Is there hope for persons with Panic Disorder?  Yes.  Panic disorder is very treatable.  And nearly everyone responds well to proper treatment.  Treatment consists of several steps:
A     First a person must be educated about this disorder. Simply learning some of the things mentioned in this brochure will improve matters somewhat by giving hope where there perhaps was despair. Understanding and knowledge gives confidence and a positive expectation so important to the success of any medical treatment.
B     Next, it is necessary to find a medication which can eliminate the panic attacks completely, if at all possible. Psychiatrists experienced in treating Panic Disorder have had success using any one of three kinds of medicines:
1     Certain Antidepressants. Paxil & Paxil CR (paroxetine), Zoloft (sertraline), and Prozac (fluoxetine) are examples of antidepressants that are useful in treating Panic Disorder and have official FDA approval for that indication. Many antidepressants may alleviate panic attacks.  Physical dependence does not occur on such medicine.
     Successful treatment requires full strength dosage and it usually takes four to six weeks for the medicine to begin to block the panic attacks.  Full benefit may take up to 3 months.  
     Perhaps half of persons trying this type of medicine are made initially worse to a greater or lesser degree.  Certain properties of the medicines tend to trigger more than the usual number of attacks, or more severe attacks, in the first several days of treatment.  This temporary discomfort can be considered a short term investment of worsening in return for a gain of long term relief.  In most patients this potential temporary worsening can be alleviated by taking smaller than usual starting doses of the medication. In unusually sensitive patients, experienced clinicians have even used 1/64 or 1/32 of the usual starting dose.  
     Paxil (paroxetine) is an example of a new antidepressant which has few side effects and has FDA indications for treatment of panic disorder. A newer and improved form of Paxil is Paxil CR. It is enteric coated so it is less likely to bother the stomach. It is time-released. It has even less side effects than regular Paxil (paroxetine). The other two antidepressants that have FDA approval for treating panic disorder are Zoloft (sertraline) and Prozac (fluoxetine). Experts vary in their preference of these medications. Dr. Stephen Cox, founder of the National Anxiety Foundation, favors Paxil CR. "There is a problem with using antidepressants to treat persons with panic disorder.
      When these persons take antidepressants, for the first several days they are often made worse, rather than better.  Experienced doctors know to expect this and prescribe the medicines that they have found in their personal experience to be less apt to cause this known risk of worsening of either the frequency or the severity of panic attacks. In my own experience, Paxil CR seems less likely to intensify the patient's symptoms the first few days. In my experience, Prozac has been harsh to people with panic disorder with respect to this temporary worsening risk.  I think Zoloft lies somewhere between Paxil and Prozac.  I do think that Zoloft seems definitely closer to Paxil in this regard than it does to Prozac.
      "The question arises, "Why take a medicine that has a 50% chance of making you worse?"  It turns out, the worsening, if it occurs at all, is only temporary. In the first few days of continued use, it passes.  Then people with panic disorder, with continued use of the medication, enter into a neutral period where they are actually no worse than when they started this medicine, but they are no better either.  After about 3-6 weeks, they hopefully begin to experience fewer attacks, or less severe attacks, or both.  Dr. Cox comments on this, "Experienced doctors will use less initial dose when prescribing this medicine for panic disorder than they would if they were prescribing it for depression.  If I prescribe Zoloft (sertraline) for panic disorder, I start with 25 mgs. not 50 mgs. (the usual dose for depression).  I don't often prescribe Prozac (fluoxetine) for panic disorder. I usually prescribe Paxil CR and I personally find it so unusual to temporarily worsen panic disorder that I commonly start not with the lowest dose of 12.5 mg, but with 25 mg, the same usual dose used for depression.  I sometimes prescribe Xanax (alprazolam), in the form of Xanax XR, along with the Paxil CR in the beginning of treatment if I need to give this patient immediate relief.  I have no problem with prescribing Xanax XR alone for persons with panic disorder if that is appropriate.  There is a study by Munford, et al, that suggests to me that Xanax XR is substantially less apt to be abused by persons who are prone to abuse drugs.  Fortunately, persons with panic disorder are not prone to be the type persons who abuse drugs.  Usually, if a genuine panic disorder patient is not taking their Xanax as prescribed, they are more than likely taking less than has been prescribed.
     "There is still one question that stumps medical science. Why do so many patients with panic disorder get worse when they first start taking antidepressant medication?  Dr. Cox has his own theory about this puzzle that goes back to the carbon dioxide sensitivity that was discussed at the beginning of the panic disorder section.  "When Dr. Sheehan, Dr. Lawrence, and I published our research on the higher levels of carbon dioxide in environments of claustrophobia, I presented this discovery at the annual NCDEU meeting that year.  A man approached me and commented that he noted that I mentioned that antidepressants lowered the brain cell sensitivity to carbon dioxide.  He said that that effect is actually a biphasic effect.  Antidepressants first make brain cells more sensitive to carbon dioxide, then after a while, with continued use, they make the brain cells less sensitive to carbon dioxide.  I was excited to learn of this and I asked him if he knew who discovered that, as I wanted to read more about it.  He responded humbly, "I did.  "This researcher was Dr. Sheldon Preskorn, the prominent expert in antidepressant therapy.  Few people realize it, but Dr. Preskorn did extensive basic science research of great importance before he became noted as a clinical expert and a teacher of clinicians.
     "If you ask most doctors or representatives of pharmaceutical companies that make antidepressants about why antidepressants make people with panic disorder worse in the beginning of treatment, they will repeat back something they have heard about serotonin causing initial worsening of neuronal sensitivity or such. The trouble is, when you ask them to get you a scientific reference on that, they come up mostly empty handed. It is a theory and a widely held theory.
     "Dr. Cox continues his comments, "The carbon dioxide theory, on the other hand, is based on scientific observations that fit the scientific data and clinical observations. I remain convinced this is the main reason why antidepressants make people with panic disorder worse at first and better in the long run.  It is this biphasic effect of antidepressants upon brain cell carbon dioxide sensitivity which is abnormal in persons with panic disorder."
Stephen Cox, MD
President - NAF
Medical Director

Linda Vernon Blair

C. Todd Strecker

Board of Directors:
Father Edward Bradley
Georgann Chenault
Sarah Wood Cox
Keith Hartman MD

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