Introduction

Panic disorder is where you have recurring and regular panic attacks, often for no apparent reason.

Everyone experiences feelings of anxiety and panic at certain times during their lifetime. It is a perfectly natural response to dangerous or stressful situations.  However, for someone with panic disorder, feelings of anxiety, stress and panic occur regularly and at any time.

Anxiety 

Anxiety is a feeling of unease. It can range from mild to severe, and can include feelings of worry and fear.
 
There are several different conditions that can cause severe anxiety. They include:

  • phobias, an extreme or irrational fear of an animal, object, place, situation or feeling
  • generalised anxiety disorder (GAD), a long-term condition that causes excessive anxiety and worry relating to a variety of situations
  • post-traumatic stress disorder, a condition that has psychological and physical symptoms and is caused by very frightening or distressing events

Panic attacks

A panic attack occurs when your body experiences a rush of intense psychological (mental) and physical symptoms.

You may experience an overwhelming sense of fear, apprehension, and anxiety. As well as these feelings, you may also experience physical symptoms, such as:

  • nausea
  • sweating
  • trembling
  • a sensation that your heart is beating irregularly (palpitations)

The number of panic attacks that you have will depend on the severity of your condition. Some people may have one or two attacks each month, while others may have several attacks a week.

Read more about the symptoms of panic disorder.

A panic attack can be very frightening and intense, but it is not dangerous. It will not cause you any physical harm and it is unlikely that you will be admitted to hospital if you have had a panic attack.

What causes panic disorder?

As with many mental health conditions, the exact cause of panic disorder isn't fully understood.

However, it's thought the condition is probably linked to a combination of physical and psychological factors.

Read about the possible causes of panic disorder.

It’s important to be aware that some physical conditions and disorders can have similar symptoms to those of anxiety. For example:

  • mitral valve prolapse
  • postural orthostatic tachycardic syndrome (POTS)
  • anaemia
  • paroxysmal atrial tachycardia – episodes of rapid and regular heartbeats that begin and end abruptly
  • thyrotoxicosis – where large amounts of thyroid hormones are released into the bloodstream, causing rapid heartbeat, sweating, tremor and anxiety
  • poorly controlled diabetes
  • adrenal tumours – growths that develop on the adrenal glands (two triangular-shaped glands that form part of the kidneys)
  • carcinoid syndrome – a set of symptoms caused by some carcinoid tumours that can develop in the cells of the endocrine system (glands that produce and secrete hormones)
  • Zollinger-Ellison syndrome – causes overproduction of insulin and low blood sugar (hypoglycaemia)

Diagnosing panic disorder

See your GP if you have symptoms of anxiety or panic disorder (see above).

You may be diagnosed with panic disorder if you experience recurrent and unexpected panic attacks followed by at least one month of continuous worry or concern about having further attacks.

Read more about how panic disorder is diagnosed.

Treating panic disorder

The aim of treating panic disorder is to reduce the number of panic attacks you have and ease the severity of your symptoms.

Psychological therapy and medication are the two main types of treatment for panic disorder.

Read more about treating panic disorder and things you can do to help yourself during a panic attack.

Having panic disorder may affect your ability to drive. It's your legal obligation to inform the Driver and Vehicle Licensing Agency (DVLA) about a medical condition that could have an impact on your driving ability.

GOV.UK has further information and advice about driving with a disability or health condition.

Complications of panic disorder

Panic disorder is treatable, but to make a full recovery it's important that you seek medical help as soon as possible. Treatment for panic disorder is much more effective if it's given at an early stage.

Left untreated, panic disorder can become a very debilitating and isolating illness. It can also increase your risk of developing other mental health conditions, such as agoraphobia or other phobias.

Agoraphobia is a fear of being in situations where escape might be difficult, or help wouldn't be available if things go wrong.

Read more about the complications of panic disorder.

How common is panic disorder?

At least one in 10 people experience occasional panic attacks, which are usually triggered by a stressful event.

Panic disorder is where a person has recurring and regular panic attacks. In the UK, it affects about two in 100 people, and it's about twice as common in women as it is in men.

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Symptoms

The symptoms of a panic attack can be very frightening and distressing.

Symptoms tend to occur suddenly, without warning and often for no apparent reason.

As well as overwhelming feelings of anxiety, a panic attack can also cause a variety of other symptoms, including:

  • a sensation that your heart is beating irregularly (palpitations)
  • sweating
  • trembling
  • hot flushes
  • chills
  • shortness of breath
  • a choking sensation
  • chest pain
  • nausea
  • dizziness
  • feeling faint
  • numbness or pins and needles
  • dry mouth
  • a need to go to the toilet
  • ringing in your ears
  • a feeling of dread or a fear of dying
  • a churning stomach
  • a tingling sensation in your fingers
  • shivering
  • shaking

The physical symptoms of a panic attack are unpleasant, and they can also be accompanied by thoughts of fear and terror.

