Panic Disorder Workup

  • Author: Mohammed A Memon, MD; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych (UK)   more...
 
Updated: Mar 29, 2011
 

Approach Considerations

No invasive procedures are required to diagnose panic disorder, although they may be useful in eliminating other differential diagnoses. As previously mentioned, history, collateral information, and physical examination/Mental Status Examination remain the diagnostic cornerstones for panic disorder.

Next

Lab Studies

Laboratory studies that can exclude medical disorders other than panic disorder include the following:

  • Serum electrolytes to exclude hypokalemia and acidosis
  • Serum glucose to exclude hypoglycemia
  • Cardiac enzymes in patients suspected of acute coronary syndromes
  • Serum hemoglobin in patients with near-syncope
  • Thyroid-stimulating hormone (TSH) in patients suspected of hyperthyroidism
  • Urine toxicology screen for amphetamines, cocaine, and phencyclidine in patients suspected of intoxication
  • D-dimer assay to exclude pulmonary embolism

Arterial blood gas analysis is useful in confirming hyperventilation (respiratory alkalosis) and excluding hypoxemia or metabolic acidosis. The presence of hypoxemia with hypocapnia or a widened alveolar-arterial (A-a) gradient should increase the suspicion of pulmonary embolus.

Electrolyte analysis is unnecessary, although several abnormalities may be present in the setting of hyperventilation. Serum phosphorus and ionized calcium may be diminished in patients with hyperventilation and carpopedal spasm, Chvostek sign, or Trousseau sign. The serum calcium level may be within the reference range.

Human subjects with panic anxiety have elevated levels of orexin in the cerebrospinal fluid. Orexin, also known as hypocretin, is thought to play an important role in the pathogenesis of panic in rat models.[31]

Previous
Next

Imaging Studies

No imaging study findings are currently specific for panic disorder, although they are performed to evaluate anatomic evidence of other diagnostic possibilities. Studies may include an electroencephalogram (EEG) to exclude partial complex seizures.

Investigational functional neuroimaging is not used in routine clinical practice for diagnosis or for monitoring treatment response.

Previous
Next

Mental Status

The Mental Status Examination may reveal an anxious-appearing person, although this is not required for diagnosis. The patient’s speech may reflect anxiety or urgency, or it may sound normal, and the individual’s mood may be described as similar to "anxious," with congruent affect. Incongruent affect should raise consideration of other diagnostic possibilities.

Thought processes should be logical, linear, and goal directed. Thought content is particularly important to specifically assess in order to ensure that a patient has no suicidal or homicidal thoughts. Acute anxiety, as a form of acute mental anguish, can lead to unsafe or self-injurious behavior. Abnormalities in thought process or thought content (aside from impulsive suicidal thoughts) should prompt reconsideration of other etiologies. Insight and judgment are usually present and intact.

Standardized mental status screening tests include the following:

  • Primary Care Evaluation of Mental Disorders (PRIME-MD)
  • Mobility Inventory for Agoraphobia (MIA)
  • The Agoraphobia Cognitions Questionnaire (ACA)
  • The Body Sensations Questionnaire (BSQ)
Previous
Next

Other Tests

Room air pulse oximetry values are within the reference range or at the upper limit of the reference range.

End-tidal capnography values are typically less than 30 torr during hyperventilation.

Electrocardiography (ECG) should be used to inspect for signs of ventricular preexcitation (short PR and delta wave), for short or long QT interval in patients with palpitations, and for ischemia, infarction, or pericarditis patterns in patients with chest pain.

Outpatient Holter monitoring or transtelephonic event recording is rarely necessary but should be considered in patients with palpitations associated with syncope or near-syncope.

Patients who may be at risk for pulmonary embolus require appropriate testing (eg, determination of d-dimer level, spiral computed tomography (CT) scanning, ventilation-perfusion [V/Q] scanning, duplex Doppler/ultrasonography, or pulmonary angiography).

Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Mohammed A Memon, MD  Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center

Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Coauthor(s)

Colin Y Daniels, MD  Consulting Staff, Department of Psychiatry, Madigan Army Medical Center

Colin Y Daniels, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine

Disclosure: Nothing to disclose.

Robert Harwood, MD, MPH, FACEP, FAAEM  Senior Physcian, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine

Robert Harwood, MD, MPH, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Samuel M Keim, MD  Associate Professor, Department of Emergency Medicine, University of Arizona College of Medicine

Samuel M Keim, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Michael C Plewa, MD  Research Coordinator, Consulting Staff, Department of Emergency Medicine, Lucas County Emergency Physicians, Inc, and Mercy Saint Vincent Medical Center

Michael C Plewa, MD, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Physicians for Social Responsibility, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych (UK)  Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych (UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, American Psychiatric Association, American Society of Clinical Psychopharmacology, and Royal College of Psychiatrists

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Sandra Yerkes to the development and writing of this article.

