22nd February 2024

Panic Disorder

Background

Panic disorder has a lifetime prevalence of 1-5%. Patients with this disorder experience recurrent and persistent panic attacks over one month. Panic disorders are characterised by continuous worry or anxiety about having further panic attacks or fear of developing health problems due to recurring panic attacks (such as heart attacks). Whilst all patients with a panic disorder experience panic attacks, not everyone who experiences a panic attack has a panic disorder. Appropriate management of a panic attack in the first instance can prevent the development of a panic disorder.

Panic attacks can be related to a particular situation or can occur randomly without any cause. Factors which cause a panic attack are referred to as situational triggers; these can be external or internal. External triggers can be environmental, situational, or related to a phobia. Internal triggers include stress, lack of sleep or caffeinated drinks. Panic attacks that occur without a trigger are referred to as being spontaneous. The frequency and severity of these attacks can be highly variable.

Individuals experiencing panic attacks may avoid situations they believe trigger their panic episodes; this type of behaviour change is a key feature of panic disorder. As a result, patients struggle with everyday functioning and experience a poor quality of life. Historically, agoraphobia has been associated with panic disorder, but in the more recent DSM-5, they are referred to separately. Panic disorders can be present with or without agoraphobia, however, those with debilitating panic disorder often have comorbid agoraphobia.

Symptoms

A panic attack is an episode of sudden panic and intense feeling of discomfort, which involves the following:

• Rapid heart rate or pounding chest.
• Palpitations
• Hyperventilation
• Shortness of breath
• Chest tightness or discomfort
• Shaking or trembling
• Paraesthesia
• Abdominal pain 
• Nausea 
• Feeling like the patient is dying or suffocating.

Symptoms can last from minutes to hours. Patients presenting with a panic disorder will have these attacks frequently and without notice. Whilst panic attacks usually occur due to a trigger, in panic disorder they also occur spontaneously, without a trigger. Due to the frequency of these attacks, individuals develop maladaptive behaviours. They become excessively worried about having more attacks in the future and/or are concerned about the consequences of having further attacks. These can be worries about having a heart attack, developing an injury whilst having a panic attack, worry about death due to lack of oxygen going to the brain, or worry about the panic attack not stopping once it starts. Maladaptive behaviours can manifest as excessive use of health services or avoidance behaviours, such as avoidance of people, situations or environments which the patient considers to be a trigger. 

Investigations

Many of the symptoms seen in panic attacks can mimic organic medical conditions, so all individuals with new onset of panic attacks without a clear cause should undergo medical investigations first. 

• Physical examination and measurement of vital signs to assess for hypertension, tachycardia, or shortness of breath. 
• ECG to identify any arrythmia or ischaemic change that could contribute to the symptoms. 
• Blood tests such as full blood count, electrolytes, or thyroid panel. 
• The panic disorder severity scale (PDSS) is a 10-item questionnaire. Each question is rated out of 5, with scores ranging from 0-28. The higher the score, the greater the severity. It is often used to diagnose panic disorders and as a measure of treatment progress. 

Diagnosis

There is insufficient evidence to support the use of a diagnostic tool, so a thorough history and clinical judgement is used to make a diagnosis of a panic disorder.  Patients presenting with panic disorders often have a psychiatric co-morbidity of depression or substance misuse, which can make the diagnosis of panic disorders difficult.

If a patient presents to A&E or primary care with symptoms of a panic attack, physical causes such as thyroid or coronary artery disease must be ruled out first. If basic investigations rule out a physical problem, the patient is young, has a history of anxiety, has experienced panic attacks in the past or is known to have atypical chest pain, a diagnosis of panic disorder must be considered. 

DSM-5 diagnostic criteria for panic disorder: 

1. Recurrent panic attacks, at least one without a trigger. 
2. At least 1 month of one or both of the following:
   • Persistent worry about future panic attacks or worry about the consequence of further attacks 
   • Maladaptive behaviours like avoidance or overuse of health services
3. No other physical cause identified 
4. No other psychological disorder involved

Management

NICE guidelines recommend a stepped-care approach to panic disorders.

