People who suffer from panic disorder usually have a series of intense episodes of extreme anxiety, known as panic attacks. The attacks may vary in intensity and the length of time that they last for. Symptoms may include rapid heartbeat, sweating, dizziness, trembling and feelings of fear. These can be very embarassing.

It is thought that about 1 in 25 people (3-4%) get panic attacks at some time in their life. It often happens with agoraphobia.

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Panic disorder is usually characterised by sudden attacks of anxiety (panic attacks), where there are physical symptoms. These start over about 10 minutes and come with a fear of serious illness, eg. heart attack. For a diagnosis of panic disorder, these attacks need to include four of the following:

• palpitations (heart irregular or racing)

• abdominal distress/nausea

• numbness/ tingling

• inability to breathe or shortness of breath

• choking

• sweating

• chest pains

• dizziness

• depersonalisation (common)

• flushes/chills

• fear of dying

• trembling/shaking.

About 1 in 30 people suffer with panic attacks at some time in their lives and it is a bit more common in women than men.

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Because everyone is unique, everyone's symptoms are different. So, it's not always clear what the right diagnosis is. Here is a list of some other possible causes for the symptoms of panic disorder. This is not meant to be a textbook list, just some ideas. Some of these can be very rare indeed. Sometimes it doesn't matter anyway as the symptoms of panic need to be treated anyway, no matter what causes them.

• Depression

• GAD or Generalised Anxiety Disorder

• Social anxiety

• PTSD (Post-Traumatic Stress Disorder)

• OCD (Obsessive Compulsive Disorder)

• Pure agoraphobia (in which case exposure therapy is usually effective)

• Substance misuse or prescribed medicine-induced e.g. caffeine abuse, cocaine, theophylline, amfetamines, steroids, sedative or alcohol withdrawal.

• Asthma attacks and other breathing problems

Also, some medical conditions can cause panic-like symptoms, including:

• Hormone imbalances (overactive thyroid, underactive parathyroid, low blood sugar, Cushing's disease)

• Heart problems (irregular heart beats, chest pain, prolapsed mitral valve) including "Acute Coronary Syndrome" where the symptoms are exactly the same and needs tests to make sure it isn't heart disease  

• Brain problems (epilepsy, balance or vestibular disease)

• Breathing problems (asthma)

• Blood problems (anaemia)

Just to confuse matters further, sometimes people have more than one illness (sometimes called "co-morbidity"). For example, if 1 in 10 people get depressed and 1 in 10 people get anxiety, then just by chance 1 in 10 of the depressed people get anxiety as well. However, if you're depressed, you're more likely to be anxious. Co-morbidity means what else the person is more likely to have at the same time. This can make diagnosis more difficult.

• Depression - the most common, and has a high suicide attempt rate

• Personality disorders

• Other anxiety disorders - over 1 in 2 (50%) people with panic disorder have another anxiety disorder, especially agoraphobia

• Seasonal Affective Disorder

• Bipolar mood disorder - up to 1 in 5 (20%) people with panic disorder also have bipolar mood disorder

• Alcohol abuse - 1 in 3 (33%) people with panic also abuse alcohol

^{Updated 8.11}

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Basically, anyone can get panic disorder. However, there are some "risk factors" that make it more likely that someone will get the symptoms of panic disorder. The cause of panic disorder seems to be about half genetics (what you inherit from your parents) and about half environment (where you live, job, family, friends etc). This is not a complete list but some of the main risk factors include:

• Family history e.g. if an identical twin has panic disorder, the other identical twin has a 1 in 2 chance of having panic disorder.

• Female - twice as common as in men

• Age - most often starts at 15-24 years of age and then at 45-54 years of age

• Being widowed, divorced or separated

• Poor school education

• Sexual abuse 

• A life event - occurs in about 60-90% of people e.g. separation, a loss, stress

• Trauma as a child - about 60% with panic disorder have had a major traumatic event as a child

• Smoking cannabis over many years increases the risks of having panic disorder. Cigarette smoking usually starts before panic attacks start and it is possible smoking might promote panic attacks  

There is some evidence that in panic attacks some of the brain's natural chemical messengers e.g. serotonin, GABA (the calming transmitter) and noradrenaline (the "fight or flight" transmitter) might be out of balance. It could be that the anxiety response is too sensitive, possibly a suffocation alarm or a fear response in the brain.

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The list here includes most of the main options but does not say what works and doesn't. Many may be used in combination. Most herbal and alternative therapies have not really been tested in the same rigorous way that medicines have.

Our aim is to try to help people who are taking medication (or should be) get the right medicine, dose and take it regularly for as long as is right. Any medicines should usually be part of the overall treatment, although some people are quite happy just to stick with drugs or talking treatments. If your medicines are right, then everything else can fall into place. If the medicines are wrong, then they may make the symptoms worse and self-help will not be as useful.

