What is the current "best" treatment for anxiety/panic?
January 21, 2022 6:51 PM   Subscribe

I have recently passed a tipping point with my anxiety, and am seeking help to deal with it. There seem to be many options. Are any known to be more/less useful than others? (not looking for anecdotes)

You don't need to read this part, but I guess I needed to write it. You can skip to the end without missing the point of this question.

In the past week or so, I have slept maybe 6hrs total, and have spent the rest of the time with chest pains, spiking about 5-10 times per day into panic attacks (that fit into the normal patterns of panic attacks). I have had these before, more intermittently, and have always survived them so haven't wanted to inconvenience anyone with what I felt to be my own problems. I am generally a worrier, but usually about legitimate things. I'm unable to pin down what these worries are actually ABOUT (though I've been noting when they start and I'm starting to have some suspicions). I'm not 'worrying', I'm just a spectator as my body thinks it's being chased by a tiger or something. Bizarre.

I could not stand it anymore, and called my doctor who prescribed ativan (0.5mg) to take during a panic attack so that I could break that cycle. That same day, I took one and felt the oddest sensation in my chest, like an olive was being pushed through a too-small tube. The panic attack did not stop, and about 1(ish) hours later when the next one started, I took another. Same sensation, so obviously I didn't do that again.
During this time, I spent nearly all of my time doing breathing exercises, meditation, progressive muscle relaxation, and listening to various audio recordings made to talk people down from panic attacks (thanks, people who make those!).
Also 'working', but mostly unable to focus my eyes or hold a coherent thought.
It took a few days to reach my doctor again, and during that time I did some bloodwork (probably ready by next week) and an ECG (clear).
Calling again, my doctor prescribed
1) clonazepam as an alternative to the ativan
2) an SSRI (escitalopram) (5mg per day for a week, then 10mg per day after that)
3) some time away from work

I am nervous (ha!) about the clonazepam - mostly due to the utter heartbreak when the ativan failed to save the day. I am also nervous about the SSRI due to... probably ego, but also just worries about changing the function of my brain because it is my brain and I'm used to it.

I would like to never be in a situation this bad again, though. The sheer spectrum of negative feelings and unrelenting nature of this has been humbling.


What I want to know is:
what actually works to reduce the incidence of panic attacks?

If it's SSRIs, then okay. If it's CBT or some other type of therapy, I'd like to start as soon as possible. My wife has started to find some therapists in town, but I'm not really sure what all of the different flavours of therapy are like, or which are EFFECTIVE for THIS problem.

My plan is to do the plan my GP came up with because I'm just not able to formulate my own plan right now. But later! I hope to come back here and read more about this. I also want to be clear that I trust my doctor.
(I do not plan on engaging in this thread - it was very hard to write this)
posted by Acari to Health & Fitness (21 answers total) 11 users marked this as a favorite
During my last year of grad school, despite cutting back as many additional commitments as possible I started having fairly regular panic/anxiety attacks. I had been feeling anxious and that it was probably time to see a counselor for several years but it seemed like something I kept putting off and just needed to power through another day (shockingly unhelpful!)

Things that helped:
1) talking to someone and them helping me identify some sources of anxiety
2) learning some immediate coping mechanisms like square breathing or drinking cold water during a panic attack
3) referral for psychiatrist and getting drugs
4) trying out several medications until I found one that helped

I would say that the drugs were an up and down experience. Positive because it felt like I was able to take an action in some way to improve my mental state… but the such frustration when the first drug didn’t work.

You might try some stuff right now (different counselors/therapists, medications, coping mechanisms, etc) right now that may or may not work. Just figure that it’s still a step in the right direction even if it’s “wrong.” Medication doesn’t help? Ok great, let’s try a different one. Counselor not a good fit? Ok, maybe they can recommend someone who is.
posted by raccoon409 at 7:06 PM on January 21, 2022 [1 favorite]

Would you characterize your nebulous feelings as a ‘sense of impending doom’? Because that can point to heart problems and doctors usually take it seriously as a symptom. What you’re describing sounds like it might possibly be caused by a medical problem of some kind, so maybe there’s a straightforward answer and a clear solution. I’d be going to the ER if this was me and I had such a dramatic change so quickly alongside heart spikes, to get a big workup to rule things out. But as far as solutions for anxiety and panic, people really react so incredibly differently to things that I don’t think there are any clearcut answers. But your experience sounds really rough and I hope you can find the right answers.
posted by asimplemouse at 7:09 PM on January 21, 2022 [5 favorites]

This is a very difficult question, because everyone's body reacts differently to meds and everyone's mind reacts differently to therapy, and I think it's very easy to feel either discouraged or overly optimistic based on anecdotes. Unfortunately, it is just not an easy process. The most important thing, I think, is to simply start.

