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Panic Disorder

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ℹ️ About

Panic Disorder is marked by sudden, recurrent, and unexpected panic attacks.
⚡ Panic attacks = intense episodes of fear peaking within minutes, often without warning.
Most common in young adults, with higher prevalence in women.

🧩 Symptoms

Physical: ❤️ Rapid heartbeat, sweating, trembling, breathlessness, chest pain, nausea, dizziness, chills/hot flushes, paraesthesia.
Cognitive: 😰 Fear of losing control, “going mad” or dying; feelings of derealisation/depersonalisation.
Behavioural: 🚪 Avoidance of places associated with attacks; may progress to agoraphobia.

📐 Diagnostic Criteria (DSM-5)

Recurrent, unexpected panic attacks.
At least one attack followed by ≥1 month of:
- Persistent worry about additional attacks or their consequences.
- Significant maladaptive behaviour change (e.g., avoidance).
Not attributable to substances or another medical/mental condition.

⚠️ Risk Factors

🧬 Genetic: Family history of panic/anxiety disorders.
🌪️ Environmental: Trauma, major life stressors.
🧠 Comorbid disorders: Anxiety, depression, substance misuse.
⚙️ Biological: Dysregulated fear circuitry (amygdala, locus coeruleus, serotonin/noradrenaline pathways).

🤝 Comorbidities

😔 Depression – worsens outcomes if untreated.
🚪 Agoraphobia – common, often develops secondarily.
🍷 Substance misuse – alcohol, benzodiazepines, or drugs used maladaptively.

🔎 Investigations

History & examination: Rule out medical causes (e.g., arrhythmia, asthma, hyperthyroidism).
Labs: TFTs, FBC, glucose, U&E as indicated.
Screening tools: 📋 Panic Disorder Severity Scale (PDSS), PHQ-9 for comorbid depression.

🛠️ Management (NICE CG113)

Psychological therapy (first-line):
- 🧠 CBT – challenge catastrophic thoughts, exposure to triggers, reduce avoidance.
- 🎯 Exposure therapy – systematic desensitisation to feared situations.
Pharmacotherapy:
- 💊 SSRIs (e.g., sertraline, paroxetine, fluoxetine) – NICE first-line.
- 🔁 SNRIs (e.g., venlafaxine) if SSRIs unsuitable.
- ⏱️ Benzodiazepines – avoid routine use; only very short-term crisis relief due to dependency risk.
Lifestyle & self-care:
- 🏃 Regular exercise, relaxation techniques, mindfulness.
- ☕ Reduce caffeine, nicotine, alcohol, and recreational drugs.
- 🛏️ Optimise sleep hygiene.
Support: Peer groups, family education, reassurance about benign physical symptoms.

📈 Prognosis

Many respond well to CBT and/or SSRIs, especially with early treatment.
Disorder may be chronic/relapsing if untreated; agoraphobia worsens prognosis.
Combination of therapy + medication often best for moderate–severe cases.

🔗 References

💓 Panic Disorder – Clinical Cases

Case 1 – Recurrent Panic Attacks Misinterpreted as Cardiac Disease A 39-year-old woman presents repeatedly to A&E with chest tightness, palpitations, breathlessness, and a sense of impending death. Each episode peaks within minutes and resolves spontaneously. ECG, troponin, and chest X-ray are normal. She worries constantly about having a heart attack and avoids driving alone. Teaching point: Classic panic attacks cause sudden, intense fear with autonomic symptoms and no cardiac pathology. Diagnosis: panic disorder when recurrent attacks lead to anticipatory anxiety or avoidance. Treatment: psychoeducation, CBT, graded exposure, and SSRI (sertraline or escitalopram). Avoid benzodiazepines long-term.

Case 2 – Panic Disorder in Primary Care A 28-year-old teacher describes “waves of fear” during staff meetings with palpitations, trembling, and dizziness. She fears embarrassment and now avoids confined spaces. Screening: GAD-7 = 8, PHQ-9 = 4, panic disorder screen positive. No substance misuse. Teaching point: Panic disorder can become secondary to agoraphobia as patients avoid situations where escape feels difficult. Management: CBT focusing on cognitive restructuring and interoceptive exposure. SSRIs if psychological therapy insufficient or unavailable. Encourage caffeine reduction and relaxation breathing.

Case 3 – Panic Disorder with Depression and Alcohol Use A 52-year-old man presents with panic attacks, early-morning anxiety, and self-medicating with alcohol. He describes low mood, poor sleep, and fear of “losing control” during meetings. No psychosis or suicidal ideation. Teaching point: Comorbidity with depression and alcohol misuse is common. Treat alcohol dependence first, then address panic symptoms with combined therapy. SSRIs are first-line once detoxified; refer for CBT. Short-term beta-blockers can help tremor and tachycardia during early treatment.

💡 Clinical pearl: Panic disorder is characterised by recurrent, unexpected panic attacks plus fear of further episodes. Differentiate from GAD (persistent worry) and situational phobia (triggered only by one cue). CBT remains the most effective long-term therapy. 🌿

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