22nd February 2024

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