Panic Attack in Primary Care: Fast Management
1‑Minute Clinician Summary
A panic attack is a sudden episode of intense somatic and cognitive symptoms that peaks within minutes; the experience may mimic serious cardiac or respiratory illness. The GP’s first task is to exclude medical red flags – take a history, check vital signs and perform an ECG when chest pain is present [1]. Once serious illness is ruled out, reassure the patient that the attack is self‑limiting, explain the “fight‑or‑flight” response and guide them through slow diaphragmatic breathing (inhale four seconds, hold two, exhale six) [2]. Brief psychoeducation and cognitive strategies (challenging catastrophic thoughts, grounding exercises) can rapidly reduce distress. Panic disorder is common: approximately 22.7 % of adults have experienced a panic attack and up to 12 % of emergency presentations meet diagnostic criteria [3]. Cognitive‑behavioural therapy (CBT) is the first‑line treatment and can be delivered by GPs or psychologists; sessions usually number five to ten over ≤ 4 months [4]. Create a Mental Health Treatment Plan and refer to Delta Psychology when attacks are atypical, frequent despite brief CBT, or when cardiorespiratory red flags are present.
Key Points
• Safety first – Always exclude medical emergencies. Chest pain, syncope, persistent tachycardia, hypoxia or new neurological signs warrant ECG and, if suspicious, urgent transfer [1].
• Prevalence and impact – Panic attacks are common (22.7 % lifetime prevalence). Around 12 % of emergency department patients meet criteria for panic disorder and 20–35 % of chest‑pain presentations are panic‑related [3]. Misdiagnosis delays treatment (average delay 9–15 years) and increases disability and healthcare costs [5].
• GP management – Provide brief psychoeducation on the fight‑or‑flight response, instruct patients in breathing retraining, and challenge catastrophic thoughts. Advise on sleep, caffeine reduction, physical activity and avoidance of illicit substances. Consider SSRIs or a short course of benzodiazepine only when attacks are severe or frequent [6]. Use the Panic Disorder Severity Scale or OASIS to gauge severity.
• First‑line therapy – CBT is the evidence‑based first‑line treatment; it includes psychoeducation, breathing retraining, cognitive restructuring and exposure. The number needed to treat is three [7], and sessions usually involve five to ten appointments over ≤ 4 months [4].
• Referral and safety‑netting – Refer to clinical psychology for atypical presentations, cardiorespiratory red flags, or persistent attacks despite GP‑led interventions. Provide written instructions on when to seek urgent care and ensure follow‑up. Identify and manage comorbid depression or substance use.
When to Refer
• Atypical presentation or first episode ≥ 40 years – First panic attacks in older adults, atypical symptom clusters or prolonged confusion require comprehensive medical assessment and referral to clinical psychology once organic causes are excluded.
• Cardiorespiratory red flags – Chest pain triggered by exertion, syncope, persistent tachycardia, hypoxia or abnormal neurological signs warrant urgent investigation (history, physical exam and ECG) [1]. After exclusion of medical causes, referral for psychological assessment is advisable.
• Frequent attacks despite brief CBT/first‑line support – Attacks occurring more than twice weekly, significant anticipatory anxiety or functional impairment despite 4–6 weeks of GP‑led CBT and lifestyle advice should prompt referral for specialist psychological therapy.
Immediate escalation to emergency services is indicated whenever the patient expresses suicidal intent, shows psychosis/mania, has severe substance intoxication or when a serious medical condition is suspected.
Clinical Problem at a Glance
A panic attack is defined as a distinct episode of intense somatic and cognitive symptoms (e.g., racing heart, chest pain, shortness of breath, dizziness, fear of losing control or dying) that peaks rapidly and is not better explained by a medical condition [8]. Panic disorder involves recurrent unexpected attacks and persistent concern about further episodes. In primary care, these symptoms often mimic arrhythmias, myocardial infarction, asthma or seizures, creating diagnostic uncertainty [8]. Panic attacks are common: the lifetime prevalence of panic disorder is around 3.7 %, but 22.7 % of people experience at least one attack [3]. Up to 12 % of emergency department patients meet criteria for panic disorder, and 20–35 % of chest‑pain presentations are panic‑related [3]. Misinterpretation of benign symptoms leads to multiple investigations, delayed treatment and high healthcare use, with an average delay of 9–15 years before diagnosis [5].
