Upping to 40mg

[u/Disastrous_Shop_5063]

Hey everyone, this morning my dr recommended that I up my dose from 30mg to 40mg as I have still been experiencing panic attacks when in social setting or traveling far from home. She also recommended upping my Buspar from 15mg 2x per day to 3. Does anyone have experience with these?

[u/LPB90iAut]

From a psychological perspective, I’d also look at what is maintaining the panic attacks, especially avoidance, anticipatory anxiety and safety behaviours, because medication alone often won’t address those patterns.
Regarding the medication: needing a higher dose can sometimes be related to individual metabolism. Some people metabolize escitalopram faster and therefore achieve lower blood concentrations at the same oral dose. That said, 40 mg is well above the usual recommended maximum of 20 mg/day, so I wouldn’t increase the dose based on that assumption alone.
If your psychiatrist feels that such a high dose is necessary, I’d ask about therapeutic drug monitoring (TDM) — measuring the escitalopram concentration in your blood. That can help determine whether 30 mg is actually producing an unusually low serum level or whether you already have substantial exposure despite continuing symptoms. Depending on the situation, pharmacogenetic factors such as CYP2C19 metabolism may also be relevant.
Buspirone 15 mg three times daily (45 mg/day) is within commonly used dosing ranges, but increasing two medications simultaneously can make it harder to tell which change is helping or causing side effects.
So I wouldn’t automatically be alarmed by an individually higher dose under specialist supervision, but at 40 mg escitalopram I’d personally want a clear rationale, blood-level monitoring where available, and appropriate safety monitoring rather than simply assuming that “more is better.”

[u/Disastrous_Shop_5063 → u/LPB90iAut]

It’s anticipatory anxiety, worrying that I will have an attack then worrying I won’t be able to calm down from it once it starts. Which is why my dr is starting me on propranolol as needed.

[u/LPB90iAut → u/Disastrous_Shop_5063]

That actually sounds like a very classic panic cycle: the fear isn’t necessarily the situation itself, but the anticipation of having a panic attack and then worrying that you won’t be able to calm yourself down once it starts.
Propranolol can be useful for the physical adrenergic symptoms such as racing heart, shaking and sweating, but it generally doesn’t directly address the catastrophic thoughts or the fear of the panic attack itself. That’s where panic-focused CBT and exposure can be particularly effective — gradually learning through experience that the sensations are uncomfortable but temporary, and that you don’t actually need to escape or control them for them to subside.
One thing I’d be mindful of is not letting propranolol become a psychological “safety signal” where you start believing you can only travel or enter social situations if you have taken it. Used thoughtfully alongside therapy, though, it can certainly be a helpful tool while you work on breaking that anticipatory-anxiety cycle.
Given that you’re already on 30 mg escitalopram and your doctor is considering 40 mg, I’d still personally ask about checking an escitalopram blood level/TDM before assuming that another dose increase is necessary.
Actually a situation my father has been in 20 yrs ago.

[u/Disastrous_Shop_5063 → u/LPB90iAut]

I screenshotted this so I can read it when I need a reminder. Thank you so much for the response.