The Primary Care Companion for CNS Disorders |volume=7 |issue=1 |pages=5–11 |doi=10.4088/PCC.v07n0101 |issn=2155-7780 |pmc=1076453 |pmid=15841187}}</ref> Additionally, deep breathing techniques and relaxation can be used and are found to be helpful while the person is experiencing a panic attack or immediately after as a way to calm oneself.<ref name=":8" /> Some maintaining causes include avoidance of panic-provoking situations or environments, anxious or negative [[self-talk]] ("what-if" thinking), mistaken beliefs (e.g., thinking one’s symptoms are harmful or dangerous), and withheld [[feeling]]s.

[[Cognitive behavioral therapy]] (CBT) has the most complete and longest duration of effect, followed by specific [[selective serotonin reuptake inhibitor]]s (SSRIs).<ref>{{cite book |title=Generalised anxiety disorder and panic disorder in adults: management |date=26 July 2019 |publisher=[[National Institute for Health and Care Excellence]] |series=Clinical Guideline 113 |url=https://www.nice.org.uk/guidance/cg113 |isbn=978-1-4731-2854-5 |access-date=8 January 2021 |archive-date=22 November 2018 |archive-url=https://web.archive.org/web/20181122005818/https://www.nice.org.uk/guidance/cg113 |url-status=live }}</ref> A 2009 review found positive results from therapy and medication and a much better result when the two were combined.<ref name="pmid17654408">{{cite journal |last1=Bandelow |first1=Borwin |last2=Seidler-Brandler |first2=Ulrich |last3=Becker |first3=Andreas |last4=Wedekind |first4=Dirk |last5=Rüther |first5=Eckart |title=Meta-analysis of randomized controlled comparisons of psychopharmacological and psychological treatments for anxiety disorders |journal=The World Journal of Biological Psychiatry |date=January 2007 |volume=8 |issue=3 |pages=175–187 |doi=10.1080/15622970601110273 |pmid=17654408 |s2cid=8504020 }}</ref> Even though there are modern medications to make short-term benefits to the patients life, long-term medication for panic disorder is still in the works. There is however, a method that is proven to be most effective in long-term treatment which is to combine different treatment styles. These different styles include both antidepressants and CBT therapy.<ref name=":13" />

===Lifestyle changes===
Growing research suggests that along with standardized medical treatments, lifestyle changes can help alleviate some of the most common mental health conditions.<ref>{{Cite journal |last1=Correll |first1=Terry |last2=Gentile |first2=July |last3=Correll |first3=Andrew |date=September 1, 2023 |title=Healthy Lifestyle Interventions Augmenting Psychotherapy in Anxiety and PTSD |journal=Innovations in Clinical Neuroscience |volume=20 |issue=7–9 |pages=18–26 |pmid=37817811 |pmc=10561983 }}</ref> Because of this, there has been a growing emphasis on the potential of lifestyle interventions and non-pharmacological methods for anxiety.<ref>{{Cite journal |last1=Chong |first1=Terence W. H. |last2=Curran |first2=Eleanor |last3=Southam |first3=Jenny |last4=Bryant |first4=Christina |last5=Cox |first5=Kay L |last6=Ellis |first6=Kathryn A. |last7=Anstey |first7=Kaarin J. |last8=Goh |first8=Anita |last9=Lautenschlager |first9=Nicola T |date=2023-12-01 |title=The potential of physical activity and technology interventions to reduce anxiety in older adults |url=https://www.sciencedirect.com/science/article/pii/S2666915323001713 |journal=Journal of Affective Disorders Reports |volume=14 |pages=100633 |doi=10.1016/j.jadr.2023.100633 |issn=2666-9153|hdl=1959.4/unsworks_84293 |hdl-access=free }}</ref> These lifestyle interventions include, but are not limited to, focusing on physical activity, substance avoidance, and relaxation techniques.

Exercise, especially aerobic, have become an alternative method for decreasing symptoms of anxiety and panic. Other more relaxing forms, such as yoga and tai chi, have also had similar effects in improving anxiety and can also be used as adjunctive therapy. Numerous studies have determined that exercise is inversely related to anxiety symptoms, thus as physical activity increases, levels of anxiety seem to decrease. There is evidence that suggests that this effect is correlated to the release of exercise-induced [[endorphins]] and the subsequent reduction of the stress hormone, [[cortisol]].<ref>{{cite web |date=17 July 2013 |title=3 Tips for Using Exercise to Shrink Anxiety |url=http://psychcentral.com/blog/archives/2013/07/17/3-tips-for-using-exercise-to-shrink-anxiety/ |url-status=live |archive-url=https://web.archive.org/web/20150420020719/http://psychcentral.com/blog/archives/2013/07/17/3-tips-for-using-exercise-to-shrink-anxiety/ |archive-date=20 April 2015 |access-date=14 April 2015}}{{full citation needed|date=August 2015}}</ref> One thing to keep in mind is that with exercise, often comes increased respiration rate. This can lead to hyperventilation and [[hyperventilation syndrome]], which mimics symptoms of a heart attack, thus inducing a panic attack,<ref>{{MedlinePlusEncyclopedia|003071|Hyperventilation}}</ref>  so it is important to pace the exercise regimen accordingly.<ref>{{cite web |title=Cardio Exercise for Beginners |url=http://www.livestrong.com/article/103790-cardio-exercise-beginners |url-status=live |archive-url=https://web.archive.org/web/20150423164013/http://www.livestrong.com/article/103790-cardio-exercise-beginners/ |archive-date=23 April 2015 |access-date=14 April 2015}}{{full citation needed|date=August 2015}}</ref>