I will say that the best outcomes with medicine like anti-depressants and the like may come from a licensed psychiatrist and not from a GP who often does not have the expertise but just knows the names. I say may because mileages will vary there too.

I really hope you are able to find some relief, and some answers, soon.
posted by sm1tten at 7:13 PM on January 21, 2022 [3 favorites]

I'm not your doctor, but I did have a panic disorder, so I have some experience.
Panic disorders mostly aren't rooted in a real-world cause (i.e., a real reason to panic). That's why the usual effective treatment is medication and not therapy. Basically, your doctor prescribes some pills, and you hopefully get better and move on. In other words, it's simply a wiring problem in your brain.
The klonopin/clonazepam reduces excess brain activity, which reduces panic attacks. The SSRI levels out the serotonin level in your brain, which makes you feel at peace. If you have trouble sleeping (like being constantly awoken by shots of adrenaline), you might need some Ambien, which you take and then go straight to bed (so you don't sleep-order a bunch of stuff from Amazon).
Taking these medicines for the length of time the doctor recommends gives your brain a chance to rewire itself, thereby fixing itself. You might feel a little groggy and doped if you're not used to medicine (mainly, because you're relaxed), but that's part of the process. You might have some brain zaps or dizziness when you discontinue an SSRI. But no medicine is perfect or comes without side-effects.
Like I said, this happened to me, and thankfully it's now behind me.
I agree with asimplemouse though that you should get a full workup. They can do tests to detect things like tick-borne bacterial infections that have similar symptoms.
posted by jabah at 7:17 PM on January 21, 2022 [2 favorites]

I will try to come back to this later when I have more time and give more detail, but CBT has been well-documented to be the most effective therapy for panic disorder, by a fairly decisive margin. For other conditions the particular type of therapy doesn’t matter too much, but for panic disorder CBT is the stand-out star. I say this as a clinician who generally dislikes CBT as an overall model for most disorders—I am not one to typically recommend it, but the research on CBT and panic disorder is quite clear.

The research also shows that the combination of medication and therapy is MUCH more effective for panic than either alone. So please do consider pursuing both.

But also I agree with recommendations to see a doctor in-person (you implied you only spoke with your doctor over the phone) and get a work-up because there could be many physical explanations; people with panic disorder are also at higher risk for heart problems so it could be both.

Also just to check—you haven’t recently started any different meds, have you? I was on a migraine med that gave me nightly panic attacks. This could explain the suddenness of the onset if applicable.
posted by brook horse at 7:36 PM on January 21, 2022 [7 favorites]

i would recommend getting a referral to a licensed psychiatrist – GPs are great, but they often have to do a significant amount of guesswork when it comes to psychiatric medications. for me, SNRIs seem to work better than SSRIs, but it's dealer's choice it seems. as brook horse mentioned above, medication combined with therapy (specifically CBT for anxiety/panic disorders) is significantly more effective than either one alone. it's worth specifically looking for a certified CBT therapist.

i also recently spoke with a psychiatrist who recommended "the worry cure" by robert leahy and using a mood lamp (also known as a SAD lamp or a light therapy lamp) several times a week.

i hope any of this helps

(credentials, if you need them: psych undergrad degree; lots of time invested in researching treatments for anxiety/depression and talking to doctors)
posted by =^.^= at 8:30 PM on January 21, 2022 [2 favorites]

A combination of alprazolam and propranolol has worked best for me in terms of medication. But, as others above have pointed out, the same treatments don’t work the same for everybody.
posted by The Underpants Monster at 9:04 PM on January 21, 2022 [1 favorite]

Your GP's plan is solidly in line with how anxiety and panic attacks seem to be handled now. Escitalopram is commonly prescribed because it's been around for ages and has limited side effects and works for most people. If after 2-3 weeks, you see no improvement, they will probably increase to 10mg and if it still doesn't work after another 2-3 weeks, switch to a drug with a different mechanism. Individual drug reactions vary.

Therapy alone doesn't help much with anxiety, but combined with meds, is great. CBT gives you ways to handle the anxiety while your meatbag brain gets less twitchy about regular stress. If your anxiety is due to specific issues (grief, trauma etc), you might consider regular talk therapy to process those issues and reduce your stress levels.