Image Source: Wikimedia Commons (2011). CG113, Licensed under a creative commons licence. Available for free at: https://www.nice.org.uk/guidance/cg113/chapter/Recommendations (Accessed: 6 October 2023).

Step 1 – Recognition and diagnosis of panic disorder

Panic disorders are often masked with the presentation of other medical conditions, as a result, they are often missed or misdiagnosed.  They can be comorbid with other mood disorders like depression, which makes recognition and diagnosis of panic disorders challenging. Common presentation of panic attacks is often individuals presenting to A&E with symptoms of chest pain, tightness, paraesthesia or difficulty breathing. In cases where medical causes of chest pain have been ruled out, the circumstances surrounding the presentation of the symptoms should be investigated and a diagnosis of a panic attack or panic disorder should be considered. Thorough history taking can help identify the factors causing or contributing to the disorder. This can help determine the best management plan for the individuals. The severity can be determined by the effect the symptoms have on day-to-day functioning and the individual’s mood. More debilitating cases of panic disorder may or may not present with agoraphobia. 

Psychoeducation on diagnosis:  the vicious cycles of the perception of fear, exaggerated sympathetic bodily responses and subsequent anxiety/avoidance should be explained to the patient. Patients should be encouraged to manage their anxiety using self-help resources. 

Step 2 – Treatment in Primary care

In the first instance, the following treatments can be offered to patients:

• Lifestyle factors e.g., eating well, good sleep, regular exercise etc
• Individual non-facilitated or facilitated self-help.
• Support groups 

Step 3 – Review the current treatment or offer alternatives. 

In individuals where the low-intensity management options above have been unsuccessful, the following should be offered

• CBT (7-14 hours is recommended and treatment should be completed within 4 months of commencement) is effective in those with or without agoraphobia. For some, shorter, more intensive CBT sessions are effective. 
• Drug therapy:  Antidepressants such as SSRIs, SNRIs and TCA are the only medications recommended for panic disorders.  Benzodiazepines, sedating antihistamines, and antipsychotics do not have good outcomes in this disorder and should be avoided. 

If there is no improvement in symptoms with the antidepressant after 12 weeks, an alternative class of antidepressant should be trialled. 

Step 4 – Referral to specialist services 

If a patient experiences substantial symptoms following two or more of the above interventions (psychological, pharmaceutical or combination) referral to specialist mental health services should be considered. 

Step 5 – Care in specialist mental health services

This often involves:

• Thorough risk assessment
• Management of co-morbid mental health conditions
• CBT
• Pharmacotherapy
• Referral to tertiary centres

References

• Jonge P, Roest AM, Lim CCW, Florescu SE, Bromet EJ, Stein DJ, et al. Cross-national epidemiology of panic disorder and panic attacks in the World Mental Health Surveys. Depression and Anxiety. 2016;33(12):1155–77. 
• Streeruwitz A, Hagger M, Webb S, Walker D, Jakeman N. Anxiety, obsession, and reactions to stress. In: Psychiatry PRN. Oxford, New York: Oxford University Press; 2009. p. 153–6. 
• Roy-Byrne PP. [Internet]. Panic disorder in adults: Epidemiology, clinical manifestations, and diagnosis. Wolters Kluwer; 2009 [cited 2023May1]. Available from: https://www.uptodate.com/contents/panic-disorder-in-adults-epidemiology-clinical-manifestations-and-diagnosis
• Recommendations: Generalised anxiety disorder and panic disorder in adults: Management: Guidance [Internet]. NICE ; 2020 [cited 2023 Oct 6]. Available from: https://www.nice.org.uk/guidance/cg113/chapter/Recommendations 
• 1. BMJ best practice. Panic disorders [Internet]. 2023 [cited 2023 Oct 6]. Available from: https://bestpractice.bmj.com/topics/en-gb/121