Anxiety and panic symptoms — adults
0Stop — call 999 now — before any history
- Chest pain with sweating, breathlessness or collapse → possible ACS or PE 999
- Palpitations with syncope or compromise → arrhythmia 999
- Severe tachycardia, fever, agitation in known or suspected hyperthyroidism → thyroid storm 999
- Withdrawal with fitting or confusion, or immediate danger to life → 999
1Triage — pattern of the anxiety
| Pattern | Likely disorder |
|---|---|
| Constant worry | GAD — usually 6+ months, hard to control |
| Sudden attacks | Panic disorder — peak within minutes, fear of further attacks |
| After trauma | PTSD — re-experiencing, avoidance, hyperarousal |
| Thoughts + rituals | OCD — checking, washing, counting |
| Scrutiny or illness fear | Social anxiety; health anxiety |
2Screen — one row is enough
- Hypoglycaemia on insulin or a sulfonylurea → check glucose, treat Same-day
- Alcohol or benzodiazepine withdrawal: tremor, sweating, hallucinations → Same-day medical assessment
- Suicidal intent, a plan, or unable to stay safe → crisis team Same-day (NHS 111 option 2)
- Psychotic symptoms or severe agitation → Same-day; consider stimulants
- Safeguarding: domestic abuse, coercive control, children at home → Same-day
3Assess — targeted, not blanket
☐ Pulse rate and rhythm, BP, SpO₂, weight ☐ Thyroid signs, heart, chest ☐ Caffeine, alcohol, drugs, medicines (salbutamol, steroids, levothyroxine, stimulants) ☐ Mood, suicide, past mania ☐ GAD-7 as a measure
By indication: TSH, FBC, HbA1c/glucose, ECG for palpitations or chest symptoms; plasma metanephrines only for paroxysmal headache, sweating and palpitations with hypertension.
Avoid: repeated cardiac tests after normal results in clear health anxiety.
4Classify — only if the screen is negative
- GAD or panic — stepped care: education and monitoring → self-help or groups → CBT/applied relaxation or SSRI.
- Social anxiety — individual CBT (not group). OCD — CBT with exposure and response prevention.
- PTSD — trauma-focused CBT or EMDR.
- Physical cause — thyrotoxicosis, arrhythmia, hypoglycaemia, anaemia → treat the cause.
- Substance-related — caffeine, alcohol, cannabis, stimulants → reduce or refer.
- Uncertain — say so; Talking Therapies and review in 2–4 weeks.
5Treat today — doses: SPC, local formulary
- All: explain the anxiety cycle; Talking Therapies self-referral; cut caffeine; review alcohol and drugs.
- Marked impairment or preference: SSRI — sertraline, start 25–50 mg once daily, lower if panic is likely. Warn about jitteriness in the first 1–2 weeks.
- Benzodiazepines: not for routine GAD or panic — crisis only, fixed small quantity. No antipsychotics.
- Not routine: propranolol (not a NICE treatment, dangerous in overdose); pregabalin only if SSRIs and SNRIs cannot be tolerated.
6Refer routinely
- Complex, refractory or high-risk (step 4) → community mental health.
- Documented arrhythmia, confirmed thyrotoxicosis, suspected phaeochromocytoma → relevant specialty.
- Dependence or withdrawal → drug and alcohol services.
7Never reassure by
- Calling a first attack "panic" before an ECG when there is chest pain or syncope.
- Normal observations in a person on insulin without a glucose check.
- Missing morning-after alcohol withdrawal.
- A benzodiazepine "to tide over" — linked to a less good long-term outcome in panic.
- GAD-7 alone as the diagnosis.
- Asking about anxiety but not about suicide.
8Safety-net — say it, then document it
999 “Call 999 for crushing or spreading chest pain, collapse, fainting with palpitations, severe breathlessness or a fit.” Same-day “If you have thoughts of ending your life or feel unable to stay safe, call NHS 111 option 2 today. Tell us the same day if you feel agitated after starting the tablet, get shakes and sweats after stopping alcohol or sleeping tablets, or the attacks feel different from usual.”
Follow-up: 1 week after an SSRI if under 30 or at increased risk; otherwise 1–2 weeks, then every 2–4 weeks for 3 months.