Panic Attack / Panic Disorder - Psychiatry

Snapshot

A 30-year-old man arrives at the ED stating in distress that he had " a heart attack." The event started suddenly and was associated with diaphoresis, chest pain, tachycardia, and tachypnea. Troponins and ECG are within normal limits. Upon further questioning, he reports some numbing around his lips and that he has such episodes every few days. He denies recreational or illicit drug use. He further shares that he recently divorced and has had no social support. Recent lab results have all been normal or within standard limits, including TSH and vitamin B12. The patient is reassured that he does not have a heart attack and discharged with recommendations to follow up with the hospital primary care clinic in 1 week.

Introduction

Clinical definition
- panic attack
  - symptoms arise from sympathetic overdrive
  - characterized by intense fear and discomfort
  - peaks within 10 minutes (typically 1-5 minutes)
  - does not involve a clear stimulus
    - unlike a phobia where the stimulus (e.g., spiders) must be present
  - do not assume a panic attack until an organic cause has been eliminated
- panic disorder
  - presence of 3 panic attack episodes in 3 weeks
  - fear of recurrent attacks must also be present
- agoraphobia
  - fear and avoidance of places/situations that cause despair and helplessness
- depression and anxiety often coexist with panic disorder, especially when the disorder begins in adolescence

Presentation

Symptoms
- sweating
- palpitations
- abdominal distress/nausea
- parasthesias
- lightheadedness
- chest pain
- chills
- choking
- feeling of derealization or depersonalization (being detached)
- fear of dying, losing control, or going crazy

Evaluation

Diagnosis
- recurrent and unexpected attacks where at least 4 symptoms listed above develop abruptly and reach peak within 10 minutes
- at least one attack is followed by 1 month or more of 1 of the following
  - fear of additional attacks
  - worry about implications of attacks (heart attack, losing control, "going crazy")
  - significant change in behavior related to attacks
- absence of agoraphobia
- rule out medical conditions
  - angina/MI
  - arrhythmias
  - hyperthyroidism
  - pheochromocytoma
  - vitamin B12 deficiency
- rule out other psychiatric conditions
  - substance-induced anxiety
  - post-traumatic stress disorder (PTSD)
  - generalized anxiety disorder (GAD)
  - specific phobias

Treatment

First-line: psychotherapy
- cognitive behavioral therapy (CBT)
Pharmacological options
- SSRIs
  - also considered first-line
  - choice between CBT and SSRIs may be influenced by patient preference and risk of adverse effects
  - fluoxetine, citalopram, paroxetine, fluvoxamine, sertraline
- TCAs
  - imipramine
- benzodiazepines
  - alprazolam, clonazepam
  - short term, low dose, regular schedule
  - avoid PRN use
- to prevent non-compliance due to physical side effects, explain symptoms to the patient prior to initiation of therapy

Blood, Plasma, Serum	Reference Range
ALT	8-20 U/L
Amylase, serum	25-125 U/L
AST	8-20 U/L
Bilirubin, serum (adult) Total // Direct	0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca²⁺)	8.4-10.2 mg/dL
Cholesterol, serum	Rec: < 200 mg/dL
Cortisol, serum	0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h
Creatine kinase, serum	Male: 25-90 U/L Female: 10-70 U/L
Creatinine, serum	0.6-1.2 mg/dL
Electrolytes, serum
Sodium (Na⁺)	136-145 mEq/L
Chloride (Cl^-)	95-105 mEq/L
Potassium (K⁺)	3.5-5.0 mEq/L
Bicarbonate (HCO₃^-)	22-28 mEq/L
Magnesium (Mg²⁺)	1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)
24-28 wks // 32-36 wks	30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks	40-220 ng/mL // 80-350 ng/mL
Ferritin, serum	Male: 15-200 ng/mL Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma	Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250
pH	7.35-7.45
PCO₂	33-45 mmHg
PO₂	75-105 mmHg
Glucose, serum	Fasting: 70-110 mg/dL 2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation	Fasting: <5 ng/mL Provocative stimuli: > 7ng/mL
Immunoglobulins, serum
IgA	76-390 mg/dL
IgE	0-380 IU/mL
IgG	650-1500 mg/dL
IgM	40-345 mg/dL
Iron	50-170 μg/dL
Lactate dehydrogenase, serum	45-90 U/L
Luteinizing hormone, serum/plasma	Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL
Osmolality, serum	275-295 mOsmol/kd H₂O
Parathyroid hormone, serume, N-terminal	230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C)	20-70 U/L
Phosphorus (inorganic), serum	3.0-4.5 mg/dL
Prolactin, serum (hPRL)	< 20 ng/mL
Proteins, serum
Total (recumbent)	6.0-7.8 g/dL
Albumin	3.5-5.5 g/dL
Globulin	2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma	.5-5.0 μU/mL
Thyroidal iodine (¹²³I) uptake	8%-30% of administered dose/24h
Thyroxine (T4), serum	5-12 μg/dL
Triglycerides, serum	35-160 mg/dL
Triiodothyronine (T3), serum (RIA)	115-190 ng/dL
Triiodothyronine (T3) resin uptake	25%-35%
Urea nitrogen, serum	7-18 mg/dL
Uric acid, serum	3.0-8.2 mg/dL

