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 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