For this reason, people with panic disorder start to fear the next attack, which creates a cycle of living in ‘fear of fear’ and adds to the sense of panic.

Sometimes, the symptoms of a panic attack can be so intense they can make you feel like you're having a heart attack.

However, it's important to be aware that symptoms such as a racing heartbeat and shortness of breath won't result in you having a heart attack. Although panic attacks can often be frightening, they don't cause any physical harm. People who have had panic disorder for some time usually learn to recognise this 'heart attack sensation' and become more aware of how to control their symptoms.

Most panic attacks last for five to 20 minutes. Some attacks have been reported to have lasted up to an hour. However, it's likely that in these cases one attack occurred straight after another or high levels of anxiety were felt after the first attack.

Recurrent panic attacks

People with panic disorder have panic attacks on a recurring basis. Some people have attacks once or twice a month, while others have them several times a week.

People with panic disorder also tend to have ongoing and constant feelings of worry and anxiety. The panic attacks associated with panic disorder can be very unpredictable.

If you have panic disorder, you may also feel anxious about when your next attack will be.

Depersonalisation

During a panic attack your symptoms can be so intense and out of your control that you can feel detached from the situation, your body and your surroundings. It can almost feel as if you're an observer, making the situation seem very unreal.

This sense of detachment is known as depersonalisation. Being detached from the situation doesn't provide any relief or make a panic attack less frightening. Instead, it often makes the experience more confusing and disorientating.

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Causes

As with many conditions which affect your mental health, the exact cause of panic disorder is not fully understood. 

It is thought that the disorder is most likely caused by a combination of physical and psychological factors. Some of these factors are outlined below.

Traumatic life experiences

A trauma, such as a bereavement, can sometimes trigger feelings of panic and anxiety. These feelings may be apparent soon after the event, or they may unexpectedly be triggered years later.

Genetic link

Having a close family member with panic disorder may increase your risk of developing the condition. However, the precise nature of the risk is not yet known.

Neurotransmitters

Neurotransmitters are chemicals that occur naturally in your brain. It is thought that an imbalance of these chemicals may increase your risk of getting conditions such as panic disorder.

Increased sensitivity to carbon dioxide

Some experts believe that panic disorder is linked to an increased sensitivity to carbon dioxide.  Breathing in air with high carbon dioxide levels can bring on panic attacks, and breathing techniques can help to relieve or stop panic attacks.

Catastrophic thinking

Another theory is that people who suffer panic attacks tend to focus on minor physical symptoms and interpret them in a catastrophic way. This triggers a nervous system response that causes the panic attack.

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Diagnosis

Everyone who has panic disorder will experience panic attacks.

However, not everyone who has panic attacks is diagnosed with panic disorder.

Panic attacks

Some people have panic attacks in response to specific situations. For example, they may have a phobia (overwhelming fear) of enclosed spaces (claustrophobia) and have a panic attack when faced with an enclosed space.

While most people with phobias only experience panic attacks when faced with the thing that triggers their fear, the panic attacks of people with panic disorder usually occur without warning and for no obvious reason.

This means that panic disorder will only be diagnosed after experiencing recurrent and unexpected panic attacks, and if the attacks are followed by at least one month of continuous worry or concern about having further attacks.

Talk to your GP

Your GP will ask you to describe the symptoms you've been experiencing. They'll also ask you how often your symptoms occur and in what situations.

It's important to tell your GP about how you've been feeling and how your symptoms have affected you.

Although it can sometimes be difficult to talk to someone else about your feelings, emotions and personal life, try not to feel anxious or embarrassed.

Your GP needs to gain a good understanding of your symptoms to make the correct diagnosis and recommend the most appropriate treatment for you.

Physical examination

Your GP may also want to carry out a physical examination to look for signs of any physical conditions that could be causing your symptoms.

For example, an overactive thyroid gland (hyperthyroidism) can sometimes cause similar symptoms to a panic attack.

By ruling out any underlying medical conditions, your GP will be able to make the correct diagnosis.

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Treatment

The main aim in treating panic disorder is to reduce the number of panic attacks and ease the severity of symptoms.

Psychological therapy and medication are the two main types of treatment for panic disorder.

Depending on your individual circumstances, you may need one of these treatment types or a combination of the two.

