Panic Disorder (with or without Agoraphobia)
Panic disorder, with or without agoraphobia, (PD) is an anxiety disorder that is characterised by recurrent unexpected panic attacks that are not restricted to stimuli or situations. Panic attacks are discrete episodes of intense fear or apprehension accompanied by the rapid and concurrent onset of several characteristic symptoms (e.g. palpitations or increased heart rate, sweating, trembling, shortness of breath, chest pain, dizziness or light-headedness, chills, hot flushes, fear of imminent death). Panic disorder is also characterised by persistent concern about the recurrence or significance of panic attacks, or behaviours intended to avoid their recurrence, resulting in significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. The symptoms are not a manifestation of another medical condition and are not due to the effects of a substance or medication on the central nervous system (ICD 11).
According to NICE (2011), many anxiety disorders, including panic disorders (with or without agoraphobia), are unrecognised and go undiagnosed. The co-occurrence of panic disorders with other mental health disorders (e.g., depression) may compound this. The NICE guidance for Generalised Anxiety Disorder and Panic Disorder (NICE Guideline 113, 2011) outlines principles supporting the identification and diagnosis of panic disorder. Access to psychological interventions can be affected by limits in availability of psychological services. As such, people presenting with anxiety disorders may be offered treatment with prescription drugs. Psychological therapies, medication and self-help have an evidence base in panic disorder and a discussion should be held with the person presenting with symptoms about the choice of approach based on assessment and shared decision making.
Treatment for PD in CYP should be considered in the context of the wider evidence for anxiety disorder presentations in children and young people given that co-occurrence of anxiety disorders is common and differential diagnosis can be difficult to establish in young children. (Gale) Treatment options are typically transdiagnostic in approach and are influenced by developmental stage and often include involving families, carers, schools and other systems. Further information on managing anxiety presentations in children can be found in the Matrix Generalised Anxiety guidance.
People who have panic disorder (along with their families and carers) need comprehensive information, presented in clear and understandable language, about the nature of their condition and the treatment options available. Such information is essential for shared decision-making between people with panic disorder and healthcare professionals, particularly when making choices between broadly equivalent treatments. In addition, given the emotional, social, and economic costs panic disorder usually entails, people with panic disorder (with or without agoraphobia), and their families and carers may need help in contacting support and self-help groups. Support groups can also promote understanding and collaboration between people who have panic disorder, their families and carers, and healthcare professionals at all levels of primary and secondary care (NICE Guideline 113, 2011).
In the Scottish Health Survey (Scottish Government, 2020), 14% of adults reported having two or more anxiety symptoms. Panic disorder (with or without agoraphobia), is common in the general population, with a lifetime prevalence of 1% to 4% (Pompoli 2016).
Panic disorder (with or without agoraphobia) is estimated to affect 1.6% of young adults ages 16-24 (Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2014.) Peak onset of panic disorder is mid-adolescence (Baker, 2020). Prevalence rates for the wider range of anxiety symptoms are considerably higher in children and young people (GAD table).
This information is for commissioners, managers, trainers, and health care practitioners to consider the evidence base for the delivery of psychological interventions for people with PD with or without agoraphobia. This information is also for people diagnosed with PD, their families, and carers.
This topic page covers evidence-based psychological interventions for the treatment of anxiety presentations in children and young people and PD specifically in adults, including those who may present in specialist settings. Full guidance on identifying, assessing and managing PD can be found in the NICE guidance. This topic does not cover pharmacological interventions or interventions which are not informed by psychological theory. There are a wider range of non-psychological interventions and supports that are beyond the scope of this topic and full guidance on best practice can be found (NICE). Further guidance on delivering psychological services and care for people presenting with anxiety is available in Good Practice guides for working with neurodiversity and working in CAMHS setting. (under development).
There are a range of psychological interventions that could be included in the treatment tables for PD. However, in order to be consistent with a focus on interventions with the highest levels of efficacy and the strongest levels of evidence where these exist, psychological interventions for the treatment of PD with low strength evidence and low levels of efficacy have not been included.
Overview of Evidence for Children and Young People
Available evidence for psychological interventions for the treatment of specific phobias in CYP populations is limited compared to those in adult populations. Where RCTs have been carried out treating anxiety in CYP populations, young people who have PD as the primary problem are often not included or if they are included, their specific outcomes tend to be unreported. However, high level evidence exists which supports CBT in the treatment of panic disorder in CYP, with moderate effect sizes reported (Wang).
There is some emerging evidence supporting an 8 day intensive CBT-informed intervention for PD with or without agoraphobia in alleviating symptoms of specific comorbid diagnoses, in particular specific phobias, GAD and social phobia (Gallo).
Overview of Evidence for Adults
As with Generalised anxiety disorder, NICE (113,123) recommends a stepped approach to interventions, for those with mild symptoms being recommended interventions that are easier to access such as, individual non-facilitated self-help (including internet delivered packages) and individual facilitated self-help, based on CBT principles.
There is high level evidence to support the effectiveness of Cognitive Behavioural Therapy (CBT) in the management of panic disorder (with or without agoraphobia) in adults. Both CBT and short-term psychodynamic therapy may be regarded as reasonable first-line psychotherapies in the acute phase of panic disorder (with or without agoraphobia), showing medium-to-large effect sizes. (NICE, Pompoli 2016, Papola). In head-to-head comparison of treatment effectiveness CBT and behaviour therapy performed well in comparison to third-wave CBT (Papola).
For CBT NICE recommends between 7 and 14 hours of treatment in total. This is usually provided as weekly sessions of 1–2 hours each, and the total treatment should be completed within 4 months.
Increasingly evidence suggests Internet-based CBT (ICBT) (Efron, Polak, Papola et al ) is equally as effective as face-to-face therapy in treating panic disorder, (with or without agoraphobia). Different remote delivery treatment approaches (including self-help and guided self-help iCBT) result in similar outcomes, although dropout rates tend to be much higher in self-help interventions (Efron, Polak, Papola et al). This indicates that individual preference is important and that a remote delivered stepped care pathway for panic may be possible.
There is evidence for large effects for group therapy in reducing symptoms of panic and agoraphobia when compared with no-treatment control groups, and no significant differences when group therapy was compared with individual psychotherapy (Schwartze). Group psychotherapy (primarily cognitive–behavioural therapy, CBT) should be considered as one of several treatment options for PD.
Eye Movement Desensitization and Reprocessing (EMDR) Therapy has been shown to be non-inferior to CBT for PD and may, therefore, be considered as a useful alternative to a conventional CBT treatment of PD patients, (Horst et al 2017).
Mindfulness Based Interventions (MBI’s), most frequently mindfulness based cognitive therapy and mindfulness-based stress reduction, seem promising therapeutic options for treating distress symptoms in anxiety disorders (Fumero 2020) with moderate effects sizes, however, MBI effectiveness is not superior to CBT intervention, and MBIs do not seem effective in treating symptoms of fear (Abreu Costa 2019). More research is needed to recommend MBIs as first-line treatments for anxiety and panic.
Overview of evidence for Older People
This review compared outcomes for CBT for panic with agoraphobia for older people with younger people. CBT appears feasible for over 60 years old with outcomes similar to or superior to younger people (Hendriks et al., 2014). Clinicians are advised that there are differences in presentation of psychological problems in later life and to consult Delivering Effective Psychological Therapies and Interventions to Older People for further information on factors relevant to practice.
| Recommendation | Who For? | List of Interventions | Type of Psychological Practice | Level of Evidence | Level of Efficacy |
| First line recommendation | Children and young people | CBT: Individual CBT (Wang) | Specialist | A | Moderate |
| Alternative (adolescents/ comorbidity) | Adolescents with co-morbid diagnosis | Condensed CBT (Gallo) - 8-day intensive programme
|
Specialist | A | Large |
| Recommendation | Who For? | List of Interventions | Type of Psychological Practice | Level of Evidence | Level of Efficacy |
| First Line Recommendation | Adults presenting in primary care meeting diagnostic criteria for PD (with or without agoraphobia) (mild/moderate) | Self-help (NICE 113) | Skilled / Enhanced | A | Medium to Large |
| Guided self-help (NICE 113) | |||||
| Individual internet-delivered guided self-help based on CBT principles (Polak, Efron, Papola et al)) | |||||
| First Line Recommendation | PD (with or without agoraphobia) with insufficient response to guided self-help or psychoeducation interventions or PD with marked functional impairment | Disorder specific CBT Cognitive Behavioural Therapy (NICE CG 113, CG 123,) Papola et al), Pompoli (2016)
|
Enhanced / Specialist | A | Medium to Large |
| Group CBT- for panic disorder with/without agoraphobia Schwartze (2017) | A | Large | |||
| Internet-based/delivered Cognitive Behavioural Therapy (Efron, Papola et al) | A | Medium to Large | |||
| Emerging first line recommendation | PD (with or without agoraphobia) with insufficient response to guided self-help or psychoeducation interventions or PD with marked functional impairment | Panic-focused short-term psychodynamic psychotherapy (Papola 2021 ) | Specialist | A | Medium to Large |
| Alternative if preferred | PD (with or without agoraphobia) with insufficient response to guided self-help or psychoeducation interventions or PD with marked functional impairment | Eye Movement Desensitization and Reprocessing (EMDR) therapy (Horst 2017)
|
Specialist | A | Large |
With thanks to Alice Loyal and Louise Waddington from NHS Wales who participated in the advisory and technical groups.
Advisory group:
Audrey Espie, Fhionna Moore, Suzy O’Connor, Anne Joice, Sean Harper, Alex Doherty, Gemma Brown, Naomi White, Andrew Jahoda, Suzanne Roos.
Technical group:
Marie Claire Shankland, Naomi Harding, Alia Ul-Hassan, Leeanne Nicklas, Fhionna Moore, Gemma Brown, Suzy O’Connor, Regina Esiovwa.
ICD (11) ICD-11 for Mortality and Morbidity Statistics (who.int)
National Institute for Health and Care Excellence. (2011. Updated June 2020) Generalised anxiety disorder and panic disorder in adults: management Clinical Guideline 113 Recommendations | Generalised anxiety disorder and panic disorder in adults: management | Guidance | NICE
National Institute for Health and Care Excellence. (2011, May 25) Common mental health problems: identification and pathways to care
Clinical guideline 123 Overview | Common mental health problems: identification and pathways to care | Guidance | NICE
C.K. Gale and J. Millichamp, “Generalised anxiety disorder,” BMJ Clin. Evid., vol. 2016, 2016
Scottish Government Health Survey (2020) https://www.gov.scot/publications/scottish-health-survey-2019-volume-1-main-report/pages/5/.
Pompoli, A., Furukawa, T. A., Imai, H., Tajika, A., Efthimiou, O., & Salanti, G. (2016). Psychological therapies for panic disorder with or without agoraphobia in adults: a network meta-analysis. The Cochrane Database of Systematic Reviews, 4, CD011004. https://doi.org/10.1002/14651858.CD011004.pub2
Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2014. https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/adult-psychiatric-morbidity-survey-survey-of-mental-health-and-wellbeing-england-2014
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Papola, D., Ostuzzi, G., Tedeschi, F., Gastaldon, C., Purgato, M., Del Giovane, C., Barbui, C. (2022). Comparative efficacy and acceptability of psychotherapies for panic disorder with or without agoraphobia: Systematic review and network meta-analysis of randomised controlled trials. The British Journal of Psychiatry, 221(3), 507-519. doi:10.1192/bjp.2021.148
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Polak,M., Tanzer,N.K., Bauernhofer,K., and Andersson,G. (2021) Disorder-specific internet-based cognitive-behavioral therapy in treating panic disorder, comorbid symptoms and improving quality of life: A meta-analytic evaluation of randomized controlled trials, Internet Interventions. Internet Interventions Volume 24, https://doi.org/10.1016/j.invent.2021.100364.
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Horst, F., Den Oudsten, B., Zijlstra, W., de Jongh, A., Lobbestael, J., & De Vries, J. (2017). Cognitive Behavioral Therapy vs. Eye Movement Desensitization and Reprocessing for Treating Panic Disorder: A Randomized Controlled Trial. Frontiers in Psychology, 8. https://doi.org/10.3389/fpsyg.2017.01409
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