It is really common for people to have to try several meds before finding the right one, so ativan not working for you is No Big Deal.
posted by dorothyisunderwood at 11:26 PM on January 21, 2022 [3 favorites]

Sertraline gave me the brain space to find a good therapist and get my act together enough to find a good therapist and build a skill set that let me drop the meds after a year or so (and half a year of therapy). Escitalopram is also good, I know a lot of people who are on it for years during stressful periods. It's like a badly sprained ankle - you'd take it easy, take painkillers and get physiotherapy.
posted by I claim sanctuary at 4:45 AM on January 22, 2022 [2 favorites]

Good news! There is *excellent* evidence based therapy for anxiety and panic, combined with an SSRI. Take the SSRI and seek out a therapy practice that specializes in anxiety. You’ll likely pay out of pocket, but the therapy is time-limited (like maybe 3 months). What you want to look for is a group practice where the therapists are actual psychologists, who have trained and done fellowships at major academic medical centers specifically in anxiety/OCD/PTSD, etc. It’s important that it be a group practice because this ensures proper training and supervision.

The therapy will likely be a combination of ACT and CBT these days. They will likely also focus on helping you get through panic attacks and insomnia without the use of benzos - although don’t fixate too much on that right now.

SSRIs + the right therapy are really going to help, promise.
posted by haptic_avenger at 8:02 AM on January 22, 2022 [2 favorites]

Seconding the recommendation above for SSRIs and therapy. Sertraline was the one that helped me, but that was some years ago; maybe they have better ones now.

Is there a reason beta blockers aren't on your list of options? I certainly find them helpful as "cycle breakers." They're not mood altering or addictive, but they prevent your heart rate from getting too fast, which eases the physical symptoms.

Mine are 40mg, but most of the time I only need half a pill. On particularly bad days I'll take 20mg so I can practice and 20mg before bed. If the anxiety is REALLY bad I'll take a whole one.

They're not a substitute for therapy or a long-term solution, but they're certainly useful for on-the-spot care.
posted by Pallas Athena at 8:42 AM on January 22, 2022

Trigger the Mammalian Dive Response. Science link. When I am in a panic attack I cannot assemble a bowl and ice and all that, but I have successfully ended one by running cold tap water and repeatedly splashing my face first holding my breath for 10 seconds, then 20, then 30. My plan was to do a second 30-second round if necessary but in two panic attacks since figuring out how to execute this while shaky and struggling to stand I have not needed to, it has stopped cold during the first 30-second round.

I can also stop my panic attacks by throwing up, which I assume is another form of primal mammalian survival nervous-system override, but unfortunately my stomach won't cooperate until I've been at full alarm for about an hour. Better than nothing, but try the dive response first.

I just want to tell you that I was where you are last September and escitalopram alone (I'm using an online provider who can't prescribe benzos) generated a massive improvement within two weeks. I still had a couple of depressive-anxious dips (lasting a day, maybe day and a half) in the first month but it's night and fucking day, I'm so surprised.

I've never been a great sleeper, and I found I needed to take my meds in late afternoon to not have some drowsiness at work (though I might experiment with switching back to morning now that I'm not in constant crisis and see if the drowsiness is tolerable or even still there), and sleep has been a little bit of a struggle as a result. It's not like death-march all night insomnia, it's just light sleep that's easily disturbed. I'm picking up some Trazodone today to see if a third or half of that smooths out.
posted by Lyn Never at 10:00 AM on January 22, 2022 [1 favorite]

I am nervous (ha!) about the clonazepam - mostly due to the utter heartbreak when the ativan failed to save the day.

Psychiatric drugs always require a few tries. Their effects just vary too much from person to person.

I wouldn't worry about running out of alternatives though.

I am also nervous about the SSRI due to... probably ego, but also just worries about changing the function of my brain because it is my brain and I'm used to it.

It's a conundrum isn't it? Because actually you do want to change the function of your brain with regards to anxiety. My worry was always that SSRIs were too big of a hammer for the job. There were some studies in the nineties that looked at the perception of friends and family of people starting SSRIs and found no significant personality changes. That's what settled my mind on the topic.
posted by Tell Me No Lies at 10:39 AM on January 22, 2022 [1 favorite]

I feel you. I went through very similar a couple (has it been that long now?) of months ago. I wish I could get a prescription for ativan.

I was put on mirtazapine; it hasn't helped the panic attacks much, but good grief, I can sleep now and that helps a lot.

Intense dreams (nightmares, but no worse than before) but at least I can dream/ REM sleep.

