Synopsis
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.
- 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.
- Exposure targets feared bodily sensations and avoided situations while reducing escape, checking and safety behaviours so that new learning can occur.
Key red flags
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.
Agitation with tremor, sweating, vomiting, perceptual change or seizures after reducing alcohol or sedatives suggests potentially dangerous withdrawal.
Investigation priorities
Document onset, peak, symptoms, triggers, meaning, recurrence, anticipatory fear and behavioural change.
Management branches
A person presents during an intense panic-like episode.
- Assess physiological stability and changed or atypical features before applying a previous panic label, using targeted tests when indicated.
- Explain observed findings calmly, encourage slower regular breathing without forced deep breaths, and avoid repeated unneeded reassurance loops.
- After symptoms settle, review triggers, catastrophic meaning, escape behaviour, substances and suicide risk and arrange active treatment rather than emergency-only care.