Panic Disorder
Summary
Panic Disorder is an anxiety disorder characterized by recurrent, unexpected Panic Attacks followed by persistent worry about future attacks or their consequences (e.g., losing control, heart attack) for at least one month. A Panic Attack is an abrupt surge of intense fear reaching a peak within minutes, accompanied by severe somatic and cognitive symptoms (DSM-5 requires 4+ symptoms). It is often a "Diagnosis of Exclusion" in the Emergency Department. [1,2]
Clinical Pearls
The "Paper Bag" Myth: Do NOT advise patients to breathe into a paper bag. While it theoretically corrects hypocapnia, if the patient is actually having a Pulmonary Embolism or Asthma attack (hypoxic conditions), rebreathing CO2 and limiting Oxygen can be fatal. Use "Square Breathing" techniques instead.
Syncope vs Panic: Patients with panic attacks often feel dizzy and fear they will faint. However, due to the massive surge of catecholamines (adrenaline), their Blood Pressure and Heart Rate are usually HIGH. Therefore, they almost never actually faint. If a patient collapses/faints, look for a cardiac cause (Arrhythmia/AS), not panic.
Caffeine: Patients with panic disorder are often hypersensitive to caffeine. Taking a thorough caffeine history (coffee, energy drinks, pre-workout supplements) is a high-yield intervention.
Demographics
- Prevalence: 2-3% of general population.
- Gender: Female > Male (2:1).
- Onset: Bimodal (Late adolescence and mid-30s).
- Heritability: 30-40% genetic contribution.
Comorbidities
- Major Depression (50-60%).
- Agoraphobia.
- Substance Abuse (Alcohol/Benzodiazepines).
Clark's Cognitive Model (The Cycle of Panic)
- Trigger: Internal (palpitation) or External (stress).
- Perceived Threat: "Something is wrong".
- Anxiety: Sympathetic activation.
- Somatic Symptoms: Tachycardia, Sweating, Tachypnoea.
- Catastrophic Misinterpretation: "I am having a heart attack" / "I am going mad".
- Intensified Anxiety: More adrenaline -> More symptoms. (Positive Feedback Loop).
Physiological Mechanisms
- Amygdala: Hyperactive "Fear Network".
- Locus Coeruleus: Noradrenergic dysregulation.
- Respiratory: CO2 hypersensitivity (False suffocation alarm).
DSM-5 Criteria for Panic Attack
Must have 4 or more of the following 13 symptoms:
Cardiorespiratory
- Palpitations / Tachycardia.
- Sweating.
- Trembling / Shaking.
- Shortness of Breath / Smothering sensation.
- Choking sensation ("Globus hystericus").
- Chest Pain / Discomfort.
Gastrointestinal 7. Nausea / Abdominal distress.
Neurological 8. Dizziness / Light-headedness / Faintness. 9. Paresthesias (Numbness/Tingling - usually perioral or fingers).
Psychiatric 10. Derealization (Unreality) or Depersonalization (Detachment). 11. Fear of losing control or "going crazy". 12. Fear of dying.
General 13. Chills or Heat flushes.
- General: Anxious, Tachypnoeic, Tachycardic.
- Carpopedal Spasm: "Clawing" of the hands due to hypocalcaemia (from respiratory alkalosis).
- Chvostek's Sign: Tapping facial nerve causes twitching (hypocalcaemia).
- Chest/Heart: Normal (essential to exclude Asthma/Murmurs).
Rule Out Medical Causes
- ECG: Mandatory. Exclude SVT, Ischaemia, QT prolongation.
- Bloods:
- TFTs: Thyrotoxicosis.
- FBC: Anaemia.
- Glucose: Hypoglycaemia.
- Calcium: Hypocalcaemia.
- Urine: Toxicology screen (Cocaine/Amphetamines).
- Metanephrines: Only if clinical suspicion of Phaeochromocytoma (episodic headache/HTN).
