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OverviewAetiologyPathophysiologyClinical features and red flagsInvestigationsDifferential diagnosisManagementComplicationsMonitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Panic disorder and agoraphobia

Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Panic-like symptoms with possible physical emergency

First or atypical severe chest pain, syncope, hypoxia, focal neurology, arrhythmia, anaphylaxis, hypoglycaemia, intoxication or withdrawal must be assessed as a possible medical emergency rather than assumed to be another panic attack.

Action: Use ABCDE, observations, bedside glucose, focused cardiovascular and neurological assessment and an ECG when indicated. Treat the suspected physical syndrome, assess suicide and substance risk, and only return to a panic formulation once immediate danger is addressed.

Overview

Identify recurrent panic attacks and avoidance driven by fear of panic or unavailable escape, exclude urgent physical mimics, and deliver evidence-based CBT or antidepressant treatment without reinforcing avoidance or benzodiazepine dependence.

During a panic attack, symptoms rise quickly and can include palpitations, sweating, tremor, breathlessness, chest discomfort, nausea, dizziness, chills or heat, tingling, derealisation, fear of losing control and fear of dying. Ask whether attacks are unexpected, what the person fears the sensations mean, and what changed afterwards. Panic disorder is not diagnosed from one attack: recurrent unexpected attacks are followed by at least one month of continuing concern or maladaptive behavioural change. Identify nocturnal attacks, anticipatory anxiety, emergency attendance and reliance on companions, exits, water or pulse checking.

Agoraphobic avoidance may include public transport, crowds, queues, enclosed or open places and being outside home alone. The organising fear is that escape or assistance would be difficult if symptoms arose, not simply dislike of crowds. Map what is avoided, endured with distress or managed only with a companion and how this restricts care, work and relationships. Social anxiety instead concerns scrutiny or negative evaluation; specific phobia is tied to a circumscribed stimulus; PTSD avoidance is anchored to trauma reminders.

Aetiology

01

Biological vulnerability

Sensitivity to autonomic sensations and familial vulnerability can increase the probability that benign arousal is experienced as threatening.

02

Learning after attacks

A frightening spontaneous or situational attack can condition fear of bodily sensations and of settings associated with escape difficulty.

03

Stress and substances

Sleep loss, major stress, stimulants, cannabis and alcohol or sedative withdrawal can precipitate attacks and complicate the subsequent course.

Pathophysiology

  1. 1
    Catastrophic feedback

    A benign sensation is interpreted as dangerous, increasing arousal and producing stronger sensations that appear to confirm the feared explanation.

  2. 2
    Conditioned interoceptive fear

    Internal cues such as breathlessness or dizziness become learned predictors of catastrophe even when their original trigger is absent.

  3. 3
    Avoidance reinforcement

    Escape and safety behaviours reduce fear immediately but prevent disconfirmation, strengthening future anticipatory anxiety and situational restriction.

Clinical features and red flags

Abrupt panic surge

Intense fear peaks rapidly with several bodily and cognitive symptoms rather than remaining as a steady background level of worry.

Catastrophic interpretation

Palpitations, breathlessness or dizziness is interpreted as imminent death, collapse, suffocation, loss of control or insanity.

Post-attack change

Persistent concern, body monitoring, emergency reassurance or avoidance develops after recurrent unexpected attacks and sustains disability.

Agoraphobic pattern

Travel, crowds or leaving home alone is feared because rapid escape or reliable help seems unavailable if symptoms occur.

Changed medical phenotype

Exertional symptoms, syncope, sustained arrhythmia or objective neurological or respiratory abnormality requires renewed physical assessment.

Red flags requiring action

  • Exertional or persistent chest pain, syncope, irregular pulse, hypoxia or new cardiovascular risk requires urgent medical assessment even when previous attacks were panic.
  • Focal neurological signs, seizure, fever, altered attention or a sudden maximal headache is not explained by uncomplicated panic disorder.
  • Suicidal intent, dangerous escape behaviour, inability to leave home for essential care or severe self-neglect requires urgent mental-health and safeguarding action.

