14th February 2025

Panic disorder

A panic attack is an acute episode of intense fear which develops quickly and reaches its peak in approximately 10 minutes. It rarely lasts more than an hour. It may be out of the blue, triggered by specific situations, or occur during sleep. It is characterised by both physical and cognitive symptoms of anxiety.

Panic disorder describes when panic attacks occur repeatedly and are not due to psychiatric or medical conditions or substance misuse.

Epidemiology and aetiology of panic disorder

Panic attacks are common, with a lifetime prevalence of 5-10%. Fewer meet the criteria for panic disorder. There are two incidence peaks, at 15-24 and 45-54 years.

Risk factors include family history, female gender, Caucasian ethnicity, being widowed, divorced or separated, urban living, lower educational attainment, early loss of a parent, and being a victim of physical or sexual abuse.

Presentation and diagnosis of panic disorder

Common features of a panic attack are palpitations, tachycardia, dyspnoea, trembling, chest pain, gastrointestinal upset, presyncope, paraesthesia, fear of losing control, and fear of impending harm or death. Patients may repeatedly present to medical services. There is a risk of impulsive suicide or self harm as a coping mechanism.

For panic disorder to be diagnosed, attacks must recur over a period of at least 1 month. There may be avoidance behaviours to evade triggering situations.

Usually, the history is sufficient to make a diagnosis. Organic causes may need to be ruled out with ECG, blood glucose, thyroid function tests and drug testing.

Management of panic disorder

Cognitive behavioural therapy (CBT) is first line, with the potential addition of a selective serotonin reuptake inhibitors (SSRI) (e.g. sertraline) or serotonin noradrenaline reuptake inhibitors (SNRI) (e.g. venlafaxine) for longer-term management. Second line is an alternate antidepressant such as a tricyclic antidepressant (TCA), monoamine oxidase inhibitor (MAOI) or bupropion, although these are rarely used.

Benzodiazepines are not recommended by NICE but can be used as an acute treatment or as an interim measure whilst an antidepressant is taking effect.