20th November 2023

Panic Disorder

It would be difficult to talk about ‘neuroses’ without first looking at panic attacks and panic disorder. Although the term neurosis is not used commonly anymore, the breadth of the topics it refers to is vast and affects a considerable amount of the population. Panic attacks are characterised by a collection of physiological symptoms that happen spontaneously or occur in response to a situational stimulus. These include but are not limited to tachypnoea, tachycardia, palpitations, chest pain, nausea, vomiting, sweating, tremors, dizziness, derealisation and fear of death. When these attacks occur more frequently, you will start to consider if panic disorder (ICD-10 F41.0) is present. Understandably, patients may change the way they behave to avoid the symptoms they feel when they have panic attacks. For the rest of this section, we will look deeper into panic disorder.

Predisposition, onset and maintenance

There are two peaks in the age of onset of panic disorder; these are 15-24 and 45-54 years of age. The incidence is more common in females, who are 2-3 times more likely to be affected. Risk factors for developing panic disorder also include life events such as separation or divorce from a partner, death of a spouse or a parent at a young age, history of abuse, physical illness, low educational level, and even living in a city. Understanding some biological theories behind panic disorder can help to understand potential treatments.

If treated, then 25-75% of patients recover in the first 1-2 years. However, this drops to 10-30% after 5 years. If left to go untreated, then the course is chronic. Good prognostic factors are mild symptoms at onset, absence of risk factors and other comorbidities, in particular personality disorders.

Focused history

Patients should be asked about any comorbid diagnoses or substance use, including alcohol, steroids, nicotine and caffeine. The time frame of onset of physiological symptoms should be elicited; commonly, peak intensity is reached within 10 minutes of onset and settles within half an hour. How long they have been experiencing symptoms, and how often they have been treated for something similar in the past. Most importantly, what impact this is having on the patient and their lifestyle.

Assessment of physical factors and investigations

Certainly, in the first presentation of panic attacks or disorder, it is important to rule out serious underlying pathology, but in the case of recurrent panic attacks with a clear history, this may not always be essential. Anyone who has spent time in an A&E setting will be able to think of a case where a patient presenting with chest pain, wholly convinced that they are having a heart attack, is actually in the throes of a panic attack. As there are no diagnostic investigations, the tests listed here are purely for purposes of exclusion:

• Physical observations and examination.
• Blood tests – FBC, U&E, TFTs, toxicology, calcium and glucose.
• ECG – looking for other causes of palpitations and making sure the patient isn’t right about that MI!
• ABG, urinary catecholamines, cortisol and drug screening may also be indicated.

Diagnosis

When panic attacks occur frequently for over at least one month, in the absence of other causes, a diagnosis of panic disorder can be considered. According to ICD-10 criteria, a diagnosis of panic disorder can be made when panic attacks occur when there is no real danger, in situations that cannot be predicted, with the absence of symptoms between attacks. Agoraphobia often comes hand in hand with panic disorder.

Treatment

Biological treatments – SSRIs (namely sertraline) are first-line treatment according to NICE guidance and should be started at half the recommended dose than for depression. If SSRIs are not appropriate, then tricyclic antidepressants such as imipramine can be considered. Although not recommended by NICE, in severe cases, benzodiazepines can be used only in the short term, and risks with concurrent substance use need to be considered.

Psychological treatments – Weekly CBT sessions lasting for up to 4 months or self-help programmes and groups. With waiting times for referrals being as they are, in practice, it is common to start medication first, which may also help the patient to get to a place where they are more able to engage with psychological therapies.

Social – Advice on alcohol and substance cessation and identifying social support networks.

References

• Semple D; Smyth R. (2019). Oxford Handbook of Psychiatry, fourth edition.
• National Institute for Health and Care Excellence. (2020). Generalised anxiety disorder and panic disorder in adults: management [Clinical guideline CG113]. https://www.nice.org.uk/guidance/cg113/ifp/chapter/panic-disorder
• International Statistical Classification of Diseases, tenth revision (ICD-10), Version:2016, https://icd.who.int/browse10/2016/en#/F40-F48
• International Statistical Classification of Diseases, eleventh revision (ICD-11), Version 01/2023, https://icd.who.int/browse11
• Taylor DM; Barnes TRE; Young AH. (2021). The Maudsley Prescribing Guidelines in Psychiatry, fourteenth edition.