Panic Disorder

According to NICE, many anxiety disorders, like panic disorders, can go unrecognised or undiagnosed. Treatment of panic disorders occurs mostly in primary care, however, poor recognition of panic disorders in this setting impacts the provision of care for this disorder. Co-occurrence of panic disorders with other mental health disorders (e.g., depression) could contribute to their non-recognition. For people using services for anxiety disorders, treatment may be limited to prescription drugs, partly due to unavailability of psychological services https://www.nice.org.uk/guidance/cg113/resources/generalised-anxiety-disorder-and-panic-disorder-in-adults-management-35109387756997 . In Children and Young People (CYP), there appear to be difficulties in diagnosing panic disorder, possibly due to overlapping symptoms with other comorbid disorders (especially anxiety disorders) https://acamh.onlinelibrary.wiley.com/doi/full/10.1111/camh.12372.

People who have panic disorder and 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 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. https://www.nice.org.uk/guidance/cg113/resources/generalised-anxiety-disorder-and-panic-disorder-in-adults-management-35109387756997

In the Scottish Health Survey (Scottish Government, 2020), 14% of adults reported having two or more anxiety symptoms in 2019. There has been a significant increase in reported anxiety from earlier surveys which has seen a 6% increase since 2008. Earlier surveys suggested a gender difference in reporting rates of PD (with higher rates in women than men) but this difference seems to be reducing in more recent papers (with reporting rates of 15% and 13% respectively). https://www.gov.scot/publications/scottish-health-survey-2019-volume-1-main-report/pages/5/

PD is prevalent in about 1% of adolescents and has a significant impact on social and academic functioning according to Baker (2020). However, rates for symptoms of anxiety are considerably higher. In a recent report by the UK government, anxiety disorders were more common than depressive disorders in CYP. The rates of both anxiety and depressive disorders increases with age. Of children aged 17 to 19, about one in eight had an anxiety disorder. https://acamh.onlinelibrary.wiley.com/doi/full/10.1111/camh.12372. https://files.digital.nhs.uk/14/0E2282/MHCYP%202017%20Emotional%20Disorders.pdf

This topic page covers approaches for the treatment of panic disorder with/or without agoraphobia in children, young people, and adults. This topic area includes the psychological practice/settings in which each intervention can be applied. Full guidance on best practice in identifying, assessing, and managing Panic disorder and other anxiety disorders can be found in the NICE guidance and pathways https://pathways.nice.org.uk/pathways/panic-disorder.

Within the tables below, several interventions are included with demonstrated effectiveness in adult, children and young people with panic disorder. Where there is the more research, the psychological interventions with be provided with an ‘A’ strength evidence of a medium or high level of efficacy have been included. There are several psychological treatments for adults with lower strength evidence of efficacy that are not included in the Table. There are less available interventions in the evidence tailored to children and young people and this is reflected in the tables below.

Adults (Orange):

The evidence tables below show a range of evidence-based interventions for adult with PD. The evidence provided shows five face-to face interventions, one group intervention and one form of internet-based therapy which show medium/high efficacy in treating PD in adult populations.

