Updated: 6/29/2020

Panic Attack / Panic Disorder

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Snapshot
  • A 30-year-old man arrives at the ED stating in distress that he believes that he had a heart attack. He says the episode started suddenly and was associated with sweating, chest pain, palpitations, and shallow breathing. Troponins within normal limits and ECG shows sinus tachycardia with no remarkable findings. Upon further questioning, he reports that he has been having such episodes every few days. He denies recreational or illicit drug use. He further shares that he is recently divorced and has had no social support. Recent lab results have  been normal, including TSH and vitamin B12. The patient is reassured that he does not have a heart attack and is discharged with recommendations to follow up with the hospital primary care clinic in 1 week.
Introduction
  • Overview
    • panic disorder is characterized by recurrent panic attacks associated with > 1 month of subsequent persistent worry about having another panic attack or behavioral changes related to the attack
  • Epidemiology
    • prevalence
      • 2-6% of adults in the US
    • demographics
      • women are 2-3 times more likely to have panic disorder
      • most commonly develops between 18-45 years of age
    • risk factors
      • asthma linked to a 4.5 ↑ in risk of developing panic disorder
  • Pathophysiology
    • panic disorder is a psychiatric disorder that may be caused by neurochemical dysfunction
    • symptoms arise from sympathetic overdrive
  • Genetics
    • study of panic disorder in first-degree relatives revealed heredity of ~43%
  • Associated conditions
    • major depression and anxiety
    • schizophrenia
    • obsessive-compulsive disorder
    • phobias (i.e., agoraphobia)
    • cluster C personality disorders
  • Prognosis
    • long-term prognosis is good with ~65% of patients achieving remission within 6 months
    • negative prognostic variables
      • low socioeconomic status
      • severe illness at time of initial assessment
      • high interpersonal sensitivity
Presentation
  • Symptoms
    • 4 or more panic attacks in a 4-week period, or ≥ 1 panic attacks followed by at least 1 month of fear of another panic attack 
    • panic attack symptoms may include:
      • intense fear of dying and discomfort
      • sympathetic overdrive
        • sweating
        • palpitations
        • abdominal distress/nausea
        • hyperventilation
      • paresthesias
      • light-headedness
      • chest pain
      • chills
      • choking
      • disconnectedness/loss of reality
      • shaking
    • panic attack symptoms have no precipitating stimulus and often peak within 10 minutes and last 20-30 minutes from onset
    • panic attacks may be triggered by injury, illness, interpersonal conflict or loss, cannabis use, or stimulants (i.e., caffeine or decongestants)
  • Physical exam
    • anxious mood
    • nonspecific signs of ↑ sympathetic state
      • hypertension
      • tachycardia
      • mild tachypnea
      • mild tremors
      • cool and clammy skin
Studies
  • ECG
    • rule out ischemia, infarction, or pericarditis in patients with chest pain
  • TSH, T3, and T4
    • rule out hyperthyroidism
  • Urine toxicology screen
    • screen for amphetamines, cannabis, cocaine, and phencyclidine in patients suspected of intoxication from substance use
Differential
  • Acute coronary syndrome
    • key distinguishing factor
      • ECG changes
        • i.e., ST elevation, Q waves, and T-wave inversion
  • Asthma
    • key distinguishing factor
      • wheezing on physical examination
  • Hyperthyroidism
    • key distinguishing factor
      • ↑ levels of thyroid hormones
Treatment
  • Lifestyle
    • psychotherapy
      • cognitive-behavioral therapy (CBT)
        • treatment of choice
        • consider for all patients
  • Medical
    • benzodiazepines (i.e., alprazolam or clonazepam)
      • indications
        • providing a few doses for emergency or for urgent/as-needed use may ↑ patient confidence
        • avoid in patients with known history of substance use disorder or alcoholism
    • selective serotonin reuptake inhibitors (i.e., escitalopram or sertraline)
      • indications
        • longer-term pharmacological management
Complications
  • Noncompliance or adverse medication effects
    • ↑ 4-fold in patients with panic disorder
    • treatment expectations and concerns should be discussed with the patient
 

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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.16.50) 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 | Tested Concept

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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