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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Recurrent, unexpected panic attacks: sudden-onset intense fear peaking within minutes, with ≥4 somatic/cognitive symptoms
- Key symptoms: palpitations, sweating, trembling, shortness of breath, chest pain, derealization, fear of dying
- Must exclude cardiac (ACS), endocrine (phaeochromocytoma, hyperthyroidism), and respiratory causes first
- NICE CG113: CBT (7–14 hours) is first-line. SSRI (sertraline or citalopram) if CBT unavailable/declined/insufficient
- Start SSRI at HALF the usual starting dose (e.g. sertraline 25 mg) — panic patients are more sensitive to activation
- Agoraphobia frequently co-occurs — fear and avoidance of situations where escape may be difficult
Overview
Panic disorder is characterised by recurrent, unexpected panic attacks — discrete episodes of intense fear or discomfort that develop abruptly and peak within minutes. Attacks are accompanied by prominent somatic symptoms (palpitations, sweating, trembling, dyspnoea, chest pain) and cognitive symptoms (fear of dying, fear of losing control, derealisation). Between attacks, patients develop anticipatory anxiety (fear of the next attack) and may develop agoraphobia — avoidance of situations where escape might be difficult or help unavailable. The pathophysiology involves dysregulation of the locus coeruleus (noradrenergic system), amygdala hyperactivity, and catastrophic misinterpretation of normal bodily sensations.
Epidemiology
Panic disorder has a lifetime prevalence of approximately 2–3% in the UK. It is twice as common in women. Typical onset is in the late teens to early 30s. Risk factors include family history (first-degree relatives have 4–8× increased risk), adverse childhood experiences, stressful life events, and comorbid anxiety/depression. Approximately 30–50% of patients develop agoraphobia. Panic disorder is frequently seen in emergency departments — patients present with chest pain or dyspnoea fearing a cardiac event.
Clinical Features
Symptoms
Sudden-onset intense fear or sense of impending doom — peaking within minutes
Palpitations, tachycardia, awareness of heartbeat
Sweating, trembling, shaking
Shortness of breath, sensation of choking or smothering
Chest pain or discomfort — often the presenting complaint in ED
Nausea, abdominal distress, dizziness, light-headedness
Paraesthesiae (tingling in hands/feet — from hyperventilation-induced respiratory alkalosis)
Derealisation (feeling of unreality) or depersonalisation (detachment from self)
Fear of dying, fear of losing control or "going crazy"
Agoraphobic avoidance: avoiding crowds, public transport, open spaces, leaving home
Signs
Tachycardia, tachypnoea during an attack
Sweating, visible distress, hyperventilation
Carpopedal spasm (if hyperventilation causes hypocalcaemia)
Normal examination between attacks — this is diagnostically important
Investigations
First-line
Clinical diagnosisBased on history of recurrent, unexpected panic attacks with ≥4 symptoms and anticipatory anxiety. Normal physical examination between attacks
ECGExclude cardiac arrhythmia, ACS — essential if chest pain is a prominent feature
Second-line
BloodsTFTs (hyperthyroidism), FBC, glucose, calcium. Consider 24-hour urinary catecholamines if phaeochromocytoma suspected
ABG (during attack)Respiratory alkalosis from hyperventilation (low pCO₂, raised pH) — supports but not diagnostic
Specialist
Cardiac investigationsEchocardiogram, exercise tolerance test or CT coronary angiography if cardiac cause cannot be excluded clinically
1
Acute panic attack
- Reassurance: explain this is a panic attack, not a heart attack — it will pass
- Encourage slow, controlled breathing (diaphragmatic breathing)
- Do NOT use paper bag rebreathing (risk of hypoxia in genuine respiratory pathology)
- Avoid benzodiazepines unless exceptional circumstances
2
Step 2 — Low-intensity psychological intervention
- Guided self-help based on CBT principles
- Psychoeducation about the panic cycle (catastrophic misinterpretation → adrenaline → symptoms → more fear)
3
Step 3 — CBT or pharmacotherapy
- CBT: 7–14 hours total over ~4 months (first-line per NICE)
- If CBT not available/declined/insufficient: SSRI (sertraline or citalopram)
- Start SSRI at HALF normal dose (e.g. sertraline 25 mg) and titrate slowly — panic patients are sensitive to activation side effects
- If SSRI not tolerated: imipramine or clomipramine (off-label — higher side-effect burden and cardiotoxicity in overdose)
4
Maintenance and long-term
- Continue SSRI for ≥6 months after remission, then taper gradually
- If agoraphobia: graded exposure (systematic desensitisation) as part of CBT
- Do NOT prescribe benzodiazepines routinely — short-term use only in exceptional circumstances
Complications
- Agoraphobia: Develops in 30–50% — can become housebound. Requires graded exposure within CBT
- Depression: High comorbidity (~50–65%). Screen actively at every review
- Substance misuse: Self-medication with alcohol or benzodiazepines
- Functional impairment: Avoidance behaviour restricts work, social life, and independence
- Frequent ED attendance: Recurrent presentations with chest pain — important to diagnose early to reduce unnecessary investigations
UKMLA Exam Tips
- 1Panic disorder = RECURRENT + UNEXPECTED attacks. A single panic attack is not panic disorder
- 2Always exclude cardiac cause (ACS, arrhythmia) before diagnosing panic — especially with chest pain
- 3Hyperventilation → respiratory alkalosis → low ionised calcium → paraesthesiae and carpopedal spasm
- 4Start SSRIs at HALF dose in panic disorder (e.g. sertraline 25 mg) — more sensitive to initial activation
- 5CBT for panic focuses on breaking the cycle of catastrophic misinterpretation of bodily sensations
- 6Panic disorder + agoraphobia is a common combination — agoraphobia requires graded exposure
- 7Benzodiazepines: short-term only (≤2–4 weeks). Risk of tolerance, dependence, and rebound anxiety
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