AKT · Psychiatry/Anxiety & stress

Panic disorder

Overview

Recurrent unexpected panic attacks (abrupt surge of fear peaking within minutes with somatic symptoms) plus ≥1 month of persistent worry about further attacks or maladaptive change in behaviour.

Recognise

Sudden palpitations, chest tightness, dyspnoea, sweating, trembling
Derealisation/depersonalisation, fear of dying or losing control
Anticipatory anxiety; may lead to agoraphobic avoidance

Red flags

First presentation: exclude cardiac/respiratory/endocrine cause before labelling

Differentials & how to tell them apart

GADcontinuous worry rather than discrete attacks

Acute coronary syndrome / arrhythmiamust exclude in new chest pain/palpitations

Hyperthyroidism / phaeochromocytomacheck TFTs; paroxysmal BP

Agoraphobiafear/avoidance of situations with no escape (often coexists)

Investigations

Clinical. Exclude organic: ECG, TFTs, consider phaeochromocytoma if episodic hypertension; assess caffeine/stimulant/substance use.

Management

1CBT is the most effective first-line treatment. Self-help (CBT-based) for milder cases.
2Drug: SSRI first-line. Review at 2 weeks then regularly.Gate: If no improvement after 12 weeks → switch to imipramine or clomipramine (unlicensed)
3Do not use benzodiazepines (associated with worse long-term outcome) or sedating antihistamines/antipsychotics.

SSRI — first-line drug; start low (can transiently worsen anxiety)

Imipramine/clomipramine (TCA) — if SSRI ineffective (NICE)

Key points

Warn that SSRIs may briefly increase anxiety on starting — start low, persist.

Monitor & prognosis

Attack frequency, avoidance/agoraphobia, SSRI tolerability.

Good with CBT; relapse if untreated.

Source: NICE CKS Generalized anxiety/panic / CG113