Panic disorder

Panic Disorder is an anxiety disorder characterized by recurrent, unexpected panic attacks accompanied by persistent concern about future attacks or maladaptive behavioural changes aimed at avoiding them.

A panic attack is a sudden episode of intense fear or discomfort that reaches peak intensity within minutes and occurs often without an identifiable trigger. Patients frequently experience a sense of impending doom, fear of death, or fear of losing control.

Although panic attacks are self-limiting, recurrent episodes may significantly impair occupational, social, and psychological functioning.

Risk Factors

• Family history of anxiety or panic disorder

• Female gender

• Chronic stress exposure

• Childhood trauma or abuse

• Major life transitions or losses

• Personality traits (high anxiety sensitivity)

• Substance misuse (caffeine, alcohol, stimulants)

• Coexisting depression or anxiety disorders

• Medical illnesses affecting cardiovascular or endocrine systems

Signs and Symptoms

Psychological Symptoms

• Sudden intense fear or terror

• Feeling of impending danger or death

• Fear of losing control or going insane

• Derealization or depersonalization

Physical Symptoms

• Rapid pulse or palpitations

• Shortness of breath

• Chest discomfort

• Dizziness or light-headedness

• Sweating

• Trembling

• Choking sensation

• Nausea

• Paresthesia

• Hot or cold sensations

Symptoms typically:

• Peak within 10 minutes

• Resolve within 20–30 minutes

• Occur unexpectedly

Diagnostic Criteria

Diagnosis is clinical and requires:

• Recurrent unexpected panic attacks

• Episodes characterized by intense fear and emotional discomfort

• Rapid onset with peak intensity within minutes

• Associated physical symptoms such as:

  • Palpitations

  • Shortness of breath

  • Dizziness

  • Sweating

• Persistent concern about additional attacks or behavioural avoidance lasting ≥1 month

• Symptoms not attributable to medical illness, substances, or another psychiatric disorder

Investigations

Investigations are performed primarily to exclude medical causes.

Recommended Evaluation

• Full clinical history and examination

• Mental status assessment

• Suicide risk assessment

Laboratory Tests

• Thyroid function tests (exclude thyrotoxicosis)

• Blood glucose

• Electrolytes

• Full blood count

Cardiorespiratory Assessment

• ECG (arrhythmia exclusion)

• Chest evaluation if respiratory disease suspected

Differential Diagnoses

• Acute coronary syndrome

• Asthma attack

• Pulmonary embolism

• Hyperthyroidism

• Hypoglycaemia

• Substance intoxication or withdrawal

Management

Management aims to:

• Control acute panic symptoms

• Prevent recurrence

• Reduce anticipatory anxiety

• Restore functional ability

Non-Pharmacological Management

Psychoeducation

• Explanation of panic mechanism

• Reassurance regarding non-life-threatening nature

• Identification of triggers

Psychotherapy (First-Line Long-Term Treatment)

• Cognitive Behavioural Therapy (CBT)

• Exposure therapy

• Relaxation training

• Breathing retraining

• Stress management techniques

Psychotherapy significantly reduces relapse rates.

Pharmacological Management

Acute Panic Attack Management

Initial goal: symptom control and exclusion of medical emergencies.

Benzodiazepines

• Diazepam 5 mg orally stat, repeat if necessary

OR

• Lorazepam 2 mg orally stat, repeat if necessary

OR

• Clonazepam 1 mg orally stat, repeat if necessary

Use short-term only due to dependence risk.

Long-Term Treatment of Panic Disorder

Selective Serotonin Reuptake Inhibitors (First-Line)

Fluoxetine

• 20–40 mg orally daily

OR

Citalopram

• 10–40 mg orally daily

Tricyclic Antidepressant

Amitriptyline

• 25–75 mg orally at night

Treatment Principles

• Start at low dose

• Gradually titrate based on tolerability

• Initial worsening of anxiety may occur

• Short-term benzodiazepine co-administration may be considered

• Minimum treatment duration: 6–12 months

• Long-term therapy may be required

• Gradual discontinuation recommended

Complications

• Agoraphobia

• Major depressive disorder

• Substance misuse

• Social withdrawal

• Occupational impairment

• Increased suicide risk

Prevention

• Early recognition of anxiety symptoms

• Stress reduction strategies

• Limiting stimulant intake (caffeine)

• Psychological resilience training

• Continued follow-up after recovery

• Adherence to maintenance therapy

Prognosis

With appropriate treatment combining psychotherapy and pharmacotherapy, most patients experience substantial improvement. Relapses may occur, particularly following premature discontinuation of treatment.

Patient Education

• Panic attacks are frightening but not dangerous

• Symptoms result from anxiety-related body responses

• Avoidance behaviours worsen long-term outcomes

• Medication effectiveness may take several weeks

• Consistent therapy reduces recurrence