The face-to face therapies identified were, Brief Therapist-Guided Exposure Treatment, Mindfulness-based interventions (MBIs), Cognitive-behavioural Therapy, Panic-focused psychodynamic psychotherapy and Eye Movement Desensitization and Reprocessing (EMDR) therapy which have shown relatively moderate/high effect sizes in reducing panic disorder within adults thus far. With Cognitive Behavioural Therapy^3.4.5.6 there is a substantial evidence which helps those with panic disorders which show medium and high effect sizes. With face-to-face CBT, there is also group-based CBT which has shown effective in treating panic disorder, which has been just as effective as individual CBT⁷. Evidence below shows that CBT with additional MBI has been effective intreating panic disorder also. Like face-to-face interventions, there has been internet-based interventions which have shown promise with High effect sizes and substantial research. NICE (2020) recommends 7 and 14 hours of treatment of CBT total provided as weekly sessions of 1–2 hours each, and the total treatment should be completed within 4 months. Similarly, a 4-session protocol consisting of a 60-minute lecture and 60-minute relaxation/meditation training has been recommended (Lim et al., 2018). Like Fumero et al., 2020, the 4-session protocol investigated the essential parts of mindfulness-based brief CBT to optimize treatment benefits. A meta-analysis identifies CBT being an effective treatment for those with panic disorder, compared to other means additionally (Pompoli et al., 2016). With regards to group CBT, (Bilet et al., 2020) identifies the success in group CBT within outpatient groups who suffer panic disorder and agoraphobia. Moreover, there has been a medium treatment effect for panic disorder within 12 months after treatment when CBT was compared with pill placebo, suggesting CBT is an effective means of treatment (van Dis et al., 2019). Additionally, recent evidence suggests Internet-based CBT (ICBT)^8,9,10 is equally as effective as face-to-face therapy as three studies identify ICBT an effective means in treating panic disorder. With this, the internet-based approach has seen to be effective in treating PD in those who experience phobias and panic attacks which has shown a moderate/high efficacy. Generally, the research regarding treating PD in adults has showed promise with varied interventions showing moderate/high efficacy which can be applied within primary, secondary, or potentially subclinical areas. Similarly, within the evidence, a ‘stepped care model’¹⁸ has been recommended due to the large effect size given which suggests this model is just as effective as face-to face CBT. Similarly, to CBT, a stepped care model might be useful for increasing patients’ access to evidence-based psychological treatments for anxiety disorders, specifically with those with PD.

The table of evidence should help inform possible treatment approaches for adults with PD who experience with or without agoraphobia. Although NICE¹⁹ recommends CBT as an intervention to treat PD, there is substantial evidence to suggest others means of treatment can be effective. It is important to consider the benefits of internet-based the need for treating those with PD who perhaps may benefit from this intervention. Considerations apply to people with PD with significant co-morbidity and co-occurrence of panic disorders with other mental health disorders.

Children and Young people (CYP) (Green):

There are fewer studies focusing on PD in CYP populations in comparison to adult populations. Despite this, within the research shown in the evidence tables below, there is effective means within CBT^14,15,16 for CYP as evidence shows the effectiveness of CBT within CYP populations. Firstly, research investigating the comparative effectiveness and adverse events of CBT and pharmacotherapy for childhood anxiety disorders found that CBT significantly improved primary anxiety symptoms, remission, and response. With this, Wang et al., (2017) found CBT¹⁴ reduced primary anxiety symptoms more than fluoxetine and improved remission more than sertraline. Evidence in the tables below show that face-to face CBT has been an effective means intreating PD in CYP populations which is apparent given the high effect size of this intervention. Alternatively, according to clinicians, the struggle to identify panic disorder or suitable treatment protocols for treating adolescents, although most would use CBT as the treatment approach¹⁶.

Additionally, an 8-day intensive programme consisting of: psychoeducation, cognitive restructuring training, interoceptive exposures, in-vivo exposures, and relapse prevention has been effective in adolescents ages 12-17 years of age with a primary diagnosis of PD with Agoraphobia or without Agoraphobia¹⁵. Similarly, to the evidence regarding ‘stepped care model¹⁸ in adults, this 8-day intensive programme has been recommended due to the large effect size given which has shown as being effective alongside the CBT intervention. Similarly, to the stepped care model, this intervention might be useful for increasing CYP’s access to evidence-based psychological treatments for anxiety disorders, specifically with those with PD.

There is also growing evidence to support group-based interventions for young people as group cognitive behavioural therapy (CBT) was significantly more effective than the other psychotherapies and all control conditions posttreatment within the research provided within the evidence tables¹⁷.

CBT interventions and treating CYP with PD has been the most effective treatment within the research with high levels of evidence with moderate/high effect sizes. The treatment of CYP with PD is important and considerations should be made due to difficulties due to overlapping symptoms with other comorbid disorders.