Management Algorithm (NICE CG113)
ACUTE PANIC ATTACK
↓
ASSESSMENT (Rule out medical)
- Calm environment
- "Square Breathing" (In 4, Hold 4, Out 4)
- Reassurance ("You are safe")
↓
PANIC DISORDER
(Recurrent attacks)
↓
STEPPED CARE MODEL (NICE)
┌─────────┴─────────┐
MILD MODERTAE/SEVERE
↓ ↓
STEP 2: STEP 3:
- Self-Help - CBT (High Intensity)
- Education - SSRI (Sertraline)
- Imipramine (TCA)
Psychological (First Line)
- CBT (Cognitive Behavioural Therapy):
- Psychoeducation: Explaining the Fight/Flight response.
- Cognitive Restructuring: Challenging the "I am dying" thought.
- Interoceptive Exposure: Inducing symptoms (e.g., spinning to get dizzy, running to get tachycardia) to desensitise the patient and prove they are safe.
Pharmacological
- First Line: SSRI (Sertraline, Citalopram).
- Warning: Partial agonists can initially worsen anxiety in the first 2 weeks. Start low (e.g., Sertraline 25mg) and titrate slowly. Cover with short-term Benzo if needed?
- Second Line: TCA (Imipramine / Clomipramine). Highly effective but more side effects.
- Third Line: Venlafaxine.
- Not Recommended: Long-term Benzodiazepines (dependence risk).
- Agoraphobia: Fear of places where escape is difficult. Can become housebound.
- Depression: Secondary to lifestyle restriction.
- Suicide: Increased risk.
- Cardiovascular: Long-term link to hypertension (constant sympathetic overdrive).
- Course: Chronic and fluctuating.
- Treatment: Effective. ~60-80% achieve remission with CBT/Meds.
- Relapse: High if medication stopped early. Treat for at least 12 months.
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| CG113 | NICE (2011) | Stepped care. CBT and SSRIs are equal first line. |
| Panic Disorder | BAP (2014) | Guidelines on pharmacotherapy duration. |
Landmark Evidence
1. Clark et al (1994)
- Demonstrated that Cognitive Therapy was superior to Imipramine and applied relaxation in the long term.
What is a Panic Attack?
It is a "false alarm" in your body's security system. Your brain thinks there is a life-threatening danger (like a lion), so it floods your body with adrenaline to help you run away. This makes your heart race and your breathing fast. When this happens in a supermarket (where there are no lions), your brain gets confused and assumes the danger is internal—like a heart attack. This scares you more, releasing more adrenaline.
Is it dangerous?
No. A panic attack feels terrible, but it cannot kill you. Your heart is designed to beat fast for long periods (like a marathon runner). You will not faint (your blood pressure is actually high).
Why do my fingers tingle?
Because you are breathing too fast. This changes the acid level in your blood slightly. It reverses instantly when you slow your breathing down.
Treatment
We use "Talking Therapy" (CBT) to retrain your brain not to sound the alarm so easily. We can also use medicines (SSRIs) to turn down the volume of the alarm system.
Primary Sources
- NICE. Generalised anxiety disorder and panic disorder in adults: management [CG113]. 2011.
- Clark DM. A cognitive approach to panic. Behav Res Ther. 1986.
- Baldwin DS, et al. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: A revision of the 2005 guidelines from the British Association for Psychopharmacology. J Psychopharmacol. 2014.
Common Exam Questions
- Diagnosis: "Perioral paraesthesia + Carpopedal spasm?"
- Answer: Hyperventilation / Panic Attack.
- Management: "First line drug?"
- Answer: SSRI (Sertraline).
- Pathology: "Neurotransmitter involved?"
- Answer: Serotonin / Noradrenaline / GABA.
- Counselling: "Paper bag advice?"
- Answer: Do NOT use. Risk of hypoxia.
Viva Points
- Initial worsening: Always warn patients starting SSRIs for anxiety that they might feel more anxious for the first 1-2 weeks. This improves adherence.
- Benzodiazepines: Why are they controversial? Immediate relief forms a psychological dependency ("I need my pill to survive this"). CBT aims to prove they can survive without safety behaviours.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.