# Panic disorder - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Paroxetine 20 mg Tablets SmPC section 4.2 (eMC product 537) · Xanax (alprazolam) 500 microgram tablets SmPC sections 4.2 and 4.4 (eMC product 1656) · Sertraline Hydrochloride US prescribing information, Dosage and Administration (DailyMed SetID 61835f25-bfe4-49ac-9dbf-3d6387866e78) - Verified date: 2026-08 ## Verified against - Paroxetine 20 mg Tablets SmPC section 4.2 (eMC product 537) - Xanax (alprazolam) 500 microgram tablets SmPC sections 4.2 and 4.4 (eMC product 1656) - Sertraline Hydrochloride US prescribing information, Dosage and Administration (DailyMed SetID 61835f25-bfe4-49ac-9dbf-3d6387866e78) - Panic Disorder - disease-level clinical article (panic-disorder-clinical.txt) ## Treatment metadata - Sertraline — 50 mg — oral.solid - Paroxetine — 20 mg — oral.solid - Referral & safety-netting (no drug therapy) - Alprazolam — 0.5 mg — oral.solid ## Complete treatment card ```text PANIC DISORDER Sources: Paroxetine 20 mg Tablets SmPC section 4.2 (eMC product 537) · Xanax (alprazolam) 500 microgram tablets SmPC sections 4.2 and 4.4 (eMC product 1656) · Sertraline Hydrochloride US prescribing information, Dosage and Administration (DailyMed SetID 61835f25-bfe4-49ac-9dbf-3d6387866e78) Review status: REVIEWED against Paroxetine 20 mg Tablets SmPC section 4.2 (eMC product 537), Xanax (alprazolam) 500 microgram tablets SmPC sections 4.2 and 4.4 (eMC product 1656), Sertraline Hydrochloride US prescribing information, Dosage and Administration (DailyMed SetID 61835f25-bfe4-49ac-9dbf-3d6387866e78), Panic Disorder - disease- level clinical article (panic-disorder-clinical.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (11) - Most patients report recurrent chest pain, palpitations, or breathlessness [breathlessness · chest pain · palpitations] - Sweating, shaking, a choking feeling, nausea, chills, tingling, or a sense of unreality are other common complaints [chills · nausea · sweating · tingling · tremor] - Patients tend to seek out non-psychiatric specialists for reassurance rather than mental health care, since most complaints are physical - The attack reaches its peak within minutes, and four or more physical symptoms come with it - Feeling dizzy, unsteady or light-headed, and close to fainting, is part of the attack [dizziness · syncope] - Fear of losing control and fear of dying belong to the attack itself - Attacks come without warning, usually with no trigger at all, and the patient feels a lack of control - Frequency runs from several attacks a day to only a few in a whole year - A month or more of persistent worry about further attacks, and behaviour that now avoids whatever the person blames for them, is what separates the disorder from a single attack [anxiety] - The fear and anxiety are felt in the body rather than in the mind, which is why these patients present to a physical clinic [anxiety] - Quality of life suffers and it leads on to low mood and disability, with a higher risk of alcohol and substance misuse [low mood] IF NOT THIS - what else fits (6) - Angina is on the differential - Congestive heart failure is on the differential - Mitral valve prolapse is on the differential - Pulmonary embolism is on the differential - Panic disorder is diagnosed only after other medical or psychiatric conditions that could better explain the symptoms are excluded - Substances, medicines and a general medical condition such as an overactive thyroid or vestibular disease can all produce panic attacks, and then the diagnosis is not panic disorder Source StatPearls "Panic Disorder" - disease-level clinical article Status traced to the source above 1. SERTRALINE [1st line] Adult 25 mg once daily for 1 week, then increase to 50 mg once daily; titrate up to max 200 mg daily if required Peds Specialist child and adolescent psychiatry referral required Choice Alternatives. Sertraline is first-line for panic disorder; paroxetine's discontinuation syndrome and teratogenic signal make it the second pick. Source Sertraline