Investigations

  1. 01
    Attack chronology and formulationFirst step
    Why
    Document onset, peak, symptoms, triggers, meaning, recurrence, anticipatory fear and behavioural change.
    Interpretation and limitations
    Unexpected recurrent attacks with continued concern or avoidance support panic disorder; predictable cue-bound attacks may fit another anxiety condition.
  2. 02
    Agoraphobia functional map
    Why
    Identify feared settings, accompaniment, escape plans, safety behaviours and resulting restriction.
    Interpretation and limitations
    Fear linked to unavailable escape or help distinguishes agoraphobia from social judgement, trauma reminders and ordinary access barriers.
  3. 03
    Focused physical examination
    Why
    Assess cardiovascular, respiratory, endocrine, neurological and acute physiological explanations.
    Interpretation and limitations
    Objective abnormality or atypical timing broadens investigation; a normal examination supports but does not by itself establish panic disorder.
  4. 04
    Indication-based ECG and tests
    Why
    Investigate palpitations, syncope, hypoglycaemia, anaemia, thyroid or respiratory clues when present.
    Interpretation and limitations
    Testing should answer a clinical question; repeated normal tests after an unchanged typical syndrome can inadvertently reinforce health anxiety.
  5. 05

Differential diagnosis

01

Cardiopulmonary or endocrine disease

Arrhythmia, ischaemia, asthma, pulmonary embolism, hypoglycaemia and thyroid disease require targeted assessment when phenotype and risk indicate.

02

Other anxiety disorder

Cue-specific phobia, social evaluation, obsessions or trauma reminders may provoke panic attacks without constituting panic disorder.

03

Substance or medicine effect

Caffeine, stimulants, cannabis, corticosteroids, intoxication and withdrawal can cause attacks and may need treatment before diagnostic certainty.

Management

01Acute episodeCheck danger and reduce escalationFirst stepEscalationA person presents during an intense panic-like episode.+
  1. 1Assess physiological stability and changed or atypical features before applying a previous panic label, using targeted tests when indicated.
  2. 2Explain observed findings calmly, encourage slower regular breathing without forced deep breaths, and avoid repeated unneeded reassurance loops.
  3. 3After symptoms settle, review triggers, catastrophic meaning, escape behaviour, substances and suicide risk and arrange active treatment rather than emergency-only care.
02CBT routeTest sensations and avoided situationsPanic disorder or agoraphobia is established and psychological treatment is chosen.+
  1. 1Build a collaborative cycle linking bodily sensation, catastrophic interpretation, fear, safety behaviour and short-term relief.

Complications

01

Progressive avoidance

Travel and independent activity can contract until work, education, appointments and ordinary care become inaccessible without another person.

02

Depression and self-harm

Chronic restriction and recurrent terror can produce hopelessness, depressive illness and suicide risk that requires direct longitudinal review.

03

Iatrogenic dependence

Repeated rescue benzodiazepine use or reassurance-driven investigations can maintain fear, create withdrawal symptoms and obscure effective psychological learning.

Monitoring and follow-up

  • Review within two weeks of starting a new antidepressant and make the first review earlier when individual suicide risk or emerging activation warrants it; ask directly about agitation, akathisia and self-harm.
  • During CBT, track catastrophic belief, safety behaviours, avoided situations and independent functional range rather than attack count alone.
  • Review medication effectiveness, adverse effects, adherence and substance exposure at two, four, six and twelve weeks in the early treatment phase.
  • If medication is effective, maintain it for at least six months after the optimal dose has been reached and discuss a gradual individual taper.
  • Reassess physical causes when the attack phenotype changes, objective signs appear or symptoms become exertional, prolonged or associated with syncope.

Special situations

Panic is time limited

The attack surge resolves even without escape, and remaining in a safe situation can provide corrective evidence about feared catastrophe.

Safety behaviours obscure learning

Always sitting by an exit or carrying rescue objects allows improvement to be attributed to protection rather than to the situation's safety.

Interoception can be exposure

Supervised exercises that evoke benign sensations test beliefs about dizziness, breathlessness or palpitations when medically appropriate.

Agoraphobia is about escape

The same bus or shop may be manageable with a companion, revealing feared inability to escape or obtain help rather than the place itself.

Common pitfalls

  1. 01

    Calling every episode of palpitations panic without checking atypical, exertional or objective physical features.

  2. 02

    Repeatedly ordering emergency tests for an unchanged assessed syndrome while offering no active panic treatment.

  3. 03

    Teaching relaxation as an escape ritual that must eliminate sensations before the person can remain in a situation.

  4. 04

    Prescribing benzodiazepines for ongoing panic despite their poorer long-term outcome and dependence risk.

  5. 05

    Starting an antidepressant at a high dose without warning that early anxiety can temporarily increase.

Practice

Two practice questions

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Question 1 of 2
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PsychiatryOriginal SBA

Panic-focused CBT dose

An adult with recurrent unexpected panic attacks and agoraphobic avoidance chooses psychological treatment. Which course most closely matches NICE guidance for panic-focused CBT?

