Panic Disorder

Recurrent, unexpected panic attacks, discrete episodes of intense fear peaking within minutes, with persistent concern about future attacks or their consequences (≥1 month), or significant behavioral change to avoid them, often with agoraphobic avoidance.

Panic attack: palpitations, sweating, trembling, dyspnea/choking sensation, chest pain, nausea, dizziness, derealization/depersonalization, fear of losing control/dying, paresthesia, chills/hot flushes ; peaks within 10 minutes, resolves within 20-30 minutes typically.

Anticipatory anxiety between attacks. Agoraphobia: avoidance of situations where escape might be difficult (crowds, public transport, being alone away from home).

Clinical, DSM-5 criteria.

Exclude organic mimics on first presentation: ECG (arrhythmia), TSH (thyrotoxicosis), glucose (hypoglycemia), consider troponin/D-dimer if clinical suspicion of cardiac/PE given symptom overlap.

Review caffeine, stimulant, substance use.

Differentials: cardiac arrhythmia, hyperthyroidism, pheochromocytoma, PE, asthma, substance intoxication/withdrawal (especially stimulants, caffeine), other anxiety disorders, hypoglycemia.

• Psychoeducation: explain panic physiology (fight-or-flight misfiring), breaks catastrophic misinterpretation cycle

• CBT : first-line, strong evidence, includes interoceptive exposure

• SSRIs : first-line pharmacotherapy: sertraline 25-50mg starting dose (lower than usual to avoid initial activation/worsening), titrate; effect over weeks

• SNRIs (venlafaxine): alternative

• Avoid long-term benzodiazepines : short-term only (acute severe presentation, bridging while SSRI takes effect), risk of dependence and rebound anxiety

• Breathing retraining: for hyperventilation component

• Address agoraphobic avoidance: graded exposure therapy

Referral: psychiatry for treatment resistance, severe agoraphobia, diagnostic complexity, comorbid depression/suicidality.