Panic disorders

Last reviewed: 29 Aug 2022

Last updated: 21 Apr 2021

Frequency of panic attacks may vary considerably, with some individuals reporting brief clusters of several panic episodes in a short period of time, weekly panic attacks, or periodic attacks over the course of several months.

Higher risk among first-degree relatives; onset of attacks triggered by stress; often comorbid with other anxiety, mood, and substance-use disorders.

Assessment is made through ruling out organic causes; self-report; clinical interview; and behavioral observation.

Self-help, cognitive behavioral therapy, selective serotonin-reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are first-line treatments.

Long-term management includes relapse prevention after treatment discontinuation.

Definition

Panic disorder is characterized by recurring unexpected panic attacks over a 1-month period and associated worry about their recurrence or implications. Panic attacks involve the sudden onset of intense physical and cognitive symptoms of anxiety that may be triggered by specific cues or occur unexpectedly. Panic disorder may also be characterized by avoidance of situations that may trigger the panic sensations.

History and exam

Key diagnostic factors

unexpected onset
apprehension and worry
behavioral avoidance
tachycardia
positive PRIME-MD panic screen
Panic Disorder Severity Scale (PDSS)
GAD-7 cut score ≥10

More key diagnostic factors

Other diagnostic factors

palpitations; chest pain and discomfort
nausea and abdominal pain
dizziness
perceptual abnormality
respiratory symptoms
reliance on safety cues
paresthesias
muscle shaking
sweating
fainting
chills or hot flushes

Other diagnostic factors

Risk factors

history in first-degree relatives
age 18 to 39 years
female sex
white ethnicity
major life events
comorbid disorders
psychological factors
asthma and respiratory variability
cigarette smoking and caffeine use
cardiac abnormalities

More risk factors

Diagnostic investigations

1st investigations to order

no initial test

More 1st investigations to order

Investigations to consider

ECG
blood glucose
thyroid function tests
toxicology screen

More investigations to consider

Treatment algorithm

ACUTE

acute panic attack

ONGOING

panic disorder

panic attacks without panic disorder

Contributors

Authors

Craig N. Sawchuk, PhD

Professor

Department of Psychiatry and Psychology

Mayo Clinic

Rochester

Disclosures

CNS declares that he has no competing interests.

Jason P. Veitengruber, MD

Associate Professor

Department of Psychiatry and Behavioral Sciences

University of Washington School of Medicine

Seattle

Disclosures

JPV declares that he has no competing interests.

Peer reviewers

Paul Blenkiron, BM BCh, MA

Consultant Psychiatrist

Leeds and York Partnership NHS Foundation Trust

Bootham Park Hospital

York

Disclosures

PB declares that he has no competing interests.

Jeffrey M. Lohr, PhD

Professor

Clinical Training Program

Department of Psychology

University of Arkansas

Fayetteville

Disclosures

JML declares that he has no competing interests.

Philip J. Cowen, MD, FRCPsych, FMedSci

Professor of Psychopharmacology

Warneford Hospital

Oxford

Disclosures

PJC declares that he has no competing interests.

Toshiaki A. Furukawa, MD, PhD

Professor and Chair

Department of Psychiatry and Cognitive-Behavioral Medicine

Graduate School of Medical Sciences

Nagoya City University

Nagoya

Japan

Disclosures

TAF has received research funds and speaking fees from Astellas, Dai-Nippon, Sumitomo, Eli Lilly, GlaxoSmithKline, Janssen, Meiji, Otsuka, Schering-Plough, and Yoshitomi. He was on a research advisory board for Meiji and Mochida, and is currently on research advisory boards for Sekisui chemicals and Takeda Science Foundation. He has received royalties from Igaku-Shion and Seiwa-Shoten Publishers. The Japanese Ministry of Education, Science, and Technology and the Japanese Ministry of Health, Labor, and Welfare have also funded his research.

Differentials
- Agoraphobia
- Specific phobia
- Social anxiety disorder
More Differentials
Guidelines
- Generalised anxiety disorder and panic disorder in adults: management
- Generalised anxiety disorder and panic disorder in adults: management
More Guidelines
Patient leaflets
Panic attacks: what are they?
Panic attacks: what treatments work?
More Patient leaflets
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Panic disorders

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

acute panic attack

panic disorder

panic attacks without panic disorder

Contributors

Authors

Craig N. Sawchuk, PhD

Disclosures

Jason P. Veitengruber, MD

Disclosures

Peer reviewers

Paul Blenkiron, BM BCh, MA

Disclosures

Jeffrey M. Lohr, PhD

Disclosures

Philip J. Cowen, MD, FRCPsych, FMedSci

Disclosures

Toshiaki A. Furukawa, MD, PhD

Disclosures

Differentials

Guidelines

Patient leaflets

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice