Updated: 11/30/2019

Panic Attack / Panic Disorder

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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
 

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Questions (3)
Lab Values
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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(0/8)

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Alprazolam, reassurance, encouraging patient to slow breathing

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(8/8)

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Albuterol breathing treatment

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SSRI therapy

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Cognitive behavioral therapy

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