Substance avoidance can be important in reducing anxiety and panic symptoms, as many substances can cause, exacerbate, or mimic symptoms of panic disorder. For example, [[caffeine]] has been known to have anxiety and panic-inducing properties that can especially present in those who are more susceptible to panic attacks.<ref>{{Cite journal |last1=Klevebrant |first1=Lisa |last2=Frick |first2=Andreas |date=2022 |title=Effects of caffeine on anxiety and panic attacks in patients with panic disorder: A systematic review and meta-analysis |url=https://pubmed.ncbi.nlm.nih.gov/34871964/ |journal=General Hospital Psychiatry |volume=74 |pages=22–31 |doi=10.1016/j.genhosppsych.2021.11.005 |issn=1873-7714 |pmid=34871964}}</ref>  Anxiety and panic can also temporarily increase during [[Drug withdrawal|withdrawal]] from caffeine and various other drugs and substances.<ref>American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev., p. 479). Washington, D.C.: American Psychiatric Association.{{page needed|date=January 2021}}</ref>

Meditation may also be helpful in the treatment of panic disorder.<ref>{{cite journal |last1=Kabat-Zinn |first1=J |last2=Massion |first2=AO |last3=Kristeller |first3=J |last4=Peterson |first4=LG |last5=Fletcher |first5=KE |last6=Pbert |first6=L |last7=Lenderking |first7=WR |last8=Santorelli |first8=SF |date=July 1992 |title=Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders |journal=American Journal of Psychiatry |volume=149 |issue=7 |pages=936–943 |citeseerx=10.1.1.474.4968 |doi=10.1176/ajp.149.7.936 |pmid=1609875}}</ref> Muscle relaxation techniques are useful to some individuals as well. These can be learned using recordings, videos, or books. While muscle relaxation has proved to be less effective than cognitive behavioral therapy in controlled trials, many people still find at least temporary relief from muscle relaxation.<ref name="Panic disorder" />

===Breathing exercises===
Irregularities in breathing, including [[Hyperventilation syndrome|hyperventilation]] and [[shortness of breath]], are key features of anxiety and panic attacks.<ref name=":10">{{Cite journal |last1=Banushi |first1=Blerida |last2=Brendle |first2=Madeline |last3=Ragnhildstveit |first3=Anya |last4=Murphy |first4=Tara |last5=Moore |first5=Claire |last6=Egberts |first6=Johannes |last7=Robison |first7=Reid |date=2023-02-02 |title=Breathwork Interventions for Adults with Clinically Diagnosed Anxiety Disorders: A Scoping Review |journal=Brain Sciences |language=en |volume=13 |issue=2 |pages=256 |doi=10.3390/brainsci13020256 |doi-access=free |issn=2076-3425 |pmc=9954474 |pmid=36831799}}</ref> [[Hyperventilation syndrome]] occurs when an individual experiences deep, quick-paced breathing, eventually affecting blood flow to the brain and altering conscious awareness.<ref name=":10" />

It has been shown that several various breathwork techniques can reduce symptoms in patients diagnosed with anxiety disorders. By managing and focusing on breathing, individuals with anxiety experience less tension and stress in their muscles, as well as a diminished stress response.<ref name=":10" /> Breathing retraining exercise helps to rebalance the oxygen and CO<sub>2</sub> levels in the blood, improving cerebral blood flow.<ref>{{Cite web |url=http://emedicine.medscape.com/article/807277-overview#a6 |title=Hyperventilation Syndrome  |date=28 November 2016 |access-date=18 September 2017 |url-status=live |archive-url=https://web.archive.org/web/20170713055956/http://emedicine.medscape.com/article/807277-overview |archive-date=13 July 2017 }}</ref> [[Capnometry]], which provides exhaled CO<sub>2</sub> levels, may help guide breathing.<ref>{{Cite web |last=Craske |first=Michelle |date=30 September 2011 |title=Psychotherapy for panic disorder |url=http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?10/7/10353/ |url-status=dead |archive-url=https://web.archive.org/web/20171014035243/http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?10%2F7%2F10353%2F |archive-date=14 October 2017 |access-date=29 April 2020}}</ref><ref>{{cite journal |last1=Meuret |first1=Alicia E. |last2=Ritz |first2=Thomas |date=October 2010 |title=Hyperventilation in panic disorder and asthma: Empirical evidence and clinical strategies |journal=International Journal of Psychophysiology |volume=78 |issue=1 |pages=68–79 |doi=10.1016/j.ijpsycho.2010.05.006 |pmc=2937087 |pmid=20685222}}</ref>

