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23.7 Panic Disorder

Table of Contents

Panic disorder is an anxiety disorder characterized by recurrent unexpected panic attacks. A panic attack is characterised by an acute onset of intense anxiety accompanied by a sense of dread/impending threat, usually for no apparent reason.

Diagnostic Criteria

The patient will experience significant fear and emotional discomfort, typically peaking within 10 minutes and resolving within 30 minutes. There will usually be accompanying physical symptoms including:

  • Rapid pulse/palpitations
  • Shortness of breath
  • Dizziness
  • Sweating

Non-Pharmacological Management

  • Psycho-education and reassurance
  • Psychotherapy, e.g. cognitive-behaviour therapy
  • Exclude an underlying medical condition, e.g. thyrotoxicosis

Pharmacological Treatment

Panic attack

Acute management

The initial aim is to control the panic symptoms and exclude an underlying medical cause.

C: Diazepam (PO) 5mg stat (repeated as necessary to control symptoms)


C: Lorazepam (PO) 2mg stat (repeated as necessary to control symptoms)


D: Clonazepam (PO) 1mg stat (repeated as necessary to control symptoms)

Panic disorder

S: Fluoxetine (PO) 20–40mg daily


S: Citalopram (PO) 10–40mg daily


A: Amitriptyline (PO) 25–75mg daily at night

Initiate at low dose and gradually titrate to therapeutic dosages according to tolerability.
Duration of therapy: variable, initially 6 months–1 year.
Long term medicine treatment may be necessary.
Relapses may occur when treatment is discontinued.
Consider short term co-administration of a benzodiazepine, due to the  slow  onset  of  action  and  the  potential  for  increased  anxiety during the initial phase of treatment with antidepressants.


Refer to the next level in the following situations:

Treatment resistance or need for benzodiazepine treatment beyond 6 weeks

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