Diagnostic framework #
Recurrent unexpected attacks followed by at least a month of persistent concern or behavioral change support panic disorder. Establish whether attacks occur only in a trauma, social, phobic or obsessional context. Record agoraphobic avoidance separately, including dependence on companions and escape routes.
Targeted clinical assessment #
Reconstruct a typical attack: onset, physical sensations, catastrophic prediction, peak, recovery and actions taken. Ask about interoceptive fear, emergency visits, exercise avoidance and reassurance seeking. Review stimulants, caffeine, sedative withdrawal and medical history; assess depression and substance use.
Differential diagnosis #
| Alternative | Assessment priority |
|---|---|
| Acute coronary/respiratory illness | Chest pain, syncope, hypoxia or abnormal examination requires directed medical assessment. |
| Arrhythmia, endocrine or metabolic contributor | Identify timing, palpitations, exertion relationship and systemic clues. |
| Other anxiety syndromes | Clarify the feared situation or trigger. |
| Intoxication/withdrawal | Establish the exposure timeline. |
Indicated investigations #
| Indication | Assessment |
|---|---|
| New, exertional or atypical symptoms | Vitals, examination, ECG and other acute testing according to findings. |
| Possible medical/substance cause | Targeted endocrine, metabolic or toxicological assessment. |
| Prescribing baseline | Drug-specific cardiac, electrolyte and interaction review. |
Treatment sequence #
View treatment map
- Initial formulation
Explain the panic cycle and address acute medical questions.
- Specific therapy
Offer panic-focused CBT, including exposure to feared sensations and avoided situations where appropriate.
- Medicine preference or indication
Discuss an SSRI and transient initial activation; start according to indication-specific labeling.
- Persistent disability
Review adequacy of CBT, dose exposure, adherence and comorbidity before switching.
| Step | Approach |
|---|---|
| Initial formulation | Explain the panic cycle and address acute medical questions. |
| Specific therapy | Offer panic-focused CBT, including exposure to feared sensations and avoided situations where appropriate. |
| Medicine preference or indication | Discuss an SSRI and transient initial activation; start according to indication-specific labeling. |
| Persistent disability | Review adequacy of CBT, dose exposure, adherence and comorbidity before switching. |
Doses & prescribing #
Each prescribing record identifies its population and source jurisdiction; international labeling does not establish Indian approval. The clinician selects treatment after assessment.
Sertraline
Panic disorder with or without agoraphobia
Adults · Immediate-release tablets · Oral · United States product labeling
- Starting dose
- 25 mg once daily for the first week; then 50 mg once daily.
- Titration
- Subsequent increases of 25–50 mg/day no more often than weekly, according to response and tolerability.
- Treatment range / target
- 50–200 mg/day.
- Maximum / limits
- 200 mg/day.
- Trial & duration
- Condition-specific trial and continuation guidance below.
- Monitoring
- Activation, mood switch, suicidality, gastrointestinal/sexual effects; sodium when indicated.
- Population & organ-function adjustments
- Mild hepatic impairment: half starting and maximum doses; moderate/severe hepatic impairment: not recommended.
- Important cautions
- Avoid MAOIs and pimozide; reconcile serotonergic and bleeding-related interactions.
Nonresponse & escalation #
NICE recommends an alternative antidepressant class or another therapy if there is no improvement after a 12-week course. Distinguish persistent unexpected attacks from residual avoidance and from medication-induced activation. Complete exposure work rather than relying only on fewer attacks.
Maintenance & discontinuation #
Continue an effective antidepressant for at least 6 months after reaching the optimal dose under NICE panic guidance, then discuss tapering. Prepare for transient bodily sensations during withdrawal so they are not automatically interpreted as a new medical catastrophe or relapse.
Special populations & comorbidity #
Physical disease can coexist with panic disorder. Older age, pregnancy, organ impairment and concurrent sedatives require a separate medicine assessment. Apply the selected label’s hepatic adjustments; avoid assuming an ordinary adult starting schedule fits frailty.
Follow-up #
For a new medicine, NICE recommends review within 2 weeks, then at 4, 6 and 12 weeks; longer-term review is usually every 8–12 weeks. Track unexpected attacks, anticipatory anxiety and specific avoided activities.
Clinical pitfalls #
Paper-bag rebreathing should not replace medical assessment of unexplained breathlessness. A normal previous investigation does not explain every future chest symptom. Avoid judging recovery only by attack frequency when the person has stopped leaving home.
Assessment tools #
Choose the instrument for its intended purpose; interpretation accompanies the linked tool.
Patient discussion #
Open a plain-language explanation
Panic produces real physical sensations. Assessment checks their cause and treatment helps reduce fear of the sensations and avoidance.
References · 4
- NICE CG113: GAD and panic treatment · United Kingdom · Checked 2026-10-26 · Supports: Treatment sequence; Nonresponse & escalation; Maintenance & discontinuation; Follow-up
- NIMH: Panic disorder · United States · Checked 2026-10-26 · Supports: Targeted clinical assessment; Differential diagnosis; Indicated investigations; Treatment sequence; Special populations & comorbidity; Clinical pitfalls
- NHS: Panic disorder diagnosis and treatment · United Kingdom · Checked 2026-10-26 · Supports: Diagnostic framework
- Sertraline tablets: indication-specific product dosing · United States label · Checked 2026-10-26 · Supports: Indicated investigations; Special populations & comorbidity; Sertraline — Panic disorder with or without agoraphobia (Immediate-release tablets)