[[David D. Burns]] recommends breathing exercises for those with anxiety. One such breathing exercise is a 5-2-5 count. Using the stomach (or diaphragm)—and not the chest—inhale (feel the stomach come out, as opposed to the chest expanding) for 5 seconds. As the maximal point at inhalation is reached, hold the breath for 2 seconds. Then slowly exhale, over 5 seconds. Repeat this cycle twice and then breathe 'normally' for 5 cycles (1 cycle = 1 inhale + 1 exhale). The point is to focus on breathing and relax the heart rate.<ref>{{Cite journal|last1=Bhagat|first1=Vidya|last2=Haque2|first2=Mainul|last3=Jaalam3|first3=Kamarudin|date=2017|title=Breathing Exercise - A Commanding Tool for Self-help Management during Panic attacks|url=https://www.researchgate.net/publication/323111032|journal=Research Journal of Pharmacy and Technology, 10(12), 4471-4473.|volume=10|issue=12|pages=4471–4473|via=}}</ref>

Although breathing into a paper bag was a common recommendation for short-term treatment of symptoms of an acute panic attack,<ref>[http://www.netdoctor.co.uk/ate/mentalhealth/205625.html Breathing in and out of a paper bag] {{webarchive|url=https://web.archive.org/web/20071021032153/http://www.netdoctor.co.uk/ate/mentalhealth/205625.html|date=21 October 2007}}</ref> it has been criticized as inferior to measured breathing.<ref>{{cite book |last1=Bergeron |first1=J. David |title=First Responder |last2=Le Baudour |first2=Chris |publisher=Pearson Prentice Hall |year=2009 |isbn=978-0-13-614059-7 |edition=8 |location=New Jersey |page=262 |chapter=Chapter 9: Caring for Medical Emergencies |quote=Do not use a paper bag in an attempt to treat hyperventilation. These patients can often be cared for with low-flow oxygen and lots of reassurance}}</ref><ref name="paperbaghazard">[http://firstaid.about.com/od/shortnessofbreat1/f/07_paper_bags.htm Hyperventilation Syndrome – Can I treat hyperventilation syndrome by breathing into a paper bag?] {{webarchive|url=https://web.archive.org/web/20130120102140/http://firstaid.about.com/od/shortnessofbreat1/f/07_paper_bags.htm|date=20 January 2013}}</ref>

===Therapy===
According to the American Psychological Association, "most specialists agree that a combination of cognitive and behavioral therapies are the best treatment for panic disorder. Medication might also be appropriate in some cases."<ref>{{cite web |title=Answers to Your Questions About Panic Disorder |url=https://www.apa.org/topics/anxiety/panic-disorder |website=American Psychological Association |year=2008 |access-date=8 January 2021 |archive-date=10 January 2021 |archive-url=https://web.archive.org/web/20210110071101/https://www.apa.org/topics/anxiety/panic-disorder |url-status=live }}</ref> The first part of therapy is largely informational; many people are greatly helped by simply understanding exactly what panic disorder is and how many others experience it. Many people with panic disorder are worried that their panic attacks mean they are "going crazy" or that the panic might induce a heart attack. [[Cognitive restructuring]] helps people to replace those thoughts with more realistic, positive ways of viewing the attacks.<ref name="Cognitive Restructuring Ability">{{Cite web|url=http://www.cehd.umn.edu/rationalnumberproject/89_2.html|title=Cognitive Restructuring Ability, Teacher Guidance and Perceptual Distracter Tasks: An Aptitude Treatment Interaction Study|last=Cramer, K., Post, T., & Behr, M.|date=January 1989|access-date=19 November 2010|url-status=live|archive-url=https://web.archive.org/web/20101222180132/http://www.cehd.umn.edu/rationalnumberproject/89_2.html|archive-date=22 December 2010}}</ref> Avoidant behavior, such as what is seen in patients with agoraphobia, is one of the key aspects that prevent people with frequent panic attacks from functioning healthily.<ref name="Panic disorder"/> Exposure therapy,<ref>{{Cite book|title = Exposure Therapy for Anxiety: Principles and Practice|url = https://books.google.com/books?id=7RAsnO1vU0UC|publisher = Guilford Press|date = 17 December 2012|isbn = 978-1-4625-0969-0|first1 = Jonathan S.|last1 = Abramowitz|first2 = Brett J.|last2 = Deacon|first3 = Stephen P. H.|last3 = Whiteside|url-status = live|archive-url = https://web.archive.org/web/20160520171142/https://books.google.com/books?id=7RAsnO1vU0UC|archive-date = 20 May 2016}}</ref> which includes repeated and prolonged confrontation with feared situations and body sensations, helps weaken anxiety responses to panic-inducing external and internal stimuli.