References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Press; 2000.

  2. Fleet RP, Dupuis G, Marchand A, Burelle D, Arsenault A, Beitman BD. Panic disorder in emergency department chest pain patients: prevalence, comorbidity, suicidal ideation, and physician recognition. Am J Med. Oct 1996;101(4):371-80. [Medline].

  3. Warshaw MG, Dolan RT, Keller MB. Suicidal behavior in patients with current or past panic disorder: five years of prospective data from the Harvard/Brown Anxiety Research Program. Am J Psychiatry. Nov 2000;157(11):1876-8. [Medline].

  4. Fleet RP, Martel JP, Lavoie KL, Dupuis G, Beitman BD. Non-fearful panic disorder: a variant of panic in medical patients?. Psychosomatics. Jul-Aug 2000;41(4):311-20. [Medline].

  5. Dannon PN, Lowengrub K, Amiaz R, Grunhaus L, Kotler M. Comorbid cannabis use and panic disorder: short term and long term follow-up study. Hum Psychopharmacol. Mar 2004;19(2):97-101. [Medline].

  6. Schifano F, Di Furia L, Forza G, Minicuci N, Bricolo R. MDMA ('ecstasy') consumption in the context of polydrug abuse: a report on 150 patients. Drug Alcohol Depend. Sep 1 1998;52(1):85-90. [Medline].

  7. González-Berríos N. Sertraline-induced panic attack. Bol Asoc Med P R. Jan-Mar 2009;101(1):59-60. [Medline].

  8. Dratcu L. Panic, hyperventilation and perpetuation of anxiety. Prog Neuropsychopharmacol Biol Psychiatry. Oct 2000;24(7):1069-89. [Medline].

  9. Molosh AI, Johnson PL, Fitz SD, Dimicco JA, Herman JP, Shekhar A. Changes in central sodium and not osmolarity or lactate induce panic-like responses in a model of panic disorder. Neuropsychopharmacology. May 2010;35(6):1333-47. [Medline]. [Full Text].

  10. Esquivel G, Fernández-Torre O, Schruers KR, Wijnhoven LL, Griez EJ. The effects of opioid receptor blockade on experimental panic provocation with CO2. J Psychopharmacol. Nov 2009;23(8):975-8. [Medline].

  11. Knuts IJ, Cosci F, Esquivel G, Goossens L, van Duinen M, Bareman M, et al. Cigarette smoking and 35% CO(2) induced panic in panic disorder patients. J Affect Disord. Jul 2010;124(1-2):215-8. [Medline].

  12. Maron E, Hettema JM, Shlik J. Advances in molecular genetics of panic disorder. Mol Psychiatry. Jul 2010;15(7):681-701. [Medline].

  13. Zwanzger P, Eser D, Nothdurfter C, Baghai TC, Möller HJ, Padberg F, et al. Effects of the GABA-reuptake inhibitor tiagabine on panic and anxiety in patients with panic disorder. Pharmacopsychiatry. Nov 2009;42(6):266-9. [Medline].

  14. Wedekind D, Bandelow B, Broocks A, Hajak G, Rüther E. Salivary, total plasma and plasma free cortisol in panic disorder. J Neural Transm. 2000;107(7):831-7. [Medline].

  15. Neumeister A, Bain E, Nugent AC, Carson RE, Bonne O, Luckenbaugh DA, et al. Reduced serotonin type 1A receptor binding in panic disorder. J Neurosci. Jan 21 2004;24(3):589-91. [Medline].

  16. Lonsdorf TB, Rück C, Bergström J, Andersson G, Ohman A, Schalling M, et al. The symptomatic profile of panic disorder is shaped by the 5-HTTLPR polymorphism. Prog Neuropsychopharmacol Biol Psychiatry. Nov 13 2009;33(8):1479-83. [Medline].

  17. Strug LJ, Suresh R, Fyer AJ, Talati A, Adams PB, Li W, et al. Panic disorder is associated with the serotonin transporter gene (SLC6A4) but not the promoter region (5-HTTLPR). Mol Psychiatry. Feb 2010;15(2):166-76. [Medline]. [Full Text].

  18. Johnson MR, Lydiard RB, Ballenger JC. Panic disorder. Pathophysiology and drug treatment. Drugs. Mar 1995;49(3):328-44. [Medline].

  19. Vythilingam M, Anderson ER, Goddard A, Woods SW, Staib LH, Charney DS, et al. Temporal lobe volume in panic disorder--a quantitative magnetic resonance imaging study. Psychiatry Res. Aug 28 2000;99(2):75-82. [Medline].

  20. Lee HB, Hening WA, Allen RP, Kalaydjian AE, Earley CJ, Eaton WW, et al. Restless legs syndrome is associated with DSM-IV major depressive disorder and panic disorder in the community. J Neuropsychiatry Clin Neurosci. Winter 2008;20(1):101-5. [Medline].