Choose one answer, then submit
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE CG113 GAD and panic disorder recommendationsPanic diagnosis, CBT duration, antidepressant use and treatments not recommended.
  • NICE panic disorder treatment informationPatient-facing CBT and medication sequence and duration.
  • NHS panic disorder overviewCurrent UK recognition information, including the one-month persistence threshold after recurrent unexpected attacks.
  • Sertraline tablets summary of product characteristicsLicensed panic-disorder starting dose, titration, maximum dose and safety information.
  • NICE NG215 dependence and withdrawal recommendationsAvoiding abrupt withdrawal and planning gradual antidepressant or dependence-forming medicine reduction.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom

A new presentation still needs proportionate physical assessment. Establish onset, duration, triggers, exertional relationship, pregnancy possibility, prescribed medicines, caffeine and other stimulants, cannabis, alcohol and sedative withdrawal. Examination and tests follow the phenotype: observations and ECG may be appropriate for palpitations or syncope, while glucose, blood tests or respiratory assessment are selected from history. Once a typical recurrent syndrome has been assessed, explain the panic cycle and avoid reflexively repeating investigations unless symptoms materially change.

For mild to moderate panic disorder, offer individual non-facilitated or facilitated self-help. For moderate to severe disorder, consider panic-focused CBT from a trained supervised practitioner; treatment develops an individual formulation, tests catastrophic interpretations through behavioural experiments and interoceptive exposure, and approaches avoided situations while dropping safety behaviours. NICE specifies seven to fourteen total hours, usually weekly one- to two-hour sessions completed within four months. If the disorder is long-standing, or psychological treatment is declined or has not helped and medication is preferred, discuss a licensed SSRI, delayed benefit, early activation, withdrawal and overdose safety. Continue an effective antidepressant for at least six months after the optimal dose is reached before gradual tapering.

Key points

  • A panic attack is an abrupt surge of intense fear or discomfort with autonomic, respiratory, cognitive and dissociative symptoms; panic disorder adds recurrent unexpected attacks followed by at least one month of persistent concern or maladaptive behavioural change.
  • Agoraphobia concerns fear and avoidance of situations where escape or help may seem difficult if panic-like or incapacitating symptoms occur; it may accompany or occur without panic disorder.
  • Diagnose clinically after a focused physical, substance and medicine assessment; repeated emergency testing without a changed phenotype can reinforce health fear.
  • For mild to moderate panic disorder, NICE offers individual non-facilitated or facilitated self-help; for moderate to severe disorder, consider panic-focused CBT or, when the disorder is long-standing or psychological treatment is declined or has not helped, an antidepressant.
  • Panic-focused CBT normally comprises seven to fourteen total hours in weekly one- to two-hour sessions completed within four months.
  • Antidepressants are the only pharmacological intervention NICE recommends for longer-term panic management; begin at a low dose, explain transient activation and titrate slowly.
  • Benzodiazepines are associated with a poorer long-term outcome and should not be prescribed for panic disorder; sedating antihistamines and antipsychotics are also not recommended.
Agitation with tremor, sweating, vomiting, perceptual change or seizures after reducing alcohol or sedatives suggests potentially dangerous withdrawal.
Mood, substance and risk review
Why
Detect depression, suicide risk, stimulant exposure, alcohol or sedative withdrawal and medicine effects.
Interpretation and limitations
A comorbid or causal problem may change urgency and treatment sequence even when panic attacks are also present.
2
Use planned behavioural experiments, interoceptive exposure and graded real-world exposure while reducing checking, escape and companion dependence.
  • 3Measure attack concern and functional range, review learning after each task and plan relapse practice within the seven- to fourteen-hour course.
    • 03Medication routeStart low and review deliberatelyPanic disorder is long-standing, or psychological treatment has been declined or has not helped, and the adult prefers medication.+
    1. 1Choose one licensed antidepressant after reviewing previous response, suicide and overdose risk, bipolar history, interactions and withdrawal burden.
    2. 2Begin at the product-specific low starting dose, explain that anxiety may transiently increase, and arrange early review before gradual titration.
    3. 3Assess benefit at about twelve weeks, continue effective treatment for at least six months after the optimal dose is reached, then taper gradually.
    Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
    A licensed SSRI option for longer-term panic treatment when medication is selected after discussion of CBT and individual risks.

    Sertraline oral

    For adult panic disorder with or without agoraphobia, give 25 mg by mouth once daily for one week, then 50 mg once daily; increase by 50 mg at intervals of at least one week to a maximum of 200 mg daily if required.

    Monitor early activation, akathisia, suicidal thinking, mania, bleeding, hyponatraemia, sexual dysfunction and serotonin toxicity; review interacting serotonergic medicines and taper in stages rather than stopping abruptly.

    Exposure targets feared bodily sensations and avoided situations while reducing escape, checking and safety behaviours so that new learning can occur.