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 (1).
According to NICE (2) 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 (2) 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 (3). 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 (2).
In the Scottish Health Survey (4), 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% (5).
Panic disorder (with or without agoraphobia) is estimated to affect 1.6% of young adults ages 16-24 (6). Peak onset of panic disorder is mid-adolescence (7). 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 (2). 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 (2). 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 CYP
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 (8).
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 (9).
Overview of evidence for adults
As with Generalised anxiety disorder, NICE (2) 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 (2,5,10). In head-to-head comparison of treatment effectiveness CBT and behaviour therapy performed well in comparison to third-wave CBT (10).
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) (11-13) 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 (11-13). 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 (14). 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 (15).
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 (16) with moderate effects sizes, however, MBI effectiveness is not superior to CBT intervention, and MBIs do not seem effective in treating symptoms of fear (17). 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. Clinicians are advised that there are differences in presentation of psychological problems in later life and to consult Delivering Psychological Therapies and Interventions for Older People for further information on factors relevant to practice (18).
| 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 (8) | Specialist | A | Medium |
| Alternative (adolescents/ comorbidity) | Adolescents with co-morbid diagnosis | Condensed CBT (9) - 8-day intensive programme
|
Specialist | A | High |
| 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 (2) | Skilled / Enhanced | A | Medium-High |
| Guided self-help (2) | |||||
| Individual internet-delivered guided self-help based on CBT principles (11-13) | |||||
| 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 (2,5,13,19) | Enhanced / Specialist | A | Medium-High |
| Group CBT- for panic disorder with/without agoraphobia (14) | A | High | |||
| Internet-based/delivered Cognitive Behavioural Therapy (11,13) | A | Medium-High | |||
| 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 (10) | Specialist | A | Medium-High |
| 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 (15) | Specialist | A | High |
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
1.ICD-11 for Mortality and Morbidity Statistics.
2.NICE Guideline 113. Recommendations | Generalised anxiety disorder and panic disorder in adults: management | Guidance | NICE2011; . Accessed Jan 29, 2026.
3.Gale C.K., Millichamp J. Generalised anxiety disorder in children and adolescents. BMJ clinical evidence 2016;2016(pagination):Date of Publication: 13 Jan 2016.
4.Scottish Government Public Health Survey 2019.
5.Pompoli A., Furukawa T.A., 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;2016(4) (pagination):Article Number: CD011004. Date of Publication: 13 Ar 2016.
6.Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2014. Accessed Jan 29, 2026.
7.Baker HJ, Waite P. The identification and psychological treatment of panic disorder in adolescents: a survey of CAMHS clinicians. Child & Adolescent Mental Health 2020;25(3):135–142.
8.Wang Z, Whiteside SPH, Sim L, Farah W, Morrow AS, Alsawas M, et al. Comparative Effectiveness and Safety of Cognitive Behavioral Therapy and Pharmacotherapy for Childhood Anxiety Disorders: A Systematic Review and Meta-analysis. JAMA Pediatrics 2017;171(11):1049–1056.
9.Gallo KP, Chan PT, Buzzella BA, Whitton SW, Pincus DB. The impact of an 8-day intensive treatment for adolescent panic disorder and agoraphobia on comorbid diagnoses. Behavior Therapy 2012 Mar;43(1):153–159.
10.Papola D, Ostuzzi G, Tedeschi F, Gastaldon C, Purgato M, Del Giovane C, et al. Comparative efficacy and acceptability of psychotherapies for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials. British Journal of Psychiatry 2022;221(3):507–519.
11.Efron G., Wootton BM. Remote cognitive behavioral therapy for panic disorder: A meta-analysis. J Anxiety Disord 2021;79(pagination):Article Number: 102385. Date of Publication: 01 Ar 2021.
12.Polak M, Tanzer NK, Bauernhofer K, Andersson G. 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 2021 Apr;24:100364.
13.Papola D, Ostuzzi G, Tedeschi F, Gastaldon C, Purgato M, Del Giovane C, et al. CBT treatment delivery formats for panic disorder: a systematic review and network meta-analysis of randomised controlled trials. Psychol Med 2023;53(3):614–624.
14.Schwartze D, Barkowski S, Strauss B, Burlingame GM, Barth J, Rosendahl J. Efficacy of group psychotherapy for panic disorder: Meta-analysis of randomized, controlled trials. Group Dynamics: Theory, Research, and Practice 2017;21(2):77–93.
15.Horst F, Den Oudsten B, Zijlstra W, de Jongh A, Lobbestael J, De Vries J. Cognitive Behavioral Therapy vs. Eye Movement Desensitization and Reprocessing for Treating Panic Disorder: A Randomized Controlled Trial. Frontiers in Psychology 2017;8:1409.
16.Fumero A, Penate W, Oyanadel C, Porter B. The Effectiveness of Mindfulness-Based Interventions on Anxiety Disorders. A Systematic Meta-Review. European Journal of Investigation in Health Psychology & Education 2020 Jul 14;10(3):704–719.
17.de Abreu Costa, M., D'Alò de Oliveira, G. S., Tatton-Ramos, T., Manfro, G. G., & Salum, G. A. Anxiety and stress-related disorders and mindfulness-based interventions: A systematic review and multilevel meta-analysis and meta-regression of multiple outcomes. 2019; .
18.Hendriks G, Kampman M, Keijsers GPJ, Hoogduin CAL, Voshaar RCO. Cognitive-behavioral therapy for panic disorder with agoraphobia in older people: a comparison with younger patients. Depress Anxiety 2014 -08;31(8):669–677.
19.Common mental health problems: identification and pathways to care | Guidance | NICE2011; . Accessed Jan 29, 2026.