For panic disorder, there are a number of alternatives, depending on your preferences and how much distress the symptoms are causing you.

Self-help

• Self-help (e.g. bibliotherapy), which is the use of books or leaflets to help people understand their psychological problems and learn ways to overcome them by changing their behaviour. Self-help CBT manuala can help some people. 
• Taking any medicines regularly and reliably
• Eating healthily and taking exercise  or being active

Help from others

• Psychological therapies such as exposure therapy, psychotherapy and cognitive behavioural therapy (CBT) may be useful. Psychotherapy has not been shown to be more effective if used with medicines.  
• Psychosocial interventions have an important part to play. They can help reduce stress and help manage symptoms
• Alternative therapies such as  aromatherapy, hypnosis or hypnotherapy, homeopathy (treating like with like) can be used with (but not instead of) conventional treatments. Acupuncture is used extensively in many countries and may help anxiety, stress and insomnia. The evidence for these treatments is not very good. All of these can be used in conjunction with other therapies. If they work then that is fine and we wouldn’t knock them. Click here for a balanced review of complementary and alternative therapies from the Royal College of Psychiatrists (e.g. Ginkgo, Sage, vitamins, other herbals etc, and some useful links).

Medicines

• Medications includes SSRIs, tricyclics and sometimes benzodiazepines  - thes can often work better with talking therapies such as CBT

^{Updated 10.11}

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If you are prescribed a medicine, then there may be many reasons why that one has been chosen. These might include:

• side effects (which ones are important to you)
• local policies or agreements (such as what your GP surgery uses or agreements in your area)
• national policies (e.g. NICE, SIGN - see last question)
• familiarity (it may be better for prescribers to use medicines they are familiar with)
• relative costs for similar medicines (if two medicines are very similar, why waste money on the more expensive one?)
• personal preference (either yours or your prescriber)
• how bad your symptoms are
• any medicine you might have done well with in the past (as it's more likely to work again)

The main medicine treatment options in UK are listed below. They are divided into "Main medicines" and "Others".

For convenience, the "Main medicines” are those medicines that are officially "approved" to treat the condition or symptoms (www.bnf.org/bnf/) and which are listed in the British National Formulary (BNF). To be listed in the BNF there needs to be good evidence that the medicine works and that the manufacturers have applied for a license (a long and costly exercise). "Others" are those medicines where there is some evidence that they help, but either not enough for a license or that no license has been applied for. These should usually only be used where other standard treatments have failed.

The NICE guidelines suggest starting with an SSRI. If that doesn’t help, then switching to imipramine or clomipramine may be possible, although these usually have more side effects than the SSRIs. NICE does not recommend benzodiazepines because they are may be less useful in the long term.

Main medicines

• SSRIs (such as citalopram, escitalopram, paroxetine) - these tend to be much slower-acting, can make panic worse to start with (so start with a much lower dose than normal and build up), but better over the long-term

• Tricyclics (such as imipramine or clomipramine)

• Benzodiazepines (such as clonazepam, diazepam, chlordiazepoxide) - these tend to be quicker acting but not as good in the long-term, but can be useful as "when required" help  

Others:

• Other SSRIs (such as fluoxetine, sertraline, fluvoxamine)

• Gabapentin

• Beta-blockers (such as propranolol) - to help reduce increased heart rate and shaking that can occur in panic 

Some people say that just having a tablet to hand to take in case a panic attck starts is enough to help them manage the attack.  

Sometimes the symptoms of panic can become very severe. This can result in the person becoming very distressed and/or too difficult to cope with and might need to be admitted to hospital. This might then become what is called an "acute psychiatric emergency" or crisis. The treatments for this may need to include some other medicines just to calm the person down and prevent harm to that person, or others. If this happens, follow the link to some information that might help explain what might be going on.

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Download a handy summary chart (PDF format) comparing the main medicines for panic e.g. names, how they work, doses, how long they take to work, some side effects, how long to take and how to stop.

Alternatively you can read the chart now in the window below. Use the controls at the bottom of the window to navigate through the chart and magnify the information. The 'Download', 'Print' and 'Fullscreen' links at the top of the window are particularly helpful.

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You should think carefully about taking any chemical that affects your body, including your brain. So think carefully before your next cup of tea or coffee!

For panic disorder, the biggest analysis of the 21 trials, the first choice seems to be psychotherapy, or psychotherapy plus medicines ^{(Furakara CDSR 2007)}. For example, an SSRI plus self-administered CBT (Cognitive Behavioural Therapy) was better than either alone ^{(Koszycki 2010)}. 

For an appeal for everyone to have a sense of balance about medicines and talking therapies please click here for our take on it.