In deeper-level psychoanalytic approaches, in particular [[object relations theory]], panic attacks are frequently associated with [[splitting (psychology)]], [[paranoid-schizoid and depressive positions]], and [[paranoid anxiety]]. They are often found to be comorbid with [[borderline personality disorder]] and [[child sexual abuse]].<ref>{{cite book|last=Waska|first=Robert|title=Treating Severe Depressive and Persecutory Anxiety States: To Transform the Unbearable|year=2010|publisher=Karnac Books|isbn=978-1855757202}}{{page needed|date=January 2021}}</ref>

There was a meta-analysis of the comorbidity of panic disorders and agoraphobia that used exposure therapy to treat hundreds of patients over a period of time.<ref name=pmid11459386>{{cite journal |last1=Fava |first1=G. A. |last2=Rafanelli |first2=C. |last3=Grandi |first3=S. |last4=Conti |first4=S. |last5=Ruini |first5=C. |last6=Mangelli |first6=L. |last7=Belluardo |first7=P. |title=Long-term outcome of panic disorder with agoraphobia treated by exposure |journal=Psychological Medicine |date=July 2001 |volume=31 |issue=5 |pages=891–898 |doi=10.1017/s0033291701003592 |pmid=11459386 |s2cid=5652068 }}</ref> A result was that thirty-two percent of patients had a panic episode after treatment. They concluded that the use of exposure therapy has lasting efficacy for a client who is living with a panic disorder and agoraphobia.<ref name=pmid11459386/>

=== Medication ===
Medication options for panic attacks typically include benzodiazepines and antidepressants. Benzodiazepines are being prescribed less often because of their potential side effects such as [[Benzodiazepine dependence|dependence]], fatigue, slurred speech, and memory loss.<ref name="Evidence-based pharmacotherapy of p">{{cite journal |last1=Batelaan |first1=Neeltje M. |last2=Van Balkom |first2=Anton J. L. M. |last3=Stein |first3=Dan J. |title=Evidence-based pharmacotherapy of panic disorder: an update |journal=The International Journal of Neuropsychopharmacology |date=April 2012 |volume=15 |issue=3 |pages=403–415 |doi=10.1017/S1461145711000800 |pmid=21733234 |doi-access=free |hdl=1871/42311 |hdl-access=free }}</ref> Antidepressant treatments for panic attacks include selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and [[MAO inhibitor|monoamine oxidase inhibitor]]s (MAOIs).<ref name="pmid12197851" /> 

SSRIs in particular tend to be the first drug treatment used to treat panic attacks. SSRIs and tricyclic antidepressants appear similar for short-term efficacy.<ref name="pmid12197851">{{cite journal |last1=Bakker |first1=A. |last2=Van Balkom |first2=A. J. L. M. |last3=Spinhoven |first3=P. |title=SSRIs vs. TCAs in the treatment of panic disorder: a meta-analysis |journal=Acta Psychiatrica Scandinavica |date=2002 |volume=106 |issue=3 |pages=163–167 |doi=10.1034/j.1600-0447.2002.02255.x |pmid=12197851 |s2cid=26184300 }}</ref>

SSRIs carry a relatively low risk since they are not associated with much [[Drug tolerance|tolerance]] or [[Substance dependence|dependence]], and have a more tolerable side effect profile. TCAs are similar to SSRIs in their many advantages but come with more common side effects such as weight gain and cognitive disturbances. MAOIs are generally suggested for patients who have not responded to other forms of treatment.<ref name="pmid18728820">{{cite journal |last1=Marchesi |first1=Carlo |title=Pharmacological management of panic disorder |journal=Neuropsychiatric Disease and Treatment |date=March 2008 |volume=4 |issue=1 |pages=93–106 |doi=10.2147/ndt.s1557 |pmid=18728820 |pmc=2515914 |doi-access=free }}</ref>

While the use of drugs in treating panic attacks can be very successful, it is generally recommended that people also be in some form of therapy, such as cognitive behavioral therapy. Drug treatments are usually used throughout the duration of panic attack symptoms and discontinued after the patient has been free of symptoms for at least six months. It is usually safest to discontinue these drugs [[Tapering (medicine)|gradually]] while undergoing therapy.<ref name="Panic disorder"/> While drug treatment seems promising for children and adolescents, they are at an increased risk of suicide while taking these medications and their well-being should be monitored closely.<ref name=pmid18728820/>