Panic disorder and panic attacks: symptoms, causes and treatment

Key points

• A panic attack is a sudden rush of intense fear with strong physical symptoms, usually lasting 5 to 20 minutes [2][3].
• Attacks are frightening but not dangerous, and will not cause physical harm, the NHS states [2].
• Panic disorder is more than one attack: it is repeated attacks plus lasting worry about more, or avoidance built around them [2][7].
• Attacks are often mistaken for heart problems: one US review found panic disorder in 18% to 26% of emergency department chest pain patients [9].
• NICE recommends self-help first, then CBT of 7 to 14 hours or an antidepressant, and advises against benzodiazepines [1].

What panic disorder is

Panic disorder is an anxiety disorder in which a person has repeated, sudden panic attacks and then worries persistently about having more, or avoids situations because of them [2][7]. A single panic attack is not panic disorder. A panic attack is a short episode of intense fear with physical symptoms such as a racing heart, and it is not dangerous [2][3].

If you need help now. Samaritans: call 116 123, free, 24/7. Shout: text SHOUT to 85258. NHS 111, then choose the mental health option. Call 999 if anyone is in immediate danger.

The Adult Psychiatric Morbidity Survey 2023/4 found that 1.0% of adults in England met the criteria for panic disorder [5]. In ICD-11, the World Health Organization’s current classification, worry about further attacks and avoidance are core features of the diagnosis [7].

Symptoms

Symptoms come in two layers: during an attack, and between attacks. Most attacks last 5 to 20 minutes [2].

Physical symptoms during an attack:

• a racing, pounding or irregular heartbeat [2][3]
• chest pain or tightness, shortness of breath, or a choking feeling [2]
• sweating, trembling, hot flushes, chills, dizziness or nausea [2][3]

Psychological symptoms during an attack:

• a sense of dread, or of losing control [2][3]
• fear of fainting, dying or having a heart attack, and feeling detached from the body [2][3]

Between attacks, panic disorder shows in behaviour: worry about the next attack, avoidance of places linked to a previous one, and repeat visits to a GP or A&E [1][7][9].

Panic attacks are often confused with a heart attack: chest pain, breathlessness and an irregular heartbeat are common to both [2][9]. Anxiety attack is an everyday phrase, not a clinical one; the NHS and ICD-11 use panic attack [3][7].

Types

Panic disorder has no formal subtypes. NICE describes it in two forms, with and without agoraphobia [1].

• Panic disorder without agoraphobia. Repeated attacks and worry about them, without avoidance of places where escape would be difficult [1].
• Panic disorder with agoraphobia. Agoraphobia is fear of situations where escape might be hard or help unavailable, such as public transport or leaving home, and the NHS describes it as often a complication of panic disorder [4].
• Nocturnal panic attacks. Attacks that wake a person from sleep in a state of panic. A meta-analysis reported that 52.1% of patients with panic disorder had at least one in their lifetime, arising between stage 2 and stage 3 sleep, unconnected to nightmare content [8].

Causes and risk factors

There is no single cause. The NHS describes panic disorder as likely to result from a combination of factors [2].

Factors linked to higher risk:

• traumatic or very stressful life experiences [2]
• a close family member with panic disorder [2]
• an imbalance of neurotransmitters, the chemical messengers in the brain [2]
• depression or substance misuse, which NICE names as common alongside it [1]

Two popular explanations go further than the evidence. A family history raises the chance of panic disorder but does not decide it, and neurotransmitter imbalance is one factor among several, so calling panic a chemical imbalance overstates what is known [2].

How it is diagnosed

In the UK a GP usually makes the diagnosis and starts treatment [2]. Psychiatrists, registered with the GMC, and practitioner psychologists, registered with the HCPC, diagnose in specialist services [1].

Assessment is a conversation, not a test. NICE states it should draw out personal history, any self-medication and cultural or individual characteristics, and that clinicians should be alert to panic disorder occurring alongside depression or substance misuse [1].

NICE sets out what should happen when someone attends A&E during an attack: the minimum investigations needed to exclude acute physical problems, no admission to a bed in most cases, and referral to primary care [1]. Recognition is often missed. One US review found panic disorder in 18% to 26% of emergency department chest pain patients, and in one study none were identified [9].

NHS Talking Therapies services record the PHQ-9 and GAD-7 to track change, and adults aged 18 and over in England can refer themselves without a GP [3][6]. Nine out of ten people were seen within 6 weeks of referral, though waits vary by area [6]. A diagnosis names a pattern and opens access to treatment. It is not a permanent label.

Treatment

NICE guideline CG113 sets out stepped care, least intrusive effective option first [1].

• Step 1. Recognition and diagnosis [1].
• Step 2. For mild to moderate panic disorder, non-facilitated or facilitated self-help, with contact from a primary care professional usually every 4 to 8 weeks [1].
• Step 3. For moderate to severe panic disorder, with or without agoraphobia, referral for CBT or an antidepressant. CBT should total 7 to 14 hours, usually weekly sessions of 1 to 2 hours within a maximum of 4 months. Briefer CBT should be around 7 hours, built around structured self-help materials [1].
• Steps 4 and 5. Referral to specialist services if two interventions have been given and significant symptoms remain, then reassessment and combined treatment [1].