Functionally, panic attacks interfere with work, parenting and relationships. Avoidance behaviour can progress to agoraphobia, restricting travel and social engagement. Sleep disturbance, absenteeism and reduced productivity are common. Co‑morbidity with depression, substance use or other anxiety disorders increases the risk of self‑harm. Rapid recognition and evidence‑based management in general practice can reduce unnecessary emergency transfers and improve patient outcomes.
Rapid Triage & Stepped Care
| Presentation | What to do in General Practice now | Threshold to Refer to Clinical Psychology | Escalate/Urgent |
|---|---|---|---|
| Typical panic attack in known patient – sudden palpitations, chest tightness, dyspnea, fear of dying; pattern consistent with previous episodes; stable vital signs | Seat patient and measure vitals; take brief history (triggers, previous episodes, medications); ensure oxygen saturation ≥ 95 %. Provide reassurance; explain that adrenaline causes the sensations and they will peak and settle quickly. Guide through slow diaphragmatic breathing (inhale 4 s, hold 2 s, exhale 6 s). Use 5‑4‑3‑2‑1 grounding technique. Offer written advice on caffeine reduction, sleep, exercise and alcohol moderation. Schedule review within 1–2 weeks. | If functional impairment persists, patient has strong avoidance/anticipatory anxiety or requests therapy, refer for CBT/ACT. | If chest pain is new or accompanied by syncope, severe dyspnea, neurological deficit or arrhythmia, perform ECG and transfer to ED. |
| First or atypical episode – first attack ≥ 40 years, gradual onset or prolonged confusion, prominent neurological signs, substance use | Obtain comprehensive history (family and cardiovascular history, substance use, medications); perform physical examination; check blood glucose and ECG. Screen for thyroid disease, anaemia and arrhythmias. Consider panic attack only after excluding medical causes. Provide psychoeducation and breathing retraining when stable. | After investigation, if symptoms are consistent with panic disorder and the patient is willing, refer to clinical psychology. | Urgent ED referral if chest pain is exertional, radiates or is accompanied by diaphoresis, hypotension, presyncope or focal neurology. |
| Frequent attacks despite 4–6 weeks of GP support – ≥ 2 attacks/week, significant anticipatory anxiety, avoidance of work/social activities | Reassess adherence to breathing and cognitive strategies; review for comorbid mood disorders and substance use. Consider starting an SSRI (e.g., sertraline 25 mg daily) and provide a short course (≤ 4 weeks) of benzodiazepine for severe attacks. Use structured rating scales (PDSS, OASIS) to monitor progress. | Persistent symptoms or patient preference for psychological therapy should trigger referral for structured CBT/ACT. | If the patient develops suicidal ideation, self‑neglect or risk behaviours, arrange urgent psychiatry assessment or crisis team involvement. |
| Comorbid mental illness or significant functional impairment – depression, PTSD, substance use, pregnancy, postpartum | Conduct risk assessment (suicidality, self‑harm). Address comorbid conditions; avoid alcohol/benzodiazepine if substance misuse. Provide psychoeducation to patient and family; consider perinatal mental health referral for pregnant or postpartum patients. | Early referral to clinical psychology and, where appropriate, psychiatrist or perinatal mental health service. | Urgent if psychosis, severe depression, postpartum psychosis or substance intoxication. |
| Risk of harm – suicidal intent, psychosis/mania, severe substance intoxication or violence | Provide crisis intervention; ensure patient is not left alone; involve family/support persons. | Immediate referral to mental health crisis team or ambulance. | Call emergency services; follow local mental health emergency protocol. |
What Works (Practical Management in General Practice)
Psychoeducation and normalisation – Explain the physiological fight‑or‑flight response and how adrenaline causes palpitations, dyspnea, chest tightness and dizziness. Emphasise that panic attacks reach a peak within minutes and then subside.
