Talk to Psychiatry on Panic Disorder And Anxiety

I am a 28-year-old male with recurrent panic attacks and anxiety since 2020. Attacks often occur while driving, talking for long periods, teaching, during presentations, or after noticing physical sensations. During attacks I fear fainting, dying, heart stopping, or dangerous BP changes, with sweating, shaking, weakness, dizziness/presyncope, dry mouth and throat sensations. Episodes usually last 10–20 minutes. I have never lost consciousness. Multiple ECGs, thyroid/electrolyte tests and recent CBC, ferritin, creatinine and HbA1c have been reassuring.

I used paroxetine for about 5 years. It initially worked well for anxiety, focus and confidence but later caused marked lethargy, apathy, brain fog, weight gain and emotional blunting. Sertraline up to 100 mg for about one year was not satisfactory. I currently take venlafaxine XR 75 mg daily. I previously took 150 mg for about 40 days without adequate panic control and 225 mg for 10 days, which caused severe lethargy, absent-mindedness and cognitive slowing. Bupropion XL 150 mg worsened agitation/anxiety and was stopped. Clonazepam 0.5 mg PRN works well for severe panic.

Currently I still have panic, background anxiety, poor focus, irritability, noise sensitivity, low productivity and cigarette dependence. Sleep is good. I want a safe long-term plan for strong panic control, lower anxiety, calm focus, clear cognition with minimal sedation, less irritability and eventual smoking cessation.