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)
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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?

QID: 103341
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Morphine, oxygen, nitrogylcerin, aspirin, beta blockers, ACE inhibitor, and heparin

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(0/9)

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Alprazolam, reassurance, encouraging patient to slow breathing

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(9/9)

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Albuterol breathing treatment

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(0/9)

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SSRI therapy

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(0/9)

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Cognitive behavioral therapy

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(0/9)

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