Hydrochloride US prescribing information, Dosage and Administration (DailyMed SetID 61835f25-bfe4-49ac-9dbf-3d6387866e78) Why Sertraline is an SSRI that increases serotonergic transmission and is first-line pharmacotherapy for panic disorder, reducing the frequency and severity of panic attacks as treatment continues. Caution Start at half-standard dose (25 mg) to prevent initial paradoxical worsening of panic symptoms. Educate patient on 2-4 week onset delay before clinical response. Do not stop abruptly; taper slowly to prevent discontinuation syndrome. Egypt OPIRALINE 50 MG 20 F.C. TABS. EL-OBOUR 29.00 EGP (1.45/unit) AGRELOCIT 50 MG 20 TAB. MEMPHIS > ATM... 34.80 EGP (1.74/unit) DEPR-STAT 50MG 10 CAPS. MEMPHIS 21.60 EGP (2.16/unit) SESERINE 50MG 30 TAB. ADWIA 75.00 EGP (2.50/unit) SERPASS 50MG 30 F.C.TAB. GLOBAL NAPI P... 102.00 EGP (3.40/unit) SIRTO 50MG 10 F.C. TABS. HI-PHARM 34.00 EGP (3.40/unit) MOODAPEX 50 MG 30 F.C.TAB. MULTI-APEX 111.00 EGP (3.70/unit) LUSTRAL 50 MG 20 F.C.TABS. VIATRIS 136.00 EGP (6.80/unit) 2. PAROXETINE [1st line] Adult Start on 10 mg/day, gradually increased in 10 mg steps to recommended dose of 40 mg daily (maximum 60 mg/day if response is insufficient) - long-term Peds Contraindicated in children and adolescents under 18 years (increased risk of suicidal behavior) Source Paroxetine 20 mg Tablets SmPC section 4.2 (eMC product 537) Why Paroxetine is an SSRI alternative to sertraline for panic disorder; its teratogenic risk in early pregnancy and heavier discontinuation-syndrome burden make it a second-choice agent for many patients. Caution There is a teratogenic risk (cardiac malformations) in the first trimester of pregnancy. Paroxetine has the highest incidence of discontinuation syndrome among SSRIs; a strict gradual taper is required. Egypt XANDOL 20MG 20 TAB. EUROPEAN EGYP... 42.00 EGP (2.10/unit) PAXETIN 20 MG 10 F.C.TABS. PHAROPHARMA 22.80 EGP (2.28/unit) DEPANX 20MG 10 F.C. TAB. GLOBAL NAPI P... 24.00 EGP (2.40/unit) PAROXETINE 20 MG 30 F.C.TABS. EVA PHARMA 93.00 EGP (3.10/unit) 3. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Panic Disorder - disease-level clinical article (panic-disorder-clinical.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - Because of suicide risk, some patients with panic disorder may need inpatient monitoring until symptoms subside - a different pathway from outpatient drug therapy. 4. ALPRAZOLAM [add-on - not a substitute] Adult 0.25-0.5 mg 3 times daily as needed for severe disabling acute panic crisis - Maximum of 2-4 weeks Peds Contraindicated in children Source Xanax (alprazolam) 500 microgram tablets SmPC sections 4.2 and 4.4 (eMC product 1656) Why Short-term bridging agent during initial 2-3 weeks of SSRI initiation; avoid monotherapy due to dependence risk Caution Alprazolam has a high liability for dependence, tolerance, and severe withdrawal seizures if stopped abruptly. Strictly limit treatment duration to 2-4 weeks total. Two to four weeks, taper included. Not a repeat prescription. Never above 3 mg a day. Elderly start at 0.25 mg two or three times daily. Dependence can form inside those few weeks at an ordinary dose. Coming off brings the anxiety back worse than it started, and withdrawal can go as far as seizures - so reduce gradually, never stop dead. With an opioid this combination causes sedation, respiratory depression, coma and death. In a country where both are easy to obtain, that is the sentence that matters. Drowsiness, ataxia, and memory impairment can occur. Egypt ZOLAPAR 0.5 MG 20 TABS. DELTA PHARMA 12.00 EGP (0.60/unit) ZOLAPAR XR 0.5 MG 20 TABS. DELTA PHARMA 12.00 EGP (0.60/unit) PRAZONEX 0.5 MG 30 TABS. UP PHARMA 19.50 EGP (0.65/unit) PRAZOLAM 0.5 MG 30 TABS. EVA PHARMA 36.00 EGP (1.20/unit) RESTOLAM 0.5 MG 20 TABS. GLOBAL NAPI P... 24.00 EGP (1.20/unit) RESTOLAM 0.5 MG 30 TABS. GLOBAL NAPI P... 36.00 EGP (1.20/unit) ZOLAM 0.5 MG 30 TABS. AMOUN 36.00 EGP (1.20/unit) XANAX 0.5 MG 100 TABS. PFIZER > VIAT... 195.00 EGP (1.95/unit) Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)