If you're offered psychological therapy, it will probably be in the form of cognitive behavioural therapy (CBT, see below). If this doesn't work, medication may be recommended.

Before starting any form of treatment, your GP will discuss all of the options with you, outlining the advantages of each type and making you aware of any possible risks or side effects.

No single treatment works for everyone and you may need to try a number of treatments before finding one that works for you. The treatment that's recommended will depend on your general level of health, the severity of your condition and your personal preferences.

It's important you understand what your treatment will involve. If you don't understand something your GP has told you, ask them to explain it in more detail.

Cognitive behavioural therapy

Psychological therapy has proven long-term benefits and it's recommended for treating panic disorder. It will usually take the form of cognitive behavioural therapy (CBT).

CBT is thought to be one of the most effective psychological treatments for panic disorder. It involves having regular sessions with a therapist.

The therapist may discuss with you how you react when you have a panic attack and what you think about when you're experiencing an attack.

Once you and your therapist have identified any negative thoughts and beliefs, you can work on replacing them with more realistic and balanced ones. Your therapist can also teach you ways of changing your behaviour, making it easier for you to deal with future panic attacks.

For example, they may be able to show you breathing techniques that can be used to help keep you calm during a panic attack.

The National Institute for Health and Care Excellence (NICE) recommends a total of seven to 14 hours of CBT to be completed within a four month period. Treatment will usually involve having a weekly one to two hour session.

NICE also recommends that in certain situations a shorter programme of CBT may be appropriate. This can involve a reduced number of hours of CBT with ‘homework’ being set between sessions so that you can practice what you've learnt after each session.

You should visit your GP regularly while you're having CBT so that they can assess your progress and see how you're doing.

Support groups

Support groups can provide useful information and advice about how you can effectively manage your panic disorder. They're also a good way of meeting other people who've had similar experiences of the condition.

Panic attacks can sometimes be frightening and isolating, so it can be helpful to know that other people are experiencing the same feelings and emotions as you.

A number of UK-based charities such as Anxiety UK and Triumph Over Phobia UK provide information and support for people with anxiety disorders.

Support groups often involve face-to-face meetings where you can talk about your problems and difficulties with others. Many can also provide support and guidance over the telephone or in writing.

Ask your GP about support groups for panic disorder near you. Search for local groups.

Antidepressants

Antidepressants are often associated with depression, but they can also be used to treat a number of other psychological conditions.

Antidepressants can take two to four weeks before becoming effective. It's therefore important to continue taking them, even if you feel they're not working. You should only ever stop taking prescribed medication if your GP specifically advises you to do so.

Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants are two types of antidepressants that are often recommended for treating panic disorder.

When starting a new type of medication, you should be regularly assessed by your GP at two, four, six and 12 week intervals. This will allow you to discuss any issues that you have with your medication, and enables your GP to assess which treatment is most effective. It will also provide you with the opportunity to try a different type of medication if you want to.

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressant that work by increasing the level of a chemical called serotonin in your brain.

They're the most commonly prescribed type of antidepressant for treating panic disorder. They're usually started at a low dose before gradually being increased as your body adjusts to the medicine.

Common side effects of SSRIs include:

  • nausea
  • headaches
  • low sex drive (loss of libido)
  • blurred vision
  • diarrhoea or constipation
  • dizziness
  • dry mouth
  • loss of appetite
  • sweating
  • feeling agitated
  • insomnia (sleep problems)
  • abdominal pain

When you first start taking SSRIs, your feelings of anxiety and panic may get slightly worse. In most cases, this is temporary and your symptoms will start to return to normal levels within a few days of taking the medicine.

Speak to your GP if you feel that your symptoms have got worse and that they're not showing signs of returning to normal levels after a few days.

After you start to take a SSRI, you should visit your GP after two, four, six, and 12 weeks so that they can check on your progress and see whether you're responding to the medicine. Not everyone responds well to antidepressant medicines, so it's important that your progress is carefully monitored.

If your GP feels it necessary, you may require regular blood tests or blood pressure checks when taking antidepressants. If after 12 weeks of taking the medication you don't show any signs of improvement, your GP may prescribe an alternative SSRI to see if it has any effect.

The length of time that you'll have to take a SSRI for will vary depending on how well you respond to the treatment. Even if you feel that your panic disorder has been successfully treated, it's likely that you'll need to keep taking the medication for at least six to 12 months.

If you stop taking your medication before this time, the risk of your symptoms recurring may be increased. Some people may have to take SSRIs for longer than the usual six to 12 month period.