Decisions about medicines belong to a prescriber. NICE states that unless otherwise indicated an SSRI licensed for panic disorder should be offered, and that if an SSRI is unsuitable or there is no improvement after 12 weeks, imipramine or clomipramine may be considered [1].

NICE is direct about benzodiazepines: they are associated with a less good outcome in the long term and should not be prescribed for panic disorder. Sedating antihistamines and antipsychotics should not be prescribed for it either [1].

A Cochrane network meta-analysis of 60 studies found CBT the most studied and often superior to the alternatives, but concluded there is no high-quality evidence favouring one psychological therapy over another, rating the evidence low for all outcomes [10].

Living with panic disorder

Avoidance is the pattern that keeps panic disorder going. The NHS advises against avoiding situations that make you anxious, and suggests building up time in them gradually [3].

During an attack, the NHS suggests staying where you are if you can, breathing slowly and deeply, and reminding yourself that it will pass and is not life threatening [2].

Day to day, the NHS suggests regular exercise, cutting down on caffeine, alcohol and sugary food, stopping smoking, and self-help books based on CBT, which is what step 2 refers to [1][2].

If attacks affect your work or studies, you can tell an employer or university what you find difficult and what would help, such as a seat near a door or flexibility about travelling at busy times. UK charities named by the NHS are Anxiety UK, Mind, No Panic and Triumph Over Phobia [2].

When to speak to a professional

See a GP if:

• you have had panic attacks and they are happening again [2]
• worry about the next attack is changing where you go or how you travel [4][7]
• self-help has not worked, or you want to discuss treatment [3]
• you are using alcohol or drugs to manage the attacks [1]

If you are 18 or over and in England, you can refer yourself to NHS Talking Therapies without a GP appointment [3][6].

Get help straight away if you are struggling to keep yourself safe. Samaritans: call 116 123, free, 24/7. Shout: text SHOUT to 85258. NHS 111, then the mental health option. Call 999 if anyone is in immediate danger.

Common questions

Can a panic attack cause a heart attack?

No. The NHS states that although panic attacks are frightening, they are not dangerous, an attack will not cause physical harm, and it is unlikely anyone would be admitted to hospital because of one [2].

What is the difference between a panic attack and an anxiety attack?

Panic attack is the term used by the NHS and in ICD-11 [3][7]. Anxiety attack is an everyday phrase with no fixed medical meaning, usually describing a build-up of anxiety rather than the sudden peak of a panic attack [2][3].

How do you stop a panic attack?

The NHS advises staying put if possible, breathing slowly and deeply, and remembering that the attack will pass and is not life threatening [2]. For repeated attacks, NICE recommends CBT-based self-help first [1].

Can panic attacks happen while you are asleep?

Yes. Nocturnal panic attacks wake a person from sleep in a state of panic. A meta-analysis reported that 52.1% of people with panic disorder had experienced at least one, arising from sleep rather than from a nightmare [8].

Clinical review pending

References

1. National Institute for Health and Care Excellence. Generalised anxiety disorder and panic disorder in adults: management. NICE clinical guideline CG113, 2020. Guideline text accessed via NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK552847/
2. NHS. Panic disorder. nhs.uk, page last reviewed 22 August 2023. https://www.nhs.uk/mental-health/conditions/panic-disorder/
3. NHS. Anxiety, fear and panic. nhs.uk, page last reviewed 13 July 2026. https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/feelings-and-symptoms/anxiety-fear-panic/
4. NHS. Overview: Agoraphobia. nhs.uk, page last reviewed 31 October 2022. https://www.nhs.uk/mental-health/conditions/agoraphobia/overview/
5. NHS England Digital. Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2023/4. Chapter 1: Common mental health conditions. https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/survey-of-mental-health-and-wellbeing-england-2023-24/common-mental-health-conditions
6. NHS England. NHS Talking Therapies for anxiety and depression Manual, version 7.1. https://www.england.nhs.uk/wp-content/uploads/2018/06/nhs-talking-therapies-manual-v7.1-updated.pdf
7. Stein DJ, Szatmari P, Gaebel W, et al. Mental, behavioral and neurodevelopmental disorders in the ICD-11: an international perspective on key changes and controversies. BMC Medicine, 2020, volume 18, article 21. https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-020-1495-2
8. Belleville G, Potocnik A. A meta-analysis of sleep disturbances in panic disorder. In: Psychopathology, An International and Interdisciplinary Perspective. IntechOpen, 2019. https://www.intechopen.com/chapters/67142
9. Katerndahl DA. Panic and plaques: panic disorder and coronary artery disease in patients with chest pain. Journal of the American Board of Family Practice, 2004, volume 17, number 2, pages 114 to 126. https://www.jabfm.org/content/jabfp/17/2/114.full.pdf
10. Pompoli A, Furukawa TA, Imai H, Tajika A, Efthimiou O, Salanti G. Psychological therapies for panic disorder with or without agoraphobia in adults: a network meta-analysis. Cochrane Database of Systematic Reviews, 2016, issue 4, article CD011004. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011004.pub2/full