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At its worst panic attacks strike in clusters or can be continuous. When this happens it is a medical emergency.
When panic attacks are sporadic the need for immediate treatment is less urgent than when they occur in clusters. When this happens it is rapidly disabling and often intolerably uncomfortable. At times people experience "status panicus" where a panic attack is prolonged, lasting days or weeks.
Clusters and panicus demand rapid treatment because of the high level of discomfort and disabling nature of this experience. While panic attacks are generally considered "harmless", anyone who is undergoing multiple daily panic attacks or a prolonged panic attack knows how exhausted and ill they feel and the cardiovascular strain is clearly excessive. Suicide can occur when this level of discomfort is allowed to persist.
The antidepressants (SSRI and tricyclic antidepressants) will usually aggravate panic attacks and are to be avoided. My experience is that the high potency benzodiazepines (Klonopin, Xanax) are the only rapid acting, effective medications. They should be used at a dose that is adequate to totally stop the panic attacks. It is usually necessary to treat the associated reflux with Carafate (coats the stomach and binds with bile in the stomach) and proton pump inhibitors (Prilosec or Prevacid).
There is enormous controversy over the use of these agents because of potential side effects and potential dependency. (See the FAQ on side effects of benzodiazepines). Ideally it is best to use BDZs at an adequate dosage for complete relief for about two weeks. In reality it turns out that the sense of relief and fear of return of symptoms is so profound that people do not want to stop these medicines after two weeks and chronic use is common. Some people do better using these medications long term, however BDZs can become part of the problem when used chronically.
When panic attacks are unremitting then the benefits outweigh the risks for the use of high potency BDZs.