Various side effects, but blessed sleep.
posted by porpoise at 10:42 AM on January 22, 2022

I have experienced panic attacks, including in the office of a very good therapist. Her advice? Cold, wet washcloth on the face. Panic attacks are physiological, and making your face cold affects the diving reflex and the vagal nerve. I still usually carry a washcloth. You can also learn to stimulate the vagal nerve with the Valsalva maneuver; I recommend talking to a doctor; you can go overboard with it.

Regular exercise and time in nature are really, really helpful.

Fear and anxiety take a double hit from vagal nerve stimulation

Fighting Anxiety: Strengthen Your Vagus Nerve
posted by theora55 at 11:19 AM on January 22, 2022 [1 favorite]

I'm unable to pin down what these worries are actually ABOUT (though I've been noting when they start and I'm starting to have some suspicions). I'm not 'worrying', I'm just a spectator as my body thinks it's being chased by a tiger or something. Bizarre.

It sounds like this is part of an old/deep pattern for you, and I bet medication, therapy, trauma awareness and lifestyle changes will all be helpful! However I just wanted to mention there are medical reasons why you might be stuck in activated state even without emotional triggers. If other interventions don't pan out, you might want to look into dysautonomia.
posted by lloquat at 12:14 PM on January 22, 2022

I'm unable to pin down what these worries are actually ABOUT (though I've been noting when they start and I'm starting to have some suspicions). I'm not 'worrying', I'm just a spectator as my body thinks it's being chased by a tiger or something. Bizarre.

Do you have a history of childhood trauma? The Body Keeps The Score is a good resource for understanding the kinds of lifelong effects that this can cause and the range of treatments currently available to help work around those.
posted by flabdablet at 12:55 PM on January 22, 2022

Are you taking any other medications? I find OTC allergy medicine triggers physical panic attacks, some brands worse than others.
I have had very good luck with neurofeedback for anxiety. It is a process- usually requires about 20-40 sessions to fully work (I found it starts to help after 2-5 sessions but it keeps my brain quiet longer as I have more sessions) but after you go through the course you should be in much better shape and may only need an occasional tune up.
posted by john_snow at 1:13 PM on January 22, 2022

I'm a lifelong panic attack sufferer and I'm really sorry you're going through this. A little over 5 years ago, I went through a spate of panic attacks so bad I had to take a leave of absence from work and move in with my parents for a couple of months because I was too freaked out to be alone. It was AWFUL. Now, I will have the occasional mini-attack a few times a year, but that's about it.

What helped me:
- Benzodiazepines, and in my case, Ativan. (I'm sorry it didn't work for you!) My panic attacks tend to be in the middle of the night (HOW FUN FOR ME) so I would take 0.5 mg every night before bed, for several months. Getting some rest without worrying about panicking helped reset my body.
- Lexapro, aka escitalopram. I had avoided SSRIs for YEARS because I'd heard such horror stories about the side effects. I will always regret not trying it earlier, because it's irrevocably changed my life for the better. I did have side effects (drowsiness, some changes in libido) for maybe a month, but they went away after that. I started off with 5 mg and eventually end up with 15 mg.
- CBT. There are two books I can recommend: When Panic Attacks by David Burns, and Embracing the Fear by Judith Bemis. The Bemis book in particular was HUGELY helpful for me, even though it's really more focused on agoraphobia. I've read it like 5 times and will return to it every year or two as a tune-up. The basic idea is that when you start to experience physiological signs of panic, you need to train your brain to react differently. Instead of thinking, "I can't get through this and I feel like I'm dying," you think, "Welp, I'm having a panic attack so I'm just going to let it happen and trust that I'll ride it out, just like I have every time before." I know that sounds simple, but self-talk makes a HUGE difference when you're experiencing these symptoms.

Feel free to message me if you want to chat more!
posted by leftover_scrabble_rack at 4:46 PM on January 22, 2022 [2 favorites]

Response by poster: Thanks everybody. I truly appreciate you taking the time to help me.

I'll be reading these in more detail in the next week.
I actually came here to say that I'd remembered about the dive reflex and that it was a BIG help (as long as I could hold my breath.) It brought my heart rate down by 20 BPM just about every time!

I'm on day 3 of the ssri and it's not super fun but at least I knew that going in.

I got brave enough to try the clonazepam this morning, and though it feels like a medium hangover I'll definitely take it. I ate a whole breakfast! And made an appointment at a CBT clinic!
posted by Acari at 9:09 AM on January 24, 2022 [3 favorites]

Nth-ing SSRIs, benzos, and therapy. Do you drink coffee or other caffeinated beverages? If so stop or cut back. Same with alcohol. I really think the things we eat and drink have a bigger effect on our mood than most realize.
posted by Billy Rubin at 2:42 PM on January 25, 2022

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