Hematologic	Reference Range
Bleeding time	2-7 minutes
Erythrocyte count	Male: 4.3-5.9 million/mm³ Female: 3.5-5.5 million mm³
Erythrocyte sedimentation rate (Westergren)	Male: 0-15 mm/h Female: 0-20 mm/h
Hematocrit	Male: 41%-53% Female: 36%-46%
Hemoglobin A1c	≤ 6 %
Hemoglobin, blood	Male: 13.5-17.5 g/dL Female: 12.0-16.0 g/dL
Hemoglobin, plasma	1-4 mg/dL
Leukocyte count and differential
Leukocyte count	4,500-11,000/mm³
Segmented neutrophils	54%-62%
Bands	3%-5%
Eosinophils	1%-3%
Basophils	0%-0.75%
Lymphocytes	25%-33%
Monocytes	3%-7%
Mean corpuscular hemoglobin	25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration	31%-36% Hb/cell
Mean corpuscular volume	80-100 μm³
Partial thromboplastin time (activated)	25-40 seconds
Platelet count	150,000-400,000/mm³
Prothrombin time	11-15 seconds
Reticulocyte count	0.5%-1.5% of red cells
Thrombin time	< 2 seconds deviation from control
Volume
Plasma	Male: 25-43 mL/kg Female: 28-45 mL/kg
Red cell	Male: 20-36 mL/kg Female: 19-31 mL/kg

Cerebrospinal Fluid	Reference Range
Cell count	0-5/mm³
Chloride	118-132 mEq/L
Gamma globulin	3%-12% total proteins
Glucose	40-70 mg/dL
Pressure	70-180 mm H₂O
Proteins, total	< 40 mg/dL

Sweat	Reference Range
Chloride	0-35 mmol/L
Urine
Calcium	100-300 mg/24 h
Chloride	Varies with intake
Creatinine clearance	Male: 97-137 mL/min Female: 88-128 mL/min
Estriol, total (in pregnancy)
30 wks	6-18 mg/24 h
35 wks	9-28 mg/24 h
40 wks	13-42 mg/24 h
17-Hydroxycorticosteroids	Male: 3.0-10.0 mg/24 h Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total	Male: 8-20 mg/24 h Female: 6-15 mg/24 h
Osmolality	50-1400 mOsmol/kg H₂O
Oxalate	8-40 μg/mL
Potassium	Varies with diet
Proteins, total	< 150 mg/24 h
Sodium	Varies with diet
Uric acid	Varies with diet
Body Mass Index (BMI)	Adult: 19-25 kg/m²

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(M3.PY.50) A 26-year-old female with no significant past medical history presents to the emergency department complaining of chest pain. She states that she was visiting her boyfriend in the hospital and, approximately 10 minutes ago, she developed chest pain associated with sweating, palpitations, nausea, and chills. She appears very nervous and states that she is scared that she is dying. Vital signs reveal tachycardia, hypertension, and tachypnea. An EKG is obtained that is unremarkable besides tachycardia. TSH and free T4 are within normal limits. A urine drug screen is obtained and it is negative. What is the best immediate treatment for this patient? Review Topic

QID: 103341

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Morphine, oxygen, nitrogylcerin, aspirin, beta blockers, ACE inhibitor, and heparin

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Alprazolam, reassurance, encouraging patient to slow breathing

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Albuterol breathing treatment

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SSRI therapy

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Cognitive behavioral therapy

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