Panic Disorder
Management of recurring panic attacks and fear of further attacks
What is panic disorder?
A panic attack is a sudden surge of intense fear that reaches its peak within minutes and brings powerful physical sensations with it. The body's alarm response fires at full strength with nothing to fire at. It is exhausting and frightening, and it passes.
Panic disorder is the condition in which these attacks recur unexpectedly and the fear of the next one begins to govern behaviour. That second part is what turns attacks into a disorder. People stop driving alone, avoid crowds, stay near hospitals, or carry a bottle of water and a tablet everywhere, and the world contracts around the attacks.
It often begins in a person's twenties or thirties, tends to run in families, and is frequently set off during a stressful period, after a serious illness, or after heavy caffeine, stimulant or alcohol use. The condition responds well to treatment, and the first attack is very commonly mistaken for a heart problem.
What you might notice
- Sudden waves of fear with a racing heart
- A racing or skipping heartbeat
- Worry that will not switch off
How it is diagnosed
Your doctor makes the diagnosis by going through the attacks in detail: how fast they build, how long they last, what was happening beforehand, and whether they arrive out of nowhere or only in particular places. They are also asking what has changed between attacks, since the avoidance built up in those gaps is often the larger part of the problem.
A first attack with chest pain, especially in someone with diabetes, high blood pressure, a smoking history or a family history of heart disease, is assessed as a possible heart or lung problem before anything else. Once that has been done and is normal, repeating it is unhelpful and tends to reinforce the fear.
Your doctor will check thyroid function and the heart rhythm where the pattern suggests it, and will ask carefully about caffeine, energy drinks, nicotine, alcohol, cannabis, stimulants and withdrawal from any of them. They will also ask about low mood, because depression often develops alongside.
Recovery
Structured talking treatment is the most effective approach and runs over roughly eight to sixteen weekly sessions. Attacks usually become less frequent and less severe within the first six to eight weeks, and the avoidance takes longer to undo because it is unpicked one situation at a time.
Where medicine is used, allow four to six weeks at an adequate dose. Your doctor will start low, because panic can sharpen briefly at the start. A short course of a fast-acting sedative is sometimes given for the first few weeks; it is kept short deliberately, since regular use builds dependence and slows the longer-term recovery.
Most people continue working throughout. Driving, flying and travelling alone are returned to in planned steps, and treatment continues for six to twelve months after the attacks have stopped before the dose is reduced slowly.
If it is left untreated
Attacks may become less frequent on their own during a calmer period of life, and then return when stress does.
What generally grows without treatment is the avoidance. A person who has stopped driving stops travelling, then stops going out alone, and a proportion end up largely housebound after some years. Work and income are affected long before that point. Repeated visits to emergency departments, and a rising stack of normal heart tracings, are the usual pattern, and each normal result reassures for a shorter time than the last.
Depression and alcohol dependence are the two conditions that most often build on top of untreated panic, and both make the panic harder to treat. Because untreated panic narrows life steadily while treatment is straightforward and time-limited, there is little to gain from waiting. If chest pain is new, different from your usual attacks, spreads to the jaw or arm, or comes with sweating and vomiting, treat it as a heart problem and get to a hospital the same hour.
Questions about panic disorder
How do I tell a panic attack from a heart attack?
You often cannot in the moment, and the first time it happens you should not try. A panic attack builds to a peak in minutes and eases over twenty to thirty, and it tends to follow a pattern you come to recognise. Heart pain is more often a pressure or heaviness in the centre of the chest, can spread to the jaw or the left arm, comes with sweating or vomiting, and is brought on by exertion. Get a first episode of chest pain assessed at a hospital. Once your heart has been checked and found normal, further attacks that follow your familiar pattern do not need a repeat visit.
What should I do while an attack is happening?
Stay where you are if it is safe to do so, or pull over if you are driving. Let the attack run without fighting it; it peaks within minutes and comes down on its own, and nothing bad happens at the top of it. Slow breathing out for longer than you breathe in helps the physical sensations settle. Leaving the situation immediately brings relief in the moment and makes the next attack in that situation more likely, so where you can, wait until it has eased before you go. Your doctor or therapist will practise this with you until it becomes reliable.
Will I be on medication forever?
Usually not. Where medicine is used it is typically continued for six to twelve months after the attacks have settled and then reduced slowly with your doctor, since stopping abruptly often brings the attacks back. Fast-acting sedatives are prescribed only for short periods, because regular use builds dependence and blunts the longer-term treatment. Many people are treated with a talking treatment alone, and the skills from it keep working after the sessions have finished, which is the part that protects you in a future stressful stretch.
Other psychiatry treatments
Assessment and treatment of persistent low mood, loss of interest and related emotional or physical symptoms
Day CareTreatment for excessive or persistent anxiety that interferes with daily life
Day CareTalk to a care coordinator about panic disorder
Leave a number and a care coordinator calls you back with what the treatment involves and which hospital it would be at. They book a consult only if you want one