Treatment

*NES can provide details of what service levels and types of practice are to help populate these columns.

Treatment

1. Fumero, A., Peñate, W., Oyanadel, C., & Porter, B. (2020). The Effectiveness of Mindfulness-Based Interventions on Anxiety Disorders. A Systematic Meta-Review. European Journal of Investigation in Health, Psychology and Education, 10(3), 704–719. https://doi.org/10.3390/ejihpe10030052
2. Hall, C. B., & Lundh, L.-G. (2018). Brief Therapist-Guided Exposure Treatment of Panic Attacks: A Pilot Study. Behavior Modification, 43(4), 564–586. https://doi.org/10.1177/0145445518776472
3. National Institute for Health and Care Excellence. (2020, November 4). Panic disorder - NICE Pathways. Pathways.nice.org.uk. https://pathways.nice.org.uk/pathways/panic-disorder#content=view-node%3Anodes-step-3-review-and-consideration-of-alternative-treatments
4. Gensichen*1, J., S. Hiller*1, T., Breitbart, J., Brettschneider, C., Teismann, T., Schumacher, U., Lukaschek, K., Schelle, M., Schneider, N., Sommer, M., Wensing, M., König*2, H.-H., & Margraf*2, J. (2019). Panic Disorder in Primary Care. Deutsches Ärzteblatt International, 116(10), 159–166. https://doi.org/10.3238/arztebl.2019.0159
5. Lim, J.-A., Lee, Y. I., Jang, J. H., & Choi, S.-H. (2018). Investigating effective treatment factors in brief cognitive behavioral therapy for panic disorder. Medicine, 97(38), e12422. https://doi.org/10.1097/md.0000000000012422
6. 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
7. Bilet, T., Olsen, T., Andersen, J. R., & Martinsen, E. W. (2020). Cognitive behavioral group therapy for panic disorder in a general clinical setting: a prospective cohort study with 12 to 31-years follow-up. BMC Psychiatry, 20(1). https://doi.org/10.1186/s12888-020-02679-w
8. van Dis, E. A. M., van Veen, S. C., Hagenaars, M. A., Batelaan, N. M., Bockting, C. L. H., van den Heuvel, R. M., Cuijpers, P., & Engelhard, I. M. (2019). Long-term Outcomes of Cognitive Behavioral Therapy for Anxiety-Related Disorders. JAMA Psychiatry, 77(3). https://doi.org/10.1001/jamapsychiatry.2019.3986
9. Andrews, G., Basu, A., Cuijpers, P., Craske, M. G., McEvoy, P., English, C. L., & Newby, J. M. (2018). Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis. Journal of Anxiety Disorders, 55, 70–78. https://doi.org/10.1016/j.janxdis.2018.01.001
10. Schröder, J., Jelinek, L., & Moritz, S. (2017). A randomized controlled trial of a transdiagnostic Internet intervention for individuals with panic and phobias – One size fits all. Journal of Behavior Therapy and Experimental Psychiatry, 54, 17–24. https://doi.org/10.1016/j.jbtep.2016.05.002
11. Olthuis, J. V., Watt, M. C., Bailey, K., Hayden, J. A., & Stewart, S. H. (2015). Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd011565