Breathing retraining – Teach diaphragmatic breathing: sit comfortably, inhale through the nose for four seconds, hold for two seconds and exhale for six seconds; repeat and practise daily [2]. If this is difficult, start with a 3‑1‑4 pattern and focus on stomach rather than chest breathing [10]. Encourage the patient to practise once or twice daily and during early signs of panic.
Grounding and cognitive strategies – Use the 5‑4‑3‑2‑1 grounding technique (five things you can see, four you can feel, etc.), progressive muscle relaxation and mindfulness. Help patients identify catastrophic thoughts (“I am having a heart attack”) and reframe them as sensations of anxiety. Ask them to remind themselves, “I’ve had this before; it will pass.”
Lifestyle modifications – Encourage regular exercise, adequate sleep and a balanced diet. Limit stimulants (caffeine, nicotine) and alcohol. Educate about the negative effects of illicit drug use and energy drinks.
Medication – SSRIs (sertraline, escitalopram, fluoxetine) are first‑line pharmacotherapy for panic disorder when attacks are frequent or co‑occur with depression [9]. Start at a low dose and titrate over 2–4 weeks; warn patients that improvement may take several weeks. Short‑acting benzodiazepines (alprazolam 0.25–0.5 mg, lorazepam 0.5–1 mg) may be used for severe acute attacks for ≤ 4 weeks with careful monitoring [6]. Avoid long‑term benzodiazepine use due to dependence.
Screening tools – Use the Panic Disorder Severity Scale (PDSS) or Overall Anxiety Severity and Impairment Scale (OASIS) to quantify severity; screen for depression (PHQ‑9), anxiety (GAD‑7) and substance use. Always ask about suicidal ideation and domestic violence.
Common pitfalls to avoid
Misdiagnosing panic attacks without excluding cardiac, pulmonary or neurological emergencies. Always perform a history and exam; record vital signs and perform an ECG when chest pain is present.
Over‑investigating typical panic attacks once a pattern is established, leading to patient dependence on repeated reassurance.
Prescribing long‑term benzodiazepines or high doses of propranolol without psychological intervention.
Ignoring comorbid conditions such as depression, PTSD or substance use disorder.
Failing to provide follow‑up and safety‑netting; many patients will continue to seek reassurance if they do not understand what to expect.
How We Help (Clinical Psychology at Delta Psychology)
What the practice provides – Delta Psychology offers evidence‑based treatment for panic disorder and related conditions. Psychologists use cognitive‑behavioural therapy (CBT), acceptance and commitment therapy (ACT), exposure (interoceptive and in‑vivo), trauma‑focused therapy, and mindfulness. Treatment usually involves 6–10 sessions of 50 minutes each over eight to sixteen weeks. Telehealth is available for rural or remote patients.
Typical treatment approach – Patients learn to monitor triggers and bodily sensations, practise breathing retraining and progressive muscle relaxation, challenge catastrophic thoughts, and gradually face feared situations. Psychoeducation about the fight‑or‑flight response, interoceptive exposure (e.g., intentional hyperventilation) and gradual real‑world exposure help reduce anxiety [11]. Homework and symptom monitoring are emphasised; family involvement is encouraged when appropriate.
Collaboration style – We collaborate closely with referrers. After the initial assessment, we send a summary letter detailing the patient’s goals and proposed treatment plan. Interim reports are sent mid‑treatment and upon discharge. We encourage GPs to continue monitoring physical health and medication. Secure messaging, telephone and face‑to‑face case conferences are available.
What to include in the referral – Please provide:
Key symptoms and duration (e.g., palpitations, chest pain, shortness of breath, fear of dying, avoidance).
Red flags or risks (suicidal thoughts, psychosis, substance use, domestic violence).
