RCGP SCA Algorithm — UK Primary Care
A first "panic attack" is a diagnosis of exclusion. Rule out the physical emergency before reassuring.
Panic symptoms — palpitations, chest tightness, breathlessness, sweating, tremor, a sense of doom — overlap almost completely with acute cardiac, respiratory and endocrine emergencies. The first presentation, older age, cardiac risk factors or abnormal observations should push you towards physical assessment first. Severe anxiety, particularly with depression, is an independent risk factor for suicide.
Naming the specific disorder matters because NICE recommends different psychological treatments for each — for example individual CBT for social anxiety rather than group work, exposure and response prevention for OCD, and trauma-focused therapy for PTSD.
Targeted tests reassure appropriately and catch thyrotoxicosis and arrhythmia. Over-investigation, particularly in health anxiety, maintains the cycle of checking and reassurance-seeking.
Anxiety disorders commonly coexist, and with depression. When depression and anxiety coexist, NICE advises treating the depression first, unless the anxiety disorder is clearly primary.
PTSD, OCD and social anxiety go straight to the disorder-specific psychological treatment rather than generic self-help.
Stepped care offers the least intrusive effective intervention first and steps up when needed. People with marked functional impairment can enter at step 3 at the first consultation.
NHS Talking Therapies deliver the NICE-recommended psychological treatments for common anxiety disorders and accept self-referral, so the person can make contact the same day.
Next steps: see Anxiety disorders · PTSD · OCD · Depression · Hyperthyroidism · Harmful drinking and alcohol dependence · Benzodiazepines and z-drugs
NICE CG113 recommends sertraline as the first-choice drug for GAD on cost-effectiveness, advises against benzodiazepines except short-term in a crisis, and against antipsychotics in primary care. For panic disorder, benzodiazepines are associated with a less good long-term outcome. Second-line drugs, durations and disorder-specific dosing are in the Anxiety disorders protocol.
Avoidance and safety behaviours keep anxiety going by preventing the person from learning that the feared outcome does not happen — the core of CBT for anxiety.
Early review after an SSRI catches activation and emerging suicidal thoughts and prevents early drop-out. A change in the character of "panic" symptoms needs re-assessment rather than assumption.