12. Keefe, J. R., Huque, Z. M., DeRubeis, R. J., Barber, J. P., Milrod, B. L., & Chambless, D. L. (2019). In-session emotional expression predicts symptomatic and panic-specific reflective functioning improvements in panic-focused psychodynamic psychotherapy. Psychotherapy, 56(4), 514–525. https://doi.org/10.1037/pst0000215
13. 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
14. Wang, Z., Whiteside, S. P. H., Sim, L., Farah, W., Morrow, A. S., Alsawas, M., Barrionuevo, P., Tello, M., Asi, N., Beuschel, B., Daraz, L., Almasri, J., Zaiem, F., Larrea-Mantilla, L., Ponce, O. J., LeBlanc, A., Prokop, L. J., & Murad, M. H. (2017). Comparative Effectiveness and Safety of Cognitive Behavioral Therapy and Pharmacotherapy for Childhood Anxiety Disorders. JAMA Pediatrics, 171(11), 1049. https://doi.org/10.1001/jamapediatrics.2017.3036
15. Gallo, K. P., Chan, P. T., Buzzella, B. A., Whitton, S. W., & Pincus, D. B. (2012). The Impact of an 8-Day Intensive Treatment for Adolescent Panic Disorder and Agoraphobia on Comorbid Diagnoses. Behavior Therapy, 43(1), 153–159. https://doi.org/10.1016/j.beth.2011.05.002
16. Baker, H. J., & Waite, P. (2020). The identification and psychological treatment of panic disorder in adolescents: a survey of CAMHS clinicians. Child and Adolescent Mental Health, 25(3), 135–142. https://doi.org/10.1111/camh.12372
17. Zhou, X., Zhang, Y., Furukawa, T. A., Cuijpers, P., Pu, J., Weisz, J. R., Yang, L., Hetrick, S. E., Del Giovane, C., Cohen, D., James, A. C., Yuan, S., Whittington, C., Jiang, X., Teng, T., Cipriani, A., & Xie, P. (2019). Different Types and Acceptability of Psychotherapies for Acute Anxiety Disorders in Children and Adolescents. JAMA Psychiatry, 76(1), 41. https://doi.org/10.1001/jamapsychiatry.2018.3070
18. Nordgreen, T., Haug, T., Öst, L.-G., Andersson, G., Carlbring, P., Kvale, G., Tangen, T., Heiervang, E., & Havik, O. E. (2016). Stepped Care Versus Direct Face-to-Face Cognitive Behavior Therapy for Social Anxiety Disorder and Panic Disorder: A Randomized Effectiveness Trial. Behavior Therapy, 47(2), 166–183. https://doi.org/10.1016/j.beth.2015.10.004
19. National Institute for Health and Care Excellence. (2019). What treatments should I be offered for panic disorder? | Information for the public | Generalised anxiety disorder and panic disorder in adults: management | Guidance | NICE. Www.nice.org.uk. https://www.nice.org.uk/guidance/cg113/ifp/chapter/What-treatments-should-I-be-offered-for-panic-disorder#psychological-treatment
20. Scottish Government. (2020, September 29). Scottish Health Survey 2019 - Volume 1: Main Report - gov.scot. Www.gov.scot. https://www.gov.scot/publications/scottish-health-survey-2019-volume-1-main-report/pages/5/

Brief Therapist-Guided Exposure Treatment,  can be effective in treating adults with panic disorder within primary care settings where a three-session therapist-guided exposure treatment was tested in a consecutive series of eight primary health care patients suffering from panic attacks who specifically used distraction techniques as their primary safety behaviour. Additionally, a Systematic Meta-Review has reported on the effectiveness of mindfulness-based interventions (MBIs). This study shows clinical trials and experimental designs which have been implemented, with different samples and diverse MBI procedures, including panic disorder which shows the reduction in anxiety symptoms (Fumero et al., 2020).

With Cognitive Behavioural Therapy there is medium/high efficacy evidence which helps those with panic disorder. NICE (2020) recommends 7 and 14 hours of treatment of CBT total provided as weekly sessions of 1–2 hours each, and the total treatment should be completed within 4 months. Similarly, a 4-session protocol consisting of a 60-minute lecture and 60-minute relaxation/meditation training has been recommended (Lim et al., 2018). Like Fumero et al., 2020, the 4-session protocol investigated the essential parts of mindfulness-based brief CBT to optimize treatment benefits. A meta-analysis identifies CBT being an effective treatment for those with panic disorder, compared to other means additionally (Pompoli et al., 2016). With regards to group CBT, (Bilet et al., 2020) identifies the success in group CBT within outpatient groups who suffer panic disorder and agoraphobia. Moreover, there has been a medium treatment effect for panic disorder within 12 months after treatment when CBT was compared with pill placebo, suggesting CBT is an effective means of treatment (van Dis et al., 2019). Additionally, recent evidence suggests Internet-based CBT (ICBT)^8,9,10 is equally as effective as face-to-face therapy as three studies identify ICBT an effective means in treating panic disorder. With this, the internet-based approach has seen to be effective in treating PD in those who experience phobias and panic attacks which has shown a moderate/high efficacy. Generally, the research regarding treating PD in adults has showed promise with varied interventions showing moderate/high efficacy which can be applied within primary, secondary, or potentially subclinical areas. Similarly, within the evidence, a ‘stepped care model’¹⁸ has been recommended due to the large effect size given which suggests this model is just as effective as face-to face CBT. Similarly, to CBT, a stepped care model might be useful for increasing patients’ access to evidence-based psychological treatments for anxiety disorders, specifically with those with PD. (Andrews et al., 2018, Schröder, Jelinek and Moritz, 2017, Olthuis et al., 2016).

The table of evidence should help inform possible treatment approaches for adults with PD who experience with or without agoraphobia. Although NICE¹⁹ recommends CBT as an intervention to treat PD, there is substantial evidence to suggest others means of treatment can be effective. It is important to consider the benefits of internet-based the need for treating those with PD who perhaps may benefit from this intervention. Considerations apply to people with PD with significant co-morbidity and co-occurrence of panic disorders with other mental health disorders.

Additionally, Keefe et al., (2019) suggests that Panic-focused psychodynamic psychotherapy is effective in treating patients with panic disorder where those who engage in more emotional expression over the course of the first five weeks of therapy have superior symptomatic outcomes across the remainder of the treatment. Similarly, Eye Movement Desensitization and Reprocessing (EMDR) therapy has been a useful treatment, like CBT in the treatment of PD. Due to panic attacks being experienced and panic memories specific to panic disorder which also resemble traumatic memories as seen in posttraumatic stress disorder (PTSD) (Horst et al., 2017).

