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Treatments for Anxiety Disorder
Treatment With Medications
In this treatment approach, which is also called pharmacotherapy, a
prescription medication is used both to prevent panic attacks or reduce
their frequency and severity, and to decrease the associated anticipatory
anxiety. When patients find that their panic attacks are less frequent
and severe, they are increasingly able to venture into situations that
had been off-limits to them. In this way, they benefit from exposure
to previously feared situations as well as from the medication.
The three groups of medications most commonly used are the tricyclic
antidepressants, the high-potency benzodiazepines, and the monoamine
oxidase inhibitors (MAOIs). Determination of which drug to use is based
on considerations of safety, efficacy, and the personal needs and preferences
of the patient. Some information about each of the classes of drugs
The tricyclic antidepressants were the first medications shown to have
a beneficial effect against panic disorder. Imipramine is the tricyclic
most commonly used for this condition. When imipramine is prescribed,
the patient usually starts with small daily doses that are increased
every few days until an effective dosage is reached. The slow introduction
of imipramine helps minimize side effects such as dry mouth, constipation,
and blurred vision. People with panic disorder, who are inclined to
be hypervigilant about physical sensations, often find these side effects
disturbing at the outset. Side effects usually fade after the patient
has been on the medication a few weeks.
It usually takes several weeks for imipramine to have a beneficial
effect on panic disorder. Most patients treated with imipramine will
be panic-free within a few weeks or months. Treatment generally lasts
from 6 to 12 months. Treatment for a shorter period of time is possible,
but there is substantial risk that when imipramine is stopped, panic
attacks will recur. Extending the period of treatment to 6 months to
a year may reduce this risk of a relapse. When the treatment period
is complete, the dosage of imipramine is tapered over a period of several
The high-potency benzodiazepines are a class of medications that effectively
reduce anxiety. Alprazolam, clonazepam, and lorazepam are medications
that belong to this class. They take effect rapidly, have few bothersome
side- effects, and are well tolerated by the majority of patients. However,
some patients, especially those who have had problems with alcohol or
drug dependency, may become dependent on benzodiazepines.
Generally, the physician prescribing one of these drugs starts the
patient on a low dose and gradually raises it until panic attacks cease.
This procedure minimizes side effects.
Treatment with high-potency benzodiazepines is usually continued for
6 months to a year. One drawback of these medications is that patients
may experience withdrawal symptomsmalaise, weakness, and other
unpleasant effects when the treatment is discontinued. Reducing the
dose gradually generally minimizes these problems. There may also be
a recurrence of panic attacks after the medication is withdrawn.
Of the MAOIs, a class of antidepressants which have been shown to be
effective against panic disorder, phenelzine is the most commonly used.
Treatment with phenelzine usually starts with a relatively low daily
dosage that is increased gradually until panic attacks cease or the
patient reaches a maximumdosage of about 100 milligrams a day.
Use of phenelzine or any other MAOI requires the patient to observe
exacting dietary restrictions, because there are foods and prescription
drugs and certain substances of abuse that can interact with the MAOI
to cause a sudden, dangerous rise in blood pressure. All patients who
are taking MAOIs should obtain their physician's guidance concerning
dietary restrictions and should consult with their physician before
using any over-the-counter or prescription medications.
As in the case of the high-potency benzodiazepines and imipramine,
treatment with phenelzine or another MAOI generally lasts 6 months to
a year. At the conclusion of the treatment period, the medication is
Newly available antidepressants such as fluvoxamine, fluoxetine, sertraline
and related drugs that are part of a class of new agents called selective
serotonin reuptake inhibitors, appear to be effective in selected cases
of panic disorder. As with other anti panic medications, it is important
to start with very small doses and gradually raise the dosage.
Scientists supported by NIMH are seeking ways to improve drug treatment
for panic disorder. Studies are underway to determine the optimal duration
of treatment with medications, who they are most likely to help, and
how to moderate problems associated with withdrawal.
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