History
A general medical evaluation is important to rule out medical causes of panic symptoms. [55, 56] History, collateral information, and physical examination, as well as a mental status examination remain the diagnostic cornerstones for panic disorder. It is crucial to assess the specific features of the individual patient’s panic disorder, such as whether agoraphobia is present, the extent of situational fear and avoidance, and whether there are comorbid psychiatric conditions, all of which can affect the course, treatment, and prognosis of panic disorder. [55, 56]
Symptoms
DSM-5 criteria for panic disorder include 4 or more attacks in a 4-week period, or 1 or more attacks followed by at least 1 month of fear of another panic attack. [1]
The following are potential symptom manifestations of a panic attack [1] :
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Palpitations, pounding heart, or accelerated heart rate
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Sweating
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Trembling or shaking
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Sense of shortness of breath or smothering
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Feeling of choking
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Chest pain or discomfort
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Nausea or abdominal distress
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Feeling dizzy, unsteady, lightheaded, or faint
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Derealization or depersonalization (feeling detached from oneself)
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Fear of losing control or going crazy
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Fear of dying
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Numbness or tingling sensations
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Chills or hot flashes
During the episode, patients have the urge to flee or escape and have a sense of impending doom (as though they are dying from a heart attack or suffocation).
Patients with panic disorder have recurring episodes of panic, with the fear of recurrent attacks resulting in significant behavioral changes (e.g., avoiding certain situations or locations) and worry about the implications or consequences of the attack (e.g., losing control, going crazy, dying). Panic disorder may result in changes in personality traits, characterized by the patient becoming more passive, dependent, or withdrawn.
Types of panic attacks
Unexpected panic attacks have no known precipitating cue. Situationally-bound (cued) panic attacks recur predictably in temporal relationship to the trigger; these panic attacks usually implicate the diagnosis of a specific phobia. Situationally predisposed panic attacks are more likely to occur in relation to a given trigger, but they do not always occur.
A variant of panic disorder unrelated to fear (nonfearful panic disorder [NFPD]) is associated with high rates of medical resource use (32-41% of patients with panic disorder seeking treatment for chest pain) and a poor prognosis. [4]
Panic triggers
Triggers of panic can include the following:
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Injury (e.g., accidents, surgery)
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Illness
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Interpersonal conflict or loss
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Use of cannabis (can be associated with panic attacks [5] ; the associated anxiety/panic may be due to the direct physiologic effects of cannabis use)
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Use of stimulants, such as caffeine, decongestants, cocaine, and sympathomimetics (e.g., amphetamine, methylenedioxymethamphetamine [MDMA, ecstasy]) [6]
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The selective serotonin reuptake inhibitor (SSRI) discontinuation syndrome, which can induce symptoms similar to those experienced by panic patients
Assess precipitating events (e.g., major life events), phobias, agoraphobia, obsessive-compulsive behavior, and suicidal ideation and/or plan. In one study, lifetime rates of suicide attempts in patients with uncomplicated panic disorder were consistently higher (7%) than in individuals without a psychiatric disorder (1%). [69] Also assess whether there is a family history of panic or other psychiatric illness.
Exclude involvement of alcohol, nicotine, illicit drugs (e.g., cocaine, amphetamine, phencyclidine, amyl nitrate, lysergic acid diethylamide [LSD], yohimbine, 3,4-methylenedioxymethamphetamine [MDMA, ecstasy]), cannabis, and medications (e.g., caffeine, theophylline, sympathomimetics, anticholinergics), including OTC agents.
In experimental settings, symptoms can be elicited in people with panic disorder by hyperventilation, inhalation of carbon dioxide, [8] caffeine consumption, or intravenous infusions of hypertonic sodium lactate or hypertonic saline, [9] cholecystokinin, isoproterenol, flumazenil, or naltrexone. [10] The carbon dioxide inhalation challenge is especially provocative of panic symptoms in smokers. [11]
Physical Examination
There are no physical signs specific for panic disorder. If the patient presents in an acute state of panic, he or she can physically manifest any anticipated sign of an increased sympathetic state. These nonspecific signs may include hypertension, tachycardia, mild tachypnea, mild tremors, and cool, clammy skin. Blood pressure and temperature may be within the reference range. A panic attack normally lasts 20-30 minutes from onset, although in rare cases it can go on for more than an hour. Somatic concerns of death from cardiac or respiratory problems may be a major focus of patients during an attack. Patients may end up in an emergency department.
Hyperventilation may be difficult to detect by observing breathing, because respiratory rate and tidal volume may appear normal. Patients may sigh frequently or have difficulty with breath-holding. Reproduction of symptoms with overbreathing is unreliable. Chvostek sign, Trousseau sign, or overt carpopedal spasm may be present.
The remaining physical examination findings are typically normal in panic disorder. However, remember that panic disorder is largely a diagnosis of exclusion, and attention should be focused on the exclusion of other disorders.
Mental Status Examination
No results on the mental status examination are specific for panic disorder. The patient may or may not appear anxious at the time of interview, and the results on his or her Mini-Mental Status Examination, including cognitive performance, memory, serial-7, and proverb interpretation, should appear intact and consistent with the patient’s educational level and apparent baseline intellectual functioning.
During a panic attack, a mental status examination may reveal extreme anxiety, fear, and a sense of impending death or doom. The patient may have difficulty speaking as well as appear sweaty and confused. 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.
The patient’s 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:
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Primary Care Evaluation of Mental Disorders (PRIME-MD)
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The Body Sensations Questionnaire (BSQ)
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Folstein Mini-Mental Status Examination (MMSE)