When you and your GP decide that it's appropriate for you to stop taking SSRIs, you will gradually be weaned off them by slowly reducing your dosage. As with antidepressants, you should never stop taking SSRIs unless your GP specifically advises you to.

Stopping your medication straight away without being weaned off, or without seeking advice from your GP, may result in withdrawal symptoms such as:

  • dizziness
  • numbness and tingling
  • nausea and vomiting
  • headache
  • anxiety
  • sleep disturbances
  • sweating

These symptoms can also occur if you miss a dose of medication, or if your dose is reduced. The symptoms are usually mild, but they can be severe if the medication is stopped suddenly.

For some people, this means having to take SSRIs on a long-term basis. For others, a course of CBT can help to reduce the risk of their symptoms recurring.

Contact your GP if you experience troublesome side effects that don't ease.

Tricyclic antidepressants

If SSRIs aren't suitable, or if your symptoms don't improve after a 12 week course of SSRIs, your GP may try prescribing a different type of antidepressant.

Tricyclic antidepressants work in a similar way to SSRIs. They regulate the levels of the chemicals noradrenaline and serotonin in your brain, which has a positive effect on your feelings and mood.

Imipramine and clomipramine are two tricyclic antidepressants that are often prescribed to treat panic disorder. Tricyclic antidepressants aren't addictive.

SSRIs are usually prescribed before tricyclic antidepressants because they have fewer side effects. Common side effects of tricyclic antidepressants include:

  • constipation
  • difficulty urinating
  • blurred vision
  • dry mouth
  • weight gain or weight loss
  • drowsiness
  • sweating
  • lightheadedness
  • skin rash

The side effects should ease after seven to 10 days as your body starts to get used to the medication. However, see your GP if they become troublesome and don't ease.

Pregabalin

Pregabalin is another medication that’s often used to treat panic disorder. It’s an anticonvulsant that's also used to treat epilepsy (a condition that causes repeated seizures). However, it's also been found to be beneficial in treating anxiety.

Side effects of pregabalin can include:

  • drowsiness
  • dizziness
  • increased appetite and weight gain
  • blurred vision
  • headaches
  • dry mouth
  • vertigo – the sensation that you, or the environment around you, are moving or spinning

Pregabalin is less likely to cause nausea or a low sex drive than SSRIs.

Clonazepam

Clonazepam is another medication that’s often used to treat epilepsy and is also sometimes prescribed for panic disorder.

It can cause a wide variety of side effects including lethargy (lack of energy), abnormal eye movement (nystagmus), confusion and allergic reactions.

Referral

You may be referred to a mental health specialist if treatments such as attending a support group, CBT and medication don't improve your symptoms of panic disorder.

A mental health specialist will carry out an overall reassessment of your condition. They'll ask you about your previous treatment and how effective you found it. They may also ask you about things in your life that may be affecting your condition, or how much support you get from family and friends.

The specialist will be able to devise a treatment plan for you, which will aim to effectively treat your symptoms.
 
The type of mental health specialist that you'll be referred to will depend on your individual situation. For example, you may be referred to a:

  • psychiatrist – a trained medical doctor who specialises in mental health; a psychiatrist is one of the only mental health specialists who is able to prescribe medication
  • clinical psychologist – who is trained in the scientific study of human behaviour and mental processes and focuses solely on the assessment and treatment of mental health conditions; a clinical psychologist will help you to find ways of effectively managing your anxiety and panic attacks
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Self-help

There are several self-help techniques you can use to help treat the symptoms of panic disorder yourself.

Some of these techniques are listed below.

Stay where you are

If possible, you should stay where you are during a panic attack. The panic attack could last up to an hour, so you may need to pull over and park where it is safe to do so if you are driving.

Focus

If you have a panic attack, remind yourself that the frightening thoughts and sensations will eventually pass.

During an attack, try to focus on something that's non-threatening and visible, such as the time passing on your watch or items in a supermarket.

Slow deep breathing

While you're having a panic attack, try to focus on your breathing. Feelings of panic and anxiety can get worse if you breathe too quickly. Try breathing slowly and deeply while counting to three on each breath in and out.

Challenge your fear

When you have a panic attack, try to identify what it is you fear and challenge it. You can achieve this by constantly reminding yourself that what you fear isn't real and that it will pass in a few minutes.

Creative visualisation

Many things can go through your mind during a panic attack – for example, some people think about disaster or death. Instead of focusing on negative thoughts, try to concentrate on positive images.

Think of a place or a situation that makes you feel peaceful, relaxed or at ease. Once you have this image in your mind, try to focus your attention on it. It should help distract you from the situation and may also help ease your symptoms.

