Mental Health

Panic disorder

Panic disorder is recurrent unexpected panic attacks followed by at least a month of persistent concern or maladaptive behavioural change, with ongoing functional impact and no better physical, substance-related or mental-health explanation.

In a nutshell

Panic disorder is recurrent unexpected panic attacks followed by at least a month of persistent worry about further attacks or maladaptive behavioural change. Assess physical and psychiatric mimics without anchoring or repeated low-yield testing. Use stepped care: CBT-based self-help for milder disorder, focused CBT for moderate or persistent symptoms, and an SSRI licensed for panic disorder when medication is chosen. Explain initial activation and withdrawal; do not use benzodiazepines, sedating antihistamines or antipsychotics for treatment.

Classic presentation

A person has sudden, unexpected attacks of palpitations, breathlessness, chest discomfort, dizziness and fear of dying that peak within minutes, then develops at least a month of worry and avoidance. Assess red flags and comorbidity before treating the panic cycle with CBT and, if chosen, an SSRI.

Key points

Diagnosis requires recurrent unexpected attacks plus at least a month of persistent concern or maladaptive behavioural change, not one isolated attack.
A first, exertional, prolonged or atypical attack needs focused physical assessment; normal targeted tests support but do not alone prove panic disorder.
Mild to moderate disorder: offer individual CBT-based self-help; moderate, severe or persistent disorder: offer CBT or an antidepressant according to preference and circumstances.
CBT should use an evidence-based panic protocol, usually 7 to 14 hours over a maximum of 4 months.
If medication is chosen, offer an SSRI licensed for panic disorder; if unsuitable or ineffective after a 12-week course, imipramine or clomipramine may be considered.
Warn about transient activation, delayed benefit and discontinuation symptoms; monitor suicidality, particularly in people under 30.
Do not prescribe benzodiazepines, sedating antihistamines or antipsychotics for panic disorder; refer to specialist mental health services after two unsuccessful interventions.

First-line investigation

Clinical history, mental-state examination and focused physical assessment, with ECG, glucose, thyroid or other tests only when indicated by symptoms, examination, risk or medication and substance exposure.

Management

Assess, explain and safety-net

Confirm recurrent unexpected attacks and at least a month of concern or behavioural change; assess physical red flags, depression, suicide risk, agoraphobia, substances, caffeine, medicines and function.^1,2
Use a focused examination and targeted tests when indicated; do not dismiss first, exertional, prolonged or atypical chest or neurological symptoms as panic.^1,2

Use CBT-based stepped care

Mild to moderate: offer individual facilitated or non-facilitated self-help based on CBT. Moderate, severe or persistent: offer focused CBT or an antidepressant according to preference and risk.^1,2
Focused CBT targets catastrophic interpretation, interoceptive fear, avoidance and safety behaviours and is usually delivered over 7 to 14 hours within 4 months.¹

Use medication carefully

If medication is chosen, offer an SSRI licensed for panic disorder; discuss initial activation, delayed benefit, overdose risk, interactions and withdrawal. If unsuitable or ineffective after 12 weeks, consider imipramine or clomipramine with specialist prescribing checks.^1,3
Do not prescribe benzodiazepines, sedating antihistamines or antipsychotics for panic disorder; assess and safely manage existing dependence rather than abruptly stopping sedatives.^1,3

Review function and refer when refractory

Monitor attacks, anticipatory anxiety, avoidance, agoraphobia, mood, self-harm risk, substance use, adherence and adverse effects; taper antidepressants gradually when stopping.^1,3
After two unsuccessful interventions, offer specialist mental-health referral for holistic reassessment, formulation, comorbidity treatment and risk management.¹

Exam traps

One panic attack is not panic disorder: persistent concern or maladaptive behavioural change must follow recurrent unexpected attacks.
Do not anchor on panic with exertional chest pain, syncope, hypoxia, abnormal observations, focal neurology or a first atypical presentation.
CBT targets catastrophic interpretation, safety behaviours and avoidance; reassurance and repeated normal tests do not treat the maintaining cycle.
Offer an SSRI licensed for panic disorder for longer-term drug treatment; sertraline is not a universal shortcut for every panic patient.
Do not use benzodiazepines, sedating antihistamines or antipsychotics for panic disorder.
Warn about initial anxiety or agitation, delayed benefit and withdrawal symptoms; monitor suicidality and self-harm risk in younger adults.
Agoraphobia may coexist but is not required; reassess if avoidance becomes the dominant disabling problem.

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.