Reference list

1. Andrews, G., Basu, A., Cuijpers, P., Craske, M.G., McEvoy, P., English, C.L. and Newby, J.M. (2018). Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis. Journal of Anxiety Disorders, [online] 55, pp.70–78. Available at: https://www.sciencedirect.com/science/article/pii/S0887618517304474#bib0045.
2. Baker, H.J. and Waite, P. (2020). The identification and psychological treatment of panic disorder in adolescents: a survey of CAMHS clinicians. Child and Adolescent Mental Health, 25(3), pp.135–142.
3. Bilet, T., Olsen, T., Andersen, J.R. and Martinsen, E.W. (2020). Cognitive behavioral group therapy for panic disorder in a general clinical setting: a prospective cohort study with 12 to 31-years follow-up. BMC Psychiatry, 20(1).
4. Fumero, A., Peñate, W., Oyanadel, C. and Porter, B. (2020). The Effectiveness of Mindfulness-Based Interventions on Anxiety Disorders. A Systematic Meta-Review. European Journal of Investigation in Health, Psychology and Education, [online] 10(3), pp.704–719. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314302/ [Accessed 28 Jul. 2020].
5. Gallo, K.P., Chan, P.T., Buzzella, B.A., Whitton, S.W. and Pincus, D.B. (2012). The Impact of an 8-Day Intensive Treatment for Adolescent Panic Disorder and Agoraphobia on Comorbid Diagnoses. Behavior Therapy, 43(1), pp.153–159.
6. Gensichen, J., S. Hiller, T., Breitbart, J., Brettschneider, C., Teismann, T., Schumacher, U., Lukaschek, K., Schelle, M., Schneider, N., Sommer, M., Wensing, M., König*2, H.-H. and Margraf*2, J. (2019). Panic Disorder in Primary Care. Deutsches Ärzteblatt International, [online] 116(10), pp.159–166. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6482367/.
7. Hall, C.B. and Lundh, L.-G. (2018). Brief Therapist-Guided Exposure Treatment of Panic Attacks: A Pilot Study. Behavior Modification, [online] 43(4), pp.564–586. Available at: https://journals.sagepub.com/doi/10.1177/0145445518776472.
8. Horst, F., Den Oudsten, B., Zijlstra, W., de Jongh, A., Lobbestael, J. and 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.
9. Keefe, J.R., Huque, Z.M., DeRubeis, R.J., Barber, J.P., Milrod, B.L. and Chambless, D.L. (2019). In-session emotional expression predicts symptomatic and panic-specific reflective functioning improvements in panic-focused psychodynamic psychotherapy. Psychotherapy, 56(4), pp.514–525.
10. Lim, J.-A., Lee, Y.I., Jang, J.H. and Choi, S.-H. (2018). Investigating effective treatment factors in brief cognitive behavioral therapy for panic disorder. Medicine, 97(38), p.e12422.
11. National Institute for Health and Care Excellence (2019). What treatments should I be offered for panic disorder? | Information for the public | Generalised anxiety disorder and panic disorder in adults: management | Guidance | NICE. [online] www.nice.org.uk. Available at: https://www.nice.org.uk/guidance/cg113/ifp/chapter/What-treatments-should-I-be-offered-for-panic-disorder#psychological-treatment. 
12. National Institute for Health and Care Excellence (2020). Panic disorder - NICE Pathways. [online] pathways.nice.org.uk. Available at: https://pathways.nice.org.uk/pathways/panic-disorder#content=view-node%3Anodes-step-3-review-and-consideration-of-alternative-treatments [Accessed 22 Sep. 2021].
13. Pompoli, A., Furukawa, T.A., Imai, H., Tajika, A., Efthimiou, O. and Salanti, G. (2016). Psychological therapies for panic disorder with or without agoraphobia in adults: a network meta-analysis. The Cochrane database of systematic reviews, [online] 4, p.CD011004. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27071857 [Accessed 13 Dec. 2019].
14. Schröder, J., Jelinek, L. and Moritz, S. (2017). A randomized controlled trial of a transdiagnostic Internet intervention for individuals with panic and phobias – One size fits all. Journal of Behavior Therapy and Experimental Psychiatry, 54, pp.17–24.
15. Scottish Government (2020). Scottish Health Survey 2019 - Volume 1: Main Report - gov.scot. [online] www.gov.scot. Available at: https://www.gov.scot/publications/scottish-health-survey-2019-volume-1-main-report/pages/5/.
16. van Dis, E.A.M., van Veen, S.C., Hagenaars, M.A., Batelaan, N.M., Bockting, C.L.H., van den Heuvel, R.M., Cuijpers, P. and Engelhard, I.M. (2019). Long-term Outcomes of Cognitive Behavioral Therapy for Anxiety-Related Disorders. JAMA Psychiatry, [online] 77(3). Available at: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2756136.
17. Wang, Z., Whiteside, S.P.H., Sim, L., Farah, W., Morrow, A.S., Alsawas, M., Barrionuevo, P., Tello, M., Asi, N., Beuschel, B., Daraz, L., Almasri, J., Zaiem, F., Larrea-Mantilla, L., Ponce, O.J., LeBlanc, A., Prokop, L.J. and Murad, M.H. (2017). Comparative Effectiveness and Safety of Cognitive Behavioral Therapy and Pharmacotherapy for Childhood Anxiety Disorders. JAMA Pediatrics, 171(11), p.1049.

This topic area and document itself is aimed at increasing access to support for people with anxiety disorders, such as panic disorder with/or without agoraphobia. The intended audience is commissioners, managers, trainers, and practitioners to consider the evidence base for the delivery of interventions and the best way to implement training on psychological interventions into practice to help those with this disorder.