Thinking positively can be difficult, particularly if you've got used to thinking negatively over a long period of time. Creative visualisation is a technique that requires practice, but you may gradually notice positive changes in the way you think about yourself and others.

Don't fight a panic attack

Fighting a panic attack can often make it worse. Trying to resist the attack and finding you're unable to can increase your sense of anxiety and panic.

Instead, during a panic attack, reassure yourself by accepting that although it may seem embarrassing, and your symptoms may be difficult to deal with, the attack isn't life-threatening. Focus on the fact that the attack will evetually end and try your best to let it pass.

Relaxation

If you have panic disorder, you may feel constantly stressed and anxious, particularly about when your next panic attack may be. Learning to relax can help to relieve some of this tension, and it may also help you to deal more effectively with your panic attacks when they occur.

Some people find complementary therapies, such as massage and aromatherapy, help them to relax. Activities, such as yoga and pilates, can also be helpful. You can also practise breathing and relaxation techniques, which you can use during a panic attack to help ease your symptoms.

Exercise

Regular exercise, particularly aerobic exercise, will help reduce stress and release tension. It can also encourage your brain to release the chemical serotonin, which can help improve your mood.

It's recommended that adults aged 19-64 years should do at least 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity, such as cycling or fast walking, every week.

They should also do muscle-strengthening activities on two or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders and arms).

Visit your GP for a fitness assessment before starting a new exercise programme if you haven't exercised before or for a long time.

Diet

Unstable blood sugar levels can contribute to the symptoms of a panic attack. Therefore, you should maintain a healthy, balanced diet, eat regularly and avoid eating sugary food and drinks. Also, avoid caffeine, alcohol and smoking because they can all contribute to panic attacks.

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Complications

Panic disorder is a treatable condition, but to make a full recovery it is very important you seek medical help as soon as possible.

This is because treatment for panic disorder is much more effective if it's given at an early stage.

Left undiagnosed and untreated, panic disorder can become a debilitating and isolating illness. It can also increase your risk of developing other psychological conditions.

Agoraphobia and other phobias

Agoraphobia is a fear of being in situations where escape might be difficult, or help wouldn't be available if things go wrong.

If you have agoraphobia, leaving home, going out in public and travelling alone can cause intense anxiety. Many people with agoraphobia avoid everyday activities because of their phobia.

Agoraphobia is one of the conditions that can develop alongside panic disorder. People with panic disorder can develop agoraphobia because of their fear of having a panic attack in a public place.

You may worry that a panic attack in a public place will be embarrassing, or that you'll have difficulty getting help if you need it. You may also worry about public places that you would have difficulty leaving, such as a train, if you were to have a panic attack.

If you have agoraphobia, you may find it difficult to leave the house, particularly if you're not with a trusted family member or a friend.

If you have panic disorder, you may also develop other fears and phobias, which can often seem irrational. For example, you may start to worry about a particular object or action that triggers your attacks and become fearful of those things.

Children

Panic disorder is more common in teenagers than in younger children.

Panic attacks can be particularly debilitating for children and young people. Severe panic disorder may affect their development and learning. The fear of having a panic attack may stop children from going to school and engaging in a social life. They may also find it difficult to concentrate on their schoolwork.

Diagnosing panic disorder in children is usually a case of taking a detailed medical history and carrying out a thorough physical examination to rule out any physical causes for the symptoms.

Screening for other anxiety disorders may also be needed to help determine what's causing your child’s panic attacks.

Panic attacks in children are often dramatic events, including screaming and crying and an increased breathing rate (hyperventilation).

If your child displays the signs and symptoms of panic disorder over a prolonged period of time, your GP may refer them to a specialist for further assessment and treatment.

The specialist may recommend a course of psychotherapy for your child, such as cognitive behavioural therapy (CBT).

Drug and alcohol misuse

Some studies have shown that conditions that cause intense anxiety, such as panic disorder, can also increase your risk of developing an alcohol or drug problem.

The side effects or withdrawal symptoms of both prescribed medication and illegal drugs can increase the symptoms of anxiety.

Smoking and caffeine can also make your anxiety symptoms worse, so you should try to give up smoking (if you smoke) and limit the amount of caffeine in your diet

Driving

Your driving ability may be affected if you have panic disorder.

You're legally obliged to inform the Driver and Vehicle Licensing Agency (DVLA) about a medical condition that could have an impact on your driving.

See GOV.UK for further information about driving with a disability or health condition.

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The information on this page has been adapted by NHS Wales from original content supplied by NHS Choices.
Last Updated: 17/09/2014 09:03:11