Panic disorder
Recurrent episodes of severe anxiety with autonomic symptoms, fear of dying or losing control, unrelated to a specific trigger.
ICD-10 F41.06 drugs
Also known as: PD
Drugs used for this condition
- AParoxetineFirst line · Selective serotonin reuptake inhibitor (SSRI)First-line for panic disorder. Dose 20–60 mg once daily. Low start dose (10 mg) with slow titration – anxiety worsening possible in first weeks.
- ASertralineFirst line · Selective serotonin reuptake inhibitors (SSRIs)First-line therapy for panic disorder with or without agoraphobia. Start at low doses (25 mg daily for the first week) to minimize initial anxiety worsening, then titrate to therapeutic doses. CBT has comparable efficacy and is recommended concurrently or as an alternative.
- BAlprazolamThird line · Benzodiazepines. Short-to-medium-acting anxiolyticsAlprazolam is FDA- and EMA-registered for panic disorder. Benzodiazepines are not recommended for routine or long-term treatment of panic disorder; they are reserved only for short-term use. NICE CG113 explicitly advises against prescribing benzodiazepines for panic disorder because of worse long-term outcomes and, together with WFSBP 2022, lists SSRIs (escitalopram, sertraline, paroxetine) as first-line due to a more favourable long-term profile: no dependence risk or withdrawal syndrome. Benzodiazepines are discussed as a 'bridge' during the first 4–6 weeks of treatment while SSRIs reach therapeutic effect, or when SSRIs are not tolerated. As a short-acting benzodiazepine, alprazolam carries a high potential for dependence and tolerance; it must be tapered gradually under medical supervision, not stopped abruptly, because of the risk of seizures and rebound anxiety.
- BLorazepamSecond line · Anxiolytics, benzodiazepine derivativesIn panic disorder, lorazepam is used short-term for acute panic attack control. The Andrisano 2013 meta-analysis showed benzodiazepine efficacy in the acute phase. APA 2009 panic disorder guidelines list SSRIs/SNRIs and CBT as first-line; benzodiazepines are an option for inadequate response or short-term bridging at antidepressant initiation. Acute panic attack dose: 0.5–1 mg sublingually or orally.
Marketing claims without evidence base
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
- DPassionflower (Passiflora incarnata, aerial parts)Not recommended · Herbal sedative, EMA HMPC traditional herbal medicinal productPassionflower is actively marketed for panic attacks and panic disorder. Clinical data for this diagnosis are very limited: one small GAD RCT is methodologically weak, and no separate RCT in panic disorder exists. EMA HMPC does not include «panic disorder» in the traditional-use indication. NICE CG113 (2019) recommends CBT and SSRIs for panic disorder, not herbal products. Marketing promises to replace benzodiazepines or antidepressants with passionflower are not supported by evidence. Panic disorder is a serious diagnosis with effective treatment. If passionflower was prescribed in place of standard therapy, consider seeking a second opinion.
- FPhenibutNot recommended · Other anxiolytics (local classification)Evidence tier F. International guidelines for panic disorder (NICE CG113) recommend cognitive behavioural therapy and SSRIs (sertraline, paroxetine, escitalopram) or SNRIs (venlafaxine) as first-line treatment. Benzodiazepines are reserved for short-term use. Phenibut has not been studied in panic disorder in indexed international literature and is not recommended in this role. Off-label phenibut use in panic disorder carries documented risk of dependence and severe withdrawal.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit