MANY PANIC ATTACKS PROMPT AN ED VISIT
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 4 of the following 13 symptoms must accompany the attack, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5):1
- 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
- nausea or abdominal distress
- feeling dizzy, unsteady, lightheaded, or faint
- de-realization (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.
Lifetime incidence rates of panic disorder 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 panic disorder.3,4 And an estimated 6% of individuals experiencing a panic attack present to their primary physician.5 Patients with panic disorder tend to use health care resources at a disproportionately high rate.6
An international review of panic disorder research suggests the average age of onset for PD 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 panic disorder symptoms: cardiovascular, pulmonary, and neurologic diseases; endocrine diseases (eg, hyperthyroidism); drug intoxication (eg, stimulants such as 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 panic-like 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 panic-like 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).