Lacey, 37, is seen by her primary care provider (PCP) as follow-up to a visit she made to the emergency department (ED). She has gone to the ED four times in the past year. Each time, she presents with tachycardia, dyspnea, nausea, numbness in her extremities, and a fear that she is having a heart attack. Despite negative workups at each visit (ECG, cardiac enzymes, complete blood count, toxicology screen, Holter monitoring), Lacey is terrified that the ED doctors are missing something. She is still “rattled” by the chest pain and shortness of breath she experiences. Mild symptoms are persisting, and she is worried that she will have a heart attack and die without the treatment she believes she needs. How do you proceed?
Panic disorder (PD) is characterized by the spontaneous and unexpected occurrence of panic attacks and by at least one month of persistent worry about having another attack or significant maladaptive behaviors related to the attack. Frequency of such attacks can vary from several a day to only a few per year. In a panic attack, an intense fear develops abruptly and peaks within 10 minutes of onset. At least four of the following 13 symptoms must accompany the attack, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5)
- Palpitations, pounding heart, or accelerated heart rate
- Sweating
- Trembling or shaking
- Sensations of shortness of breath or smothering
- Feeling of choking
- Chest pain or discomfort
- Feeling dizzy, unsteady, lightheaded, or faint
- Nausea or abdominal distress
- Derealization (feelings of unreality) or depersonalization (being detached from oneself)
- Fear of losing control or going crazy
- Fear of dying
- Paresthesia (numbness or tingling sensations)
- Chills or hot flushes.1
Lifetime incidence rates of PD are 1% to 3% for the general population.2 A closer look at patients presenting to the ED with chest pain reveals that 17% to 25% meet criteria for PD.3,4 And an estimated 6% of individuals experiencing a panic attack present to their primary care provider.5 Patients with PD tend to use health care resources at a disproportionately high rate.6
An international review of PD research suggests the average age of onset is 32 years.7 Triggers can vary widely, and no single stressor has been identified. The exact cause of PD is unknown, but a convergence of social and biological influences (including involvement of the amygdala) are implicated in its development.6 For individuals who have had a panic attack, 66.5% will have recurrent attacks.7 Lifetime prevalence of panic attacks is 13.2%.7
Differential goes far beyond myocardial infarction. Many medical conditions can mimic PD symptoms: cardiovascular, pulmonary, and neurologic diseases; endocrine diseases (eg, hyperthyroidism); drug intoxication (eg, stimulants [cocaine, amphetamines]); drug withdrawal (eg, benzodiazepines, alcohol, sedative-hypnotics); and ingestion of excessive quantities of caffeine. Common comorbid medical disorders include asthma, coronary artery disease, cancer, thyroid disease, hypertension, ulcer, and migraine headaches.8
When patients present with paniclike symptoms, suspect a possible medical condition when those symptoms include ataxia, altered mental status, or loss of bladder control, or when onset of panic symptoms occur later in life for a patient with no significant psychiatric history.
RULE OUT ORGANIC CAUSES
In addition to obtaining a complete history and doing a physical exam on patients with paniclike symptoms, you’ll also need to ensure that the following are done: a neurologic examination, standard laboratory testing (thyroid function, complete blood cell count, chemistry panel), and possible additional testing (eg, urine toxicology screen and d-dimer assay to exclude pulmonary embolism).
If organic causes are ruled out, focus on a psychiatric assessment, including
- History of the present illness (onset, symptoms, frequency, predisposing/precipitating factors)
- Psychiatric history
- History of substance use
- Family history of psychiatric disorders (especially anxiety disorders)
- Social history (life events, including those preceding the onset of panic; history of child abuse)
- Medications
- Mental status examination
- Safety (PD is associated with higher risk for suicidal ideation).9