Related to this topic: Leaflets | Support | Patient+ | UK Guidelines | News | Weblinks | Medicines | Poem/Story | Equipment | Books | Your Experience | Other resources | Glossaries
Print options:
Other options:
(what's this?)
PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.
Panic Disorder and its Management
Panic disorder is a distressing form of anxiety characterised by unexpected panic attacks (with intense fear), which may be associated with situational avoidance. The first panic attack my be associated with a stressful episode but gradually the attacks become dissociated and occur "out of the blue". It is a chronic condition with relapses and leads to much distress and social dysfunction.1 GABA receptor dysfunction is thought to play an important role in panic disorder pathophysiology, but there are also important genetic and environmental factors involved.
Panic disorder can also be associated with the use of certain medications: SSRI's, benzodiazepine withdrawal and withdrawal from zopiclone. These should be considered in assessing any patient who presents with panic disorder.
- Lifetime prevalence between 1 - 3 % (one of the commonest psychiatric disorders).
- Familial tendency.
- Bimodal peak in age of onset - late adolescence and mid thirties.2
A panic attack is usually unexpected and involves intense symptoms (usually sympathetic system activation) that peak within 10 minutes. For panic disorder need at least four of the following:2
- Chills or hot flushes
- Dizzy or light headed
- Paraesthesia
- Trembling
- Fainting
- Chest discomfort
- Palpitations
- Sweating
- Breathlessness
- Choking sensation
- Nausea
- Abdominal pain
- Derealisation / depersonalisation
- Fear of losing control
- Fear of impending death
Diagnosis of a panic disorder requires recurrent panic attacks which are unexpected and lead to any one of the following
- Anticipatory anxiety - persistent concern about having a further attack.
- Concern regarding implication of an attack or its outcome.
- Making significant changes in behaviour as a result of the attacks, usually to avoid the situations which are likely to result in an attack (agoraphobia).
Most commonly, panic disorder presents with agoraphobia e.g. avoiding being far from home, avoiding going to new places where may not be able to exit readily or avoidance of driving.2
- Commonly unrecognised and untreated.
- Most patients are seen in general practice, although patients may present to A & E with somatic symptoms e.g. chest pain.
- Due to the physical symptoms the diagnosis of panic attacks may not be made. Therefore, a high index of suspicion is needed. Screening tools are available.3,4
- Panic attacks should not be diagnosed until other organic conditions have been excluded, although a good description of the attack is often sufficient.
- It is also important to remember that panic attacks may be a feature of other psychiatric diagnoses e.g. schizophrenia and depression.
- Full medical history (differential diagnoses include hyperthyroidism, Cushing's disease, neurological disorders).
- Full psychiatric history, including suicidal ideation.2
- Substance abuse (also ask about over the counter and herbal remedies).
- Full physical examination.
- Baseline investigations based on findings.g. ECG and ECHO and/or stress test for chest pain, cardio memo for palpitations.
Patient education
- Avoidance of agoraphobia.
- Avoid anxiety-provoking substances e.g. caffeine.
Try to involve family or carers if patient allows.
Cognitive behavioural therapy, followed by SSRIs and then self help are best, in descending order, at achieving the longest symptom free period.2,5
Pharmacological
- Selective serotonin reuptake inhibitors:
- Tricyclic antidepressants (TAD):
- Examples include: imipramine (most studied), clomipramine or nortriptyline. These are second line and should be used if SSRIs can not be used or if no response with SSRIs after 12 weeks.
- Takes 3 -4 weeks for onset of action and usually need six months therapy.
- Side effects are common and this can result in poor compliance e.g. anticholinergic side effects (dry mouth and constipation) or postural hypotension.
- For maximum benefit from TAD's complementary treatment for agoraphobia is necessary; where patients face the situations that lead to panic attacks.
- Benzodiazepines:
- Anti-histamines:
- These have been used but their sedative side effect limits their use.
- Also their efficacy in panic attacks has not been well established.