Relevant medical and psychiatric history (cardiovascular disease, asthma, thyroid disorders, previous mental health diagnoses).
Treatments tried (breathing retraining, CBT, medications) and their outcome.
Current medications and allergies.
Cultural or language factors; need for interpreter.
Accessibility needs (telehealth, mobility issues, carer involvement).
Evidence Snapshot
• RACGP HANDI – CBT for panic disorder (2016) – The Royal Australian College of General Practitioners recommends CBT, which includes psychoeducation, breathing retraining, progressive muscle relaxation, cognitive restructuring and exposure, as the first‑line therapy for panic disorder [7]. CBT may be provided by GPs or mental health professionals; face‑to‑face therapy typically involves five to ten sessions over ≤ 4 months [4]. The number needed to treat is three [12].
• Biobehavioral approach to distinguishing panic symptoms from medical illness (Frontiers in Psychiatry, 2024) – A narrative review identified six somatic symptom domains that commonly cause diagnostic confusion: non‑cardiac chest pain, palpitations, dyspnea, dizziness, abdominal distress and paresthesia [13]. The review notes that up to 12 % of emergency department patients meet criteria for panic disorder and that 20–35 % of chest‑pain presentations are panic‑related [3]. Chest pain should always be evaluated for potential cardiac causes; history, physical examination and ECG help determine whether pain is cardiac or non‑cardiac [1]. Cardiac patients typically report physical symptoms without catastrophic thoughts, whereas panic patients often report fear of dying or losing control [14].
• Breathing retraining – The Western Australian Centre for Clinical Interventions provides a simple breathing retraining protocol: sit on a comfortable chair, inhale through the nose for four seconds, hold for two seconds, exhale through the nose for six seconds and repeat; practise daily [2]. If slowing breathing is difficult, start with a 3‑1‑4 pattern and focus on stomach breathing [10].
• Pharmacotherapy guidance – Evidence suggests most panic attacks subside spontaneously within 20 minutes. If medication is necessary, a short course of benzodiazepine (e.g., alprazolam or lorazepam) may abort acute attacks, but treatment should be limited to four weeks and combined with SSRIs or CBT [6] [9]. SSRIs (paroxetine, sertraline, escitalopram) are first‑line pharmacotherapy; start low, titrate gradually and continue for 8–12 months.
Cheat‑Sheet: Panic Attack Quick Guide (for GPs)
FAQ:
Panic vs cardiac – Panic attacks can cause chest pain, palpitations and breathlessness, but cardiac chest pain is usually triggered by exertion, may radiate to the left arm or jaw and often improves with rest or nitroglycerine. Always take a history, perform an examination and ECG; unstable or exertional chest pain requires urgent evaluation [1]. Panic‑related chest pain often comes with fear of dying or losing control, palpitations and tingling; if cardiac work‑up is normal and cognitive symptoms dominate, panic disorder becomes more likely [14].
Breathing retraining steps – Diaphragmatic breathing is a first‑line technique for managing panic. Ask the patient to sit comfortably, inhale through the nose for four seconds, hold for two seconds and exhale for six seconds, then pause and repeat [2]. Practise once or twice daily and use the technique when early symptoms of panic arise; start with a 3‑1‑4 rhythm if slowing the breath is difficult and ensure the abdomen rises during inhalation [10].
Local & Administrative Notes
Medicare and PHN pathways: For eligible patients, prepare a Mental Health Treatment Plan (e.g., MBS items 2715/2717) to enable Medicare rebates for up to 10 individual and 10 group psychological sessions per calendar year. Check your local Primary Health Network (PHN) for low‑cost services (e.g., headspace for youth, Aboriginal Medical Services, Access to Allied Psychological Services). Telehealth may be available for rural/remote patients.
Cultural safety and accessibility: Offer interpreter services and ensure culturally appropriate care. Involve carers, family or Elders when appropriate. Provide resources in the patient’s preferred language. Consider telehealth for mobility or transport barriers.