  21. Kaiya H, Sugaya N, Iwasa R, Tochigi M. Characteristics of fatigue in panic disorder patients. Psychiatry Clin Neurosci. Apr 2008;62(2):234-7. [Medline].

  22. Chen YH, Hu CJ, Lee HC, Lin HC. An increased risk of stroke among panic disorder patients: a 3-year follow-up study. Can J Psychiatry. Jan 2010;55(1):43-9. [Medline].

  23. Gomez-Caminero A, Blumentals WA, Russo LJ, Brown RR, Castilla-Puentes R. Does panic disorder increase the risk of coronary heart disease? A cohort study of a national managed care database. Psychosom Med. Sep-Oct 2005;67(5):688-91. [Medline].

  24. Fleet R, Lespérance F, Arsenault A, Grégoire J, Lavoie K, Laurin C, et al. Myocardial perfusion study of panic attacks in patients with coronary artery disease. Am J Cardiol. Oct 15 2005;96(8):1064-8. [Medline].

  25. Sullivan GM, Kent JM, Kleber M, Martinez JM, Yeragani VK, Gorman JM. Effects of hyperventilation on heart rate and QT variability in panic disorder pre- and post-treatment. Psychiatry Res. Jan 30 2004;125(1):29-39. [Medline].

  26. Schmidt NB, Lerew DR, Santiago H, Trakowski JH, Staab JP. Effects of heart-rate feedback on estimated cardiovascular fitness in patients with panic disorder. Depress Anxiety. 2000;12(2):59-66. [Medline].

  27. Chen YH, Lin HC, Lee HC. Pregnancy outcomes among women with panic disorder - do panic attacks during pregnancy matter?. J Affect Disord. Jan 2010;120(1-3):258-62. [Medline].

  28. Katerndahl DA, Talamantes M. A comparison of persons with early-versus late-onset panic attacks. J Clin Psychiatry. Jun 2000;61(6):422-7. [Medline].

  29. Batelaan NM, de Graaf R, Penninx BW, van Balkom AJ, Vollebergh WA, Beekman AT. The 2-year prognosis of panic episodes in the general population. Psychol Med. Jan 2010;40(1):147-57. [Medline].

  30. Ashton H. The diagnosis and management of benzodiazepine dependence. Curr Opin Psychiatry. May 2005;18(3):249-55. [Medline].

  31. Johnson PL, Truitt W, Fitz SD, Minick PE, Dietrich A, Sanghani S, et al. A key role for orexin in panic anxiety. Nat Med. Jan 2010;16(1):111-5. [Medline]. [Full Text].

  32. Chen YH, Chen SF, Lin HC, Lee HC. Healthcare utilization patterns before and after contact with psychiatrist care for panic disorder. J Affect Disord. Dec 2009;119(1-3):172-6. [Medline].

  33. Cloos JM. The treatment of panic disorder. Curr Opin Psychiatry. Jan 2005;18(1):45-50. [Medline].

  34. Rosenberg NK, Mellergård M, Rosenberg R, Beck P, Ottosson JO. Characteristics of panic disorder patients responding to placebo. Acta Psychiatr Scand Suppl. 1991;365:33-8. [Medline].

  35. Croom KF, Perry CM, Plosker GL. Mirtazapine: a review of its use in major depression and other psychiatric disorders. CNS Drugs. 2009;23(5):427-52. [Medline].

  36. [Best Evidence] Furukawa TA, Watanabe N, Churchill R. Psychotherapy plus antidepressant for panic disorder with or without agoraphobia: systematic review. Br J Psychiatry. Apr 2006;188:305-12. [Medline].

  37. Sánchez-Meca J, Rosa-Alcázar AI, Marín-Martínez F, Gómez-Conesa A. Psychological treatment of panic disorder with or without agoraphobia: a meta-analysis. Clin Psychol Rev. Feb 2010;30(1):37-50. [Medline].

  38. Palatnik A, Frolov K, Fux M, Benjamin J. Double-blind, controlled, crossover trial of inositol versus fluvoxamine for the treatment of panic disorder. J Clin Psychopharmacol. Jun 2001;21(3):335-9. [Medline].

  39. Ströhle A, Graetz B, Scheel M, Wittmann A, Feller C, Heinz A, et al. The acute antipanic and anxiolytic activity of aerobic exercise in patients with panic disorder and healthy control subjects. J Psychiatr Res. Aug 2009;43(12):1013-7. [Medline].

  40. Bowen R, Baetz M, D'Arcy C. Self-rated importance of religion predicts one-year outcome of patients with panic disorder. Depress Anxiety. 2006;23(5):266-73. [Medline].

  41. Advocat J, Lindsay J. Internet-based trials and the creation of health consumers. Soc Sci Med. Feb 2010;70(3):485-92. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.