- They are therefore not currently recommended in the treatment of panic disorder.2
- Beta blockers:
- Current experimental therapies:
- Agents that increase GABA concentrations in the central nervous system, such as vigabatrin and tiagabine, have been shown to reduce panic attacks and anxiety in experimentally induced panic attacks.8
- Also Buspirone has been used in chronic anxiety with good outcome - it also has the added benefit of not causing dependence nor tolerance.8
Non-pharmacological
- Relaxation techniques: this usually involves learning coping strategies and there is evidence that this is an effective method of treatment for panic disorders. However, this benefit has only really been demonstrated in patients without agoraphobia.9
- Education and supportive therapy: this can involve exposure therapy e.g. therapist accompanied or self exposure. However, exposure techniques can be very distressing for the patient.10
- Cognitive and behavioural therapy and their combination: this involves cognitive therapy and interoceptive exposure where by changes in pulse rate and breathing that occur with panic attacks are identified and attempts at stopping these are made. Cognitive-behavioural therapy (CBT) in panic disorder has had good results, for example, in one trial of 8 weeks of CBT, at six months follow up more than 60% of patients had not relapsed. These benefits are seen both in group and individual based CBT.11
- Insight orientated psychotherapy.
- Review at two weeks - looking for side effects.
- Review again at 4, 6 and 12 weeks.2
- If improvement at 12 weeks continue for 6 months and then consider gradual dose reduction with a plan to discontinue medication.
- If no improvement at 12 weeks try TAD.
- If no response despite trial of SSRIs or TADs then refer to specialist mental health services.
- Self-complete questionnaires should be used to assess outcomes.12
Document References
- Saeed SA, Bruce TJ; Panic disorder: effective treatment options.; Am Fam Physician. 1998 May 15;57(10):2405-12, 2419-20. [abstract]
- NICE Guidance, Anxiety (including panic disorder), 2004, downloadable pdf
- Farvolden P, McBride C, Bagby RM, et al; A Web-based screening instrument for depression and anxiety disorders in primary care.; J Med Internet Res. 2003 Jul-Sep;5(3):e23. Epub 2003 Sep 29. [abstract]
- Stein MB, Roy-Byrne PP, McQuaid JR, et al; Development of a brief diagnostic screen for panic disorder in primary care.; Psychosom Med. 1999 May-Jun;61(3):359-64. [abstract]
- Taylor CB; Panic disorder.; BMJ. 2006 Apr 22;332(7547):951-5.
- Gliatto MF; Generalized anxiety disorder.; Am Fam Physician. 2000 Oct 1;62(7):1591-600, 1602. [abstract]
- Ninan PT; Recent perspectives on the diagnosis and treatment of generalized anxiety disorder.; Am J Manag Care. 2001 Sep;7(11 Suppl):S367-76. [abstract]
- Zwanzger P, Rupprecht R; Selective GABAergic treatment for panic? Investigations in experimental panic induction and panic disorder.; J Psychiatry Neurosci. 2005 May;30(3):167-75. [abstract]
- Ost LG, Westling BE; Applied relaxation vs cognitive behavior therapy in the treatment of panic disorder.; Behav Res Ther. 1995 Feb;33(2):145-58. [abstract]
- Park JM, Mataix-Cols D, Marks IM, et al; Two-year follow-up after a randomised controlled trial of self- and clinician-accompanied exposure for phobia/panic disorders.; Br J Psychiatry. 2001 Jun;178:543-8. [abstract]
- Telch MJ, Lucas JA, Schmidt NB, et al; Group cognitive-behavioral treatment of panic disorder.; Behav Res Ther. 1993 Mar;31(3):279-87. [abstract]
- Chambless DL, Caputo GC, Bright P, et al; Assessment of fear of fear in agoraphobics: the body sensations questionnaire and the agoraphobic cognitions questionnaire.; J Consult Clin Psychol. 1984 Dec;52(6):1090-7.
