The essential feature is recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable

Aetiology

• Typical onset late adolescence to mid-30’s
• Comorbid with other anxiety disorders (>50% also have agoraphobia), depression, drug and alcohol misuse

Clinical features

• As with other anxiety disorders, the dominant symptoms include sudden onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization or derealization)
• There is often also a secondary fear of dying, losing control, or going mad
• May occur with, or without, agoraphobia
• Not due to the direct physiological effects of a substance (drug) or general medical condition e.g. hyperthyroidism

Investigations

ICD-11 criteria

• Unpredictable and recurrent episodes of severe anxiety not confined to any specific situation or circumstances
• Secondary fears include dying, losing control, or insanity
• Attacks typically last for minutes, often exhibiting a crescendo of fear and autonomic symptoms
• Comparative freedom from anxiety symptoms between attacks, though anticipatory anxiety is common

Management

1. Self-help
2. CBT or SSRI if long standing or no benefit from CBT
   1. Do not use benzodiazepines or sedating antihistamines as associated with a less good outcome in the long term
   2. Avoid propranalol, buspirone, buprioprion
3. Consider tricyclics e.g. clomipramine, desipramine if there is no improvement after 12 weeks and further medication is indicated