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We know that as many as 3 in every 4 people become ill again if they stop medicines after 6-12 months so you might want to consider taking them for much longer e.g. a year or so.

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Before going onto another medicine, it is worth trying to get the best out of the first one. There is a risk that switching medicines too quickly means you don’t get the best out of one medicine. Then perhaps you start to search for the “magic bullet”, expecting the drugs to work quicker and having less patience. There are of course no “magic bullets”. Most symptoms have started to happen over a few weeks, months or years, not a few days, so it is perhaps unfair to expect them to go over a few days. The symptoms are more likely to go gradually over weeks or months. If side effects are the main problem with a medicine, try to cope with these by e.g. changing times, splitting the dose, manage side effects etc.

The best thing to do is set out your aims of success of any treatment in advance and be realistic. If you decide to stop, then that’s your decision, but make sure you consider the chances of becoming unwell again (and consequences of that to yourself and the people close to you).

• Benzodiazepines – these are usually fairly quick i.e. you should notice a bit of an effect in a few days, but this effect may build up as you get the right dose for you. You should probably try them for a few months before deciding to switch.

• SSRIs and tricyclics – it is worth knowing that things may get a little worse before they get better so it is usually best to start at a low dose (e.g. paroxetine 10mg, escitalopram 5mg, citalopram 10mg) for a week or so, then build to the normal dose, and then give it about 8-12 weeks before making a decision

• Gabapentin - we're not very sure, but probably give it about 4 weeks or so

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There are no easy answers to this and it is a very individual choice. Generally one medicine should always be the aim but combinations (often called “polypharmacy”) sometimes help. It is rarely of any use to combine drugs with similar ways of working. Below are some of the combinations that are used with the reasons. This is not a complete list but you might want to talk to your prescriber about any combinations not on this list you may be prescribed.

Sometimes benzodiazepines or beta-blockers can be used with an SSRI to start with to help the increased anxiety that can happen with some people, but benzodiazepines and beta-blockers are not recommended long-term. Below are some of the combinations that are used with the reasons. This is not a complete list but you might want to talk to your prescriber about any not on this list.

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If you want to read up a bit more on the best treatments, there are many guidelines that you can look at. Probably the most important of these for England and Wales are those produced by NICE (the National Institute for Health and Clinical Excellence). NICE is an independent body that is asked to produce advice about preventing and treating illnesses and promoting good health. Scotland and Northern Ireland have their own similar bodies.

Each set of NICE Guidelines is written by an independent and carefully chosen group of specialists and experts (including service users and carers). They carefully review the available evidence and base their guidelines on this.

There are two main types of NICE guidance:

• "Technology appraisal". These look at an "intervention" (i.e. a medicine, a surgical operation etc) and decide if they think the evidence is good enough to make this intervention a standard and/or if it is cost-effective compared to other treatments

• "Clinical guidelines", which look at a particular condition (e.g. hypertension, lung cancer, depression, Parkinson's disease, bipolar disorder etc) and give guidelines covering medicines, services, support etc.

The guidelines are well intentioned and give generally sound guidance (although these are sometimes controversial). They are, however, only "guidelines", so are not rigid instructions.

When NICE issues a guideline, it produces a full set, and all of these are available on the NICE website:

• Full guideline (very long and detailed, often several hundred pages, for anorak healthcare professionals only)

• Official guideline (usually 10-30 pages, the summary version for healthcare professionals)

• Quick reference guideline for healthcare professionals (usually only a couple of pages)

• User-friendly summary for service users, carers and the general public

These should then be reviewed, usually about 4-5 years or sooner if more information becomes available.

As a general rule, you should start with treatments recommended by NICE as these are the ones with most evidence that they work. However, if these do not help you, it may be useful to try other treatments.

• NICE (click here for the Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults guidelines), last updated January 2011. There is also a guideline for Common mental health disorders, Identification and pathways to care, and this includes panic.

• Scottish Intercollegiate Guidelines Network (SIGN)

• Northern Ireland

There are plenty of other guidelines and so-called "consensus statements" (where a group of experts and specialists pool their ideas, based on their own experiences as well as what the published papers say, rather than just what the published studies say). These will have been produced for healthcare professionals by such bodies as BAP (British Association for Psychopharmacology).

^{Updated 10.11}

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Use the resources below to find out more information about panic disorder. Please note that this is not an exhaustive list. We welcome your feedback on resources that you think should be listed here.

If you want a more in-depth read, you could no better than visit the BAP (British Association for Psychopharmacology) public web pages, where there are some fairly scientific articles, including about anxiety disorders so click here, to get there.

Mental Health Ireland has a great links page on this extensive site

Your Mental Health Ireland, with a young person’s page as well

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