Panic Disorder
General Psychiatry Article Disclaimer
- DSM-5 criteria or ICD-11 diagnostic requirements are used to structure the Clinical Features and Diagnosis section. The classification system used is selected according to its clarity and suitability for non-specialist learning.
- The criteria are summarised and simplified rather than reproduced in full, while preserving their original diagnostic meaning.
- Where appropriate, a student-friendly pattern-recognition summary is provided to highlight the most clinically and exam-relevant features.
Exam tip (re-psychiatry questions)
- Do not attempt to memorise every DSM-5 or ICD-11 criterion word-for-word. However, it is important to read through the criteria and become familiar with the key symptom clusters, duration thresholds, exclusions, and distinguishing features highlighted in this article.
- Exam questions may not provide every feature required to meet the full diagnostic criteria. Familiarity with the criteria can help one recognise the most likely diagnosis, exclude important alternatives, and narrow the differential diagnosis.
Clinical Features and Diagnosis
Important: panic attack ≠ panic disorder
High-yield pattern recognition for panic disorder:
- Recurrent, unexpected panic attacks
- Panic attacks followed by persistent concern / worry about further attacks or behavioural changes related to the attacks
A panic attack is an abrupt onset of intense fear or intense discomfort that reaches a peak within minutes:
| Panic attack symptoms category | Specific symptoms |
|---|---|
| Cardiorespiratory |
|
| Autonomic |
|
| GI |
|
| Cognitive / perceptual |
|
DSM-5 criteria for panic disorder, ALL must be met: [Ref]
- Recurrent and unexpected panic attacks
- At least 1 attack is followed by at least 1 month of
- Persistent concern about additional attacks or their consequences, AND/OR
- A significant maladaptive change in behaviour related to the attacks
- The panic attacks are not due to the direct physiological effects of a substance (e.g. cocaine, amphetamines, excess caffeine, alcohol or benzodiazepine withdrawal, beta-2 agonists)
- The panic attacks are not due to the direct physiological effects of a medical condition (e.g. hyperthyroidism, arrhythmias, phaeochromocytoma, hypoglycaemia)
- The panic attacks are not better accounted for by another mental disorder (e.g. social phobia or social anxiety disorder, PTSD, OCD)
DSM-5 criteria for a panic attack: an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes with at least 4 of the following symptoms: [Ref]
- Palpitations, pounding heart, or accelerated heart rate
- Sweating
- Trembling or shaking
- Sensations of shortness of breath or smothering
- Feeling of choking
- Chest pain or discomfort
- Nausea or abdominal distress
- Feeling dizzy, unsteady, lightheaded, or faint
- Derealisation (feelings of unreality) or depersonalisation (being detached from oneself)
- Fear of losing control or “going crazy”
- Fear of dying
- Paraesthesias (numbness or tingling sensation)
- Chills or hot flushes (heat sensations)
Panic Disorder vs Generalised Anxiety Disorder
| Feature | Panic disorder | Generalised anxiety disorder (GAD) |
|---|---|---|
| Core problem | Recurrent unexpected panic attacks | Persistent, excessive worry about multiple areas of life |
| Course | Discrete panic attacks, with possible anticipatory anxiety between attacks | Persistent anxiety or worry |
| Typical symptoms | Palpitations, sweating, trembling, dyspnoea, chest discomfort, dizziness, fear of dying or losing control | Restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance |
Management
Scope of management:
NICE explicitly describes its population as people with panic disorder +/- agoraphobia
- Panic disorder + agoraphobia → follow the NICE panic disorder pathway
- Panic disorder without agoraphobia → follow the same NICE panic disorder pathway
- Agoraphobia without panic disorder → NICE do not provide a dedicated standalone agoraphobia pathway
Acute Panic Attack Management
Key management principles:
- Reassure the patient
- Encourage slow, controlled breathing
- Remain in a safe or calm environment where possible
It is important to exclude important differentials of a panic attack, including asthma exacerbation, anaphylaxis and acute coronary syndrome, particularly where the clinical background supports an alternative diagnosis (e.g. known asthma, known allergy, or older age with cardiovascular risk factors).
NICE noted the following points:
- In patients presenting with chest pain, panic disorder is more likely if coronary artery disease is absent, or the patient is female or relatively young
- Perform the minimum investigations necessary to exclude acute physical problems
- Do not routinely admit to a medical or psychiatric bed
- Ask whether the patient is already receiving treatment for panic disorder
- Refer to primary care for subsequent care
Long-Term Panic Disorder Management
Advise on the benefits of exercise as part of good general health to ALL patients with panic disorder
NICE recommends a stepped approach, step up accordingly if ineffective:
| Step | Management |
|---|---|
| 1 | Offer low-intensity psychological interventions that are primary-care based:
Offer information about support groups |
| 2 (consider starting here from the start if there is moderate to severe panic disorder) | Offer either of the following (guided by the patient’s preference):
Do NOT offer the following medications to treat panic disorder:
|
| 3 | If a patient has received two interventions and still experiences significant, ongoing symptoms → refer to specialist mental health services |