Panic disorder: symptoms, diagnosis and treatment

During an attack a rush of intense mental and physical symptoms comes on quickly. The NHS lists a racing heartbeat, feeling faint, sweating, nausea, chest pain, shortness of breath, trembling, hot flushes, chills, a choking sensation, dizziness, numbness or pins and needles, a dry mouth, a feeling of dread or a fear of dying, a churning stomach and feeling disconnected from your body. NHS inform adds palpitations, ringing in the ears and a need to use the toilet.

Most attacks last 5 to 20 minutes, and the NHS says the frequency varies: some people have attacks once or twice a month, while others have them several times a week. It is common to start avoiding situations that might trigger another attack, which can create a cycle of living "in fear of fear" that adds to the panic. The NHS also cautions that most of these symptoms can occur in other conditions, so not every episode is a panic attack. For instance, a racing heartbeat can be caused by very low blood pressure.

Everyone feels anxiety and panic at times, as a natural response to danger or stress. The NHS describes panic disorder as an anxiety disorder in which sudden attacks of panic or fear happen regularly and at any time, often for no apparent reason. Panic is the most severe form of anxiety.

NHS inform makes a distinction worth knowing: everyone with panic disorder has panic attacks, but not everyone who has panic attacks has panic disorder. NICE guidance makes the same point in an emergency department context, noting that a panic attack does not necessarily constitute panic disorder, and that appropriate treatment of an attack may limit the development of the disorder.

The NHS says a GP will ask you to describe your symptoms, how often they happen and how long you have had them, and may examine you to rule out other conditions that could cause them. A diagnosis of panic disorder is made if you have regular, unexpected panic attacks followed by at least a month of continuous worry about having further attacks.

NICE guidance emphasises that diagnosis depends on good consultation skills rather than a screening questionnaire, and that clinicians should be alert to other problems that commonly coexist, notably depression and substance misuse. For someone who attends A&E with a panic attack, the guidance advises the minimum investigations needed to exclude acute physical problems, usually no admission to a hospital bed, referral back to primary care and written information about panic attacks and sources of support.

The exact cause is not fully understood. The NHS says it is thought to involve a combination of factors, including a traumatic or very stressful life experience such as bereavement, having a close family member with panic disorder, and an imbalance of neurotransmitters, the chemical messengers in the brain. NHS inform adds over-breathing or hyperventilating and catastrophic thinking, where a physical sensation is interpreted as a sign of disaster.

Left untreated, the NHS says panic disorder can escalate. It increases the risk of other mental health conditions such as agoraphobia or other phobias, or an alcohol or drug problem.

The NHS says talking therapies and medicine are the main treatments, and that a CBT-based talking therapy can be reached by referring yourself directly in England, or through a GP. The therapist explores how you react during an attack and what you think, and teaches ways to change behaviour to stay calm. NHS inform adds that no single treatment works for everyone.

NICE guidance sets a stepped approach. For mild to moderate panic disorder, a low-intensity intervention such as individual self-help, with or without a facilitator, is offered. For moderate to severe panic disorder, or where there has been no benefit from or a person has declined psychological help, CBT or an antidepressant is considered. CBT should be delivered by suitably trained and supervised practitioners, in an optimal range of 7 to 14 hours in total, usually as weekly sessions of 1 to 2 hours completed within a maximum of 4 months. NICE also advises that the benefits of exercise be discussed and that information about support groups is offered.

• During an attack, the NHS suggests staying where you are if possible, breathing slowly and deeply, reminding yourself that it will pass and that it is not life threatening.

• To help prevent further attacks it suggests CBT-based self-help books, relaxation activities such as yoga or pilates, breathing exercises, regular exercise, and avoiding sugary food and drink, caffeine and alcohol, and smoking.

The NHS says that if you and your doctor think it may help, you may be prescribed a selective serotonin reuptake inhibitor (SSRI) or, if SSRIs are not suitable, a tricyclic antidepressant (usually imipramine or clomipramine). Antidepressants can take 2 to 4 weeks to start working and up to 8 weeks to work fully, and the NHS advises continuing even if they seem not to be working and stopping only on a GP's advice. It also lists pregabalin or, in severe anxiety, clonazepam among the options.

NICE guidance is more specific and more cautious. It says antidepressants should be the only pharmacological intervention used in the longer-term management of panic disorder, that an SSRI licensed for panic disorder should be offered unless otherwise indicated, and that benzodiazepines are associated with a less good outcome in the long term and should not be prescribed for panic disorder. Sedating antihistamines and antipsychotics should also not be prescribed. If there is no improvement after a 12-week course, an antidepressant from the other class or another form of therapy should be offered, and if there is improvement, medication should continue for at least 6 months after the optimal dose is reached before the dose is tapered. People should be told about the delay before the effect starts, that anxiety can briefly rise at the beginning, and that stopping abruptly can cause discontinuation symptoms.

Because the NHS summary and the NICE guideline differ on benzodiazepines and some other medicines, treatment decisions should be made with a prescriber who knows your history.

NICE guideline CG113 organises care for panic disorder into steps. The aim is to start with the least intrusive treatment that is likely to help and move on if it does not.

Panic attacks are not dangerous, but chest pain can have other causes, so it is safest not to assume. The NHS chest pain page advises calling 999 for sudden chest pain or discomfort that does not go away, pain that spreads to the arms, neck, jaw, stomach or back, or chest pain with sweating, sickness, light-headedness or shortness of breath.

If panic is affecting your daily life, you are not looking after yourself or you are finding it hard to manage responsibilities, NHS inform advises contacting your GP practice, and it points to urgent mental health help if you are in crisis. NICE says that someone who attends A&E with a panic attack should be given the minimum investigations needed to exclude acute physical problems, usually not be admitted, and be referred to primary care with written information about support.

If symptoms do not improve after CBT, medicine and support groups, the NHS says a GP may refer you to a mental health specialist such as a psychiatrist or clinical psychologist for assessment and a treatment plan. In children, a GP carries out a medical history and physical examination to exclude physical causes and may refer to a specialist who can recommend CBT.

Private psychologists, CBT therapists and psychiatrists also treat panic disorder; NICE advises that CBT is delivered only by suitably trained and supervised practitioners. Support organisations named by the NHS include Anxiety UK, Mind, No Panic and Triumph Over Phobia (TOP UK).