Internet and Further Reading
- No Panic; Help group for patients
- APA Online - patient advice
- The National Phobics' Society
- Barlow DH, Craske MG. Mastery of your anxiety and panic (MAP-3). Client workbook for anxiety and panic.3rd ed. Oxford: Oxford University Press, 2000 used in evidenced based trials
DocID: 27
Document Version: 2
DocRef: bgp26084
Last Updated: 13 Aug 2007
Review Date: 12 Aug 2008
Disclaimer: Patient UK has no control of the content of the above links. Inclusion does not imply endorsement by Patient UK.
Related pages in Patient UK
Your Experience (^ top of page)
Please add your experience about this condition / medicine
View patient experiences and discussions about this condition / medicine (39 there)Information leaflets related to this topic (^ top of page)
Antidepressants - SSRIs
Antidepressants - Tricyclic
Bedwetting - Medicine Treatments
Benzodiazepines
Benzodiazepines - Stopping After Long Term Use
Cognitive Behaviour Therapy (CBT)
Panic - A Self Help Guide
Panic Attack
Panic Disorder (Recurring Panic Attacks)Patient Support related to this topic (^ top of page)
BCNC - Benzodiazepines Co-operation Not Compensation
Benzo.org.uk (benzodiazepine addiction)
National Phobics Society
No More Panic
No Panic
Northumberland, Tyne and Wear Patient Information Centre
Stresswatch ScotlandMedical reference articles in PatientPlus related to this topic (^ top of page)
Benzodiazepine Dependence
Benzodiazepines
Cognitive and Behavioural Therapies
Insomnia
Managing Depression
Neuroleptic Malignant Syndrome
Panic Disorder
Psychotherapy and its Uses
Selective Serotonin Reuptake Inhibitors (SSRIs)
Serotonin Syndrome
Tricyclic and Related Antidepressants
Who Benefits From Antidepressants?UK guidelines related to this topic (^ top of page)
Guidelines on Cognitive Behavioral Therapy
Guidelines on Panic Disorder
Guidelines on BenzodiazepinesRecent news items related to this topic (^ top of page)
Therapy: now you're talking
Spring clean your mindLinks to other selected websites related to this topic (^ top of page)
Cognitive Behaviour Therapy (CBT)
Panic AttacksMedicines related to this topic (^ top of page)
PropranololPoems and stories related to this topic (^ top of page)
Got to DashOther - Useful resources (^ top of page)
Pictures, diagrams, photos, images, etc.Evidence based medicine
Online textbooks and journals
A-Z of UK Guidelines
A-Z of Online Videos
Medline
Other good health sites
Medical equipment products related to this topic (^ top of page)
Pill/Tablet Equipment
Books related to this topic (^ top of page)
Anxiety & Panic Attacks : British Medical Association's Family Doctors Series
Anxiety: Self-Help Programme (Overcoming)
Child's Fears and Worries (Overcoming: Your)
Cognitive Behavioural Therapy for Dummies
Coping Successfully with Panic Attacks
Depersonalization and Feelings of Unreality (Overcoming)
Low Self-Esteem: Self-Help Course (Overcoming)
Manage You Mood: Using Behavioural Activation to Manage Your Mood
Overcoming Panic
Panic (Overcoming)
Panic Attacks (Coping Successfully with)
Panic Attacks (Understanding and Overcoming Fear)
Panic Disorder. The Facts
Reason to Change: A Rational Emotive Behaviour Therapy Workbook
Relationship Problems (Overcoming)
Social Anxiety and Shyness (Overcoming)
Stress (Overcoming)
Understanding Panic Attacks and Overcoming Fear
Want to search some more? Use the Google Search box below to search our site.

Would you like to try our advanced on-line knowledge support system designed to provide professionals with relevant up to date information about recognition and management of disease or take the Mentor Challenge?
Disclaimer: Patient UK has no control of the content of the above links. Inclusion does not imply endorsement by Patient UK.
