Panic Disorder

A panic attack is a discrete period of intense fear or discomfort that develops abruptly and peaks within 10 minutes, with four or more of:

• Palpitations, pounding heart, or accelerated heart rate
• Sweating, trembling, or shaking
• Shortness of breath or a smothering sensation; a choking sensation
• Chest pain or discomfort
• Nausea or abdominal distress
• Dizziness, unsteadiness, or feeling faint
• Derealisation (feelings of unreality) or depersonalisation (detachment from oneself)
• Fear of losing control or “going crazy”; fear of dying
• Paraesthesia; chills or hot flushes

Panic attacks are common — around 40% of young people will have at least one spontaneous panic attack at some point.

Panic disorder is recurrent, unexpected panic attacks (without a clear trigger), followed by ≥1 month of persistent concern about further attacks, worry about their consequences, or a significant behavioural change because of them. It’s about three times more common in women than men, has a genetic component (~10% risk in first-degree relatives, 30–40% in twins), and may occur with or without agoraphobia.

The panic cycle

Anxiety/hypervigilance for bodily sensations → sympathetic arousal → physical sensations (dizziness, pounding heart, breathlessness, feeling “unreal”) → catastrophic anxious thoughts (“I’m having a heart attack,” “I can’t breathe”) → more anxiety/arousal, reinforcing the cycle.

Management

Psychoeducation — explain the illness (panic cycle, benign nature of the physical symptoms) in a way that fits the patient’s cultural background and beliefs.

Psychological therapy is first-line:

• Breathing/relaxation exercises — the simplest and often the first effective strategy.
• Cognitive restructuring — identifying unhelpful/inaccurate thoughts and replacing them with more realistic ones through guided reasoning and evidence-gathering.
• Graded exposure — for a specific feared stimulus or trigger (works well for phobias and PTSD too); the trigger is broken into incrementally distressing steps and the patient works through them to decondition the response.
• CBT combined with medication works well short-term, but sustained CBT alone has the best long-term outcomes — set expectations about the commitment required and the practical limits on CBT availability.

Pharmacotherapy — discuss how the medication works and what side effects to expect; for some patients, taking medication feels like relinquishing control, so involve them in the decision.

• SSRIs are first-line. There’s little evidence that TCAs, benzodiazepines, or MAOIs are more effective — but SSRIs have better tolerability and compliance.
• Start low (about half the usual starting dose) and increase slowly to an effective dose over 10–20 days — higher doses are often needed than for depression, and response can take 4–6 weeks, longer than for depression.
• Options: fluvoxamine 100–300 mg, fluoxetine 20–60 mg, citalopram 20–40 mg, sertraline 50–200 mg daily.
• SSRIs can transiently increase anxiety and change the pattern of attacks early on — warn patients about this in advance to reduce alarm. Common side effects: nausea, diarrhoea, tremor, sweating, insomnia or drowsiness, sexual dysfunction.
• Continue treatment 6–12 months, then wean off slowly.
• TCAs (clomipramine or imipramine 25 mg at night, increasing as tolerated by 25–50 mg every 2–3 days to 150 mg, max 300 mg) are effective but have a high drop-out rate from side effects — reserve for non-response to SSRIs.
• MAOIs are effective but reserved for treatment-resistant cases (side effects, need for a tyramine-free diet) — should only be initiated by a psychiatrist.
• Venlafaxine (SNRI, 37.5 mg modified-release) has less evidence than SSRIs specifically for panic disorder, but is an option for patients with a poor response to, or who cannot tolerate, SSRIs.

Benzodiazepines are controversial: moderately effective, but with a high relapse rate on cessation, risk of dependence/withdrawal, and a historical concern about interference with CBT efficacy that current guidance says has since been challenged. Limit use to two situations:

• Severe illness with risk to livelihood/social function, as a temporary bridge — make clear the relief is not curative and shouldn’t be credited over the concurrent definitive treatment.
• Chronic, resistant panic disorder as an augmenting agent alongside antidepressants and CBT with only partial response — only if there’s no history of substance dependence or personality disorder.

If a patient is already on a benzodiazepine at presentation, withdraw slowly over 2–4 months depending on the dose. Some patients keep a dose “on hand” as a safety behaviour even once panic disorder is otherwise well controlled — this itself is worth addressing in therapy.