Diagnostic Considerations

An understanding of panic disorder is particularly important for emergency physicians, because patients with this condition frequently present to the ED with various somatic complaints. Many of the symptoms of an anxiety attack correspond with symptomatology found in life-threatening medical disorders, such as myocardial infarction (MI) and pulmonary embolus, which may manifest with anxiety as a primary symptom. Approximately 25% of patients who present to an emergency department with chest pain have panic anxiety disorder^[70]and few individuals with panic disorder are referred to mental health professionals.

When making a diagnosis, keep in mind the symptomatology of medical conditions such as the following:

Angina and myocardial infarction (e.g., dyspnea, chest pain, palpitations, diaphoresis)
Cardiac dysrhythmias (e.g., palpitations, dyspnea, syncope)
Mitral valve prolapse
Pulmonary embolus (e.g., dyspnea, hyperpnea, chest pain)
Asthma (e.g., dyspnea, wheezing)
Hyperthyroidism (e.g., palpitations, diaphoresis, tachycardia, heat intolerance)
Hypoglycemia
Pheochromocytoma (e.g., headache, diaphoresis, hypertension)
Hypoparathyroidism (e.g., muscle cramps, paresthesias)
Transient ischemic attacks (TIAs)
Seizure disorder

In addition, consider other mental illnesses that may result in panic attacks, including schizophrenia, bipolar disorder, depressive disorder, posttraumatic stress disorder, phobias, and somatization disorder.

For more information, see the Medscape Reference topics Anxiety Disorders; Separation Anxiety and School Refusal; and Phobic Disorders for more complete information on these topics.

Cardiovascular disease and panic disorder

Persons with panic disorder are no less likely (and are perhaps even twice as likely) to have coronary artery disease than is the general population.^[23]In one study, approximately 44% of emergency department patients with panic disorder had a history of coronary disease.^[2]

Exclude acute coronary syndromes in patients with risk factors, history, and electrographic findings before labeling the event as panic. Patients with supraventricular tachycardia have the potential to be misdiagnosed with panic disorder in more than 50% of cases; panic disorder may be missed if cardiac event monitoring is not obtained.

Differential Diagnoses

Acute Coronary Syndrome
Acute Pericarditis
Acute Respiratory Distress Syndrome (ARDS)
Asthma
Atrial Fibrillation
Emergent Management of Atrial Flutter
Heart Failure
Mitral Valve Prolapse
Multifocal Atrial Tachycardia
Myocardial Infarction
Pulmonary Embolism (PE)

Workup

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
González-Berríos N. Sertraline-induced panic attack. Bol Asoc Med P R. Jan-Mar 2009. 101(1):59-60. [QxMD MEDLINE Link].
Dratcu L. Panic, hyperventilation and perpetuation of anxiety. Prog Neuropsychopharmacol Biol Psychiatry. Oct 2000. 24(7):1069-89. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Maron E, Hettema JM, Shlik J. Advances in molecular genetics of panic disorder. Mol Psychiatry. Jul 2010. 15(7):681-701. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
Johnson MR, Lydiard RB, Ballenger JC. Panic disorder. Pathophysiology and drug treatment. Drugs. Mar 1995. 49(3):328-44. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Lee HB, Hening WA, Allen RP, 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. [QxMD MEDLINE Link].
Kaiya H, Sugaya N, Iwasa R, Tochigi M. Characteristics of fatigue in panic disorder patients. Psychiatry Clin Neurosci. Apr 2008. 62(2):234-7. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Fleet R, Lespérance F, Arsenault A, et al. Myocardial perfusion study of panic attacks in patients with coronary artery disease. Am J Cardiol. Oct 15 2005. 96(8):1064-8. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Katerndahl DA, Talamantes M. A comparison of persons with early-versus late-onset panic attacks. J Clin Psychiatry. Jun 2000. 61(6):422-7. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Ashton H. The diagnosis and management of benzodiazepine dependence. Curr Opin Psychiatry. May 2005. 18(3):249-55. [QxMD MEDLINE Link].
Johnson PL, Truitt W, Fitz SD, et al. A key role for orexin in panic anxiety. Nat Med. Jan 2010. 16(1):111-5. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Cloos JM. The treatment of panic disorder. Curr Opin Psychiatry. Jan 2005. 18(1):45-50. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
{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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Strohle A, Graetz B, Scheel M, 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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Advocat J, Lindsay J. Internet-based trials and the creation of health consumers. Soc Sci Med. Feb 2010. 70(3):485-92. [QxMD MEDLINE Link].
Hettema JM, Neale MC, Kendler KS. A review and meta-analysis of the genetic epidemiology of anxiety disorders. Am J Psychiatry. 2001 Oct. 158(10):1568-78. [QxMD MEDLINE Link].
Weissman MM, Fyer AJ, Haghighi F, et al. Potential panic disorder syndrome: clinical and genetic linkage analysis. Am J Med Genet. 2000. 96:24-35. [QxMD MEDLINE Link].
Thorgeirsson TE, Oskarsson H, Desnica N, et al. Anxiety with panic disorder linked to chromosome 9q in Iceland. Am J Hum Genet. 2003. 72:1221-30. [QxMD MEDLINE Link].
Kaab B, Gelernter J, Woods SW, Goddard A, Page GP, Elston RC. Genome scan for loci predisposing to anxiety disorders using a novel multivariate approach: strong evidence for a chromosome 4 risk locus. Am J Hum Genet. 2006. 78:543-53. [QxMD MEDLINE Link].
Woo J-M, Yoon K-S, Yu B-H. Catechol O-methyltransferase genetic polymorphism in panic disorder. Am J Psychiat. 2002. 159:1785-7. [QxMD MEDLINE Link].
Cheng R, Juo SH, Loth JE, et al. Genome-wide linkage scan in a large bipolar disorder sample from the National Institute of Mental Health genetics initiative suggests putative loci for bipolar disorder, psychosis, suicide, and panic disorder. Molec Psychiat. 2006. 11:252-60. [QxMD MEDLINE Link].
Annerbrink K, Westberg L, Olsson M, et al. Panic disorder is associated with the Val308Iso polymorphism in the hypocretin receptor gene. Psychiatr Genet. 2011 Apr. 21(2):85-9. [QxMD MEDLINE Link].
Domschke K, Reif A, Weber H, et al. Neuropeptide S receptor gene -- converging evidence for a role in panic disorder. Mol Psychiatry. 2011 Sep. 16(9):938-48. [QxMD MEDLINE Link].
Gregersen N, Dahl HA, Buttenschon HN, et al. A genome-wide study of panic disorder suggests the amiloride-sensitive cation channel 1 as a candidate gene. Eur J Hum Genet. 2012 Jan. 20(1):84-90. [QxMD MEDLINE Link].
Hohoff C, Mullings EL, Heatherley SV, et al. Adenosine A(2A) receptor gene: evidence for association of risk variants with panic disorder and anxious personality. J Psychiatr Res. 2010 Oct. 44(14):930-7. [QxMD MEDLINE Link].
Logue MW, Bauver SR, Knowles JA, et al. Multivariate analysis of anxiety disorders yields further evidence of linkage to chromosomes 4q21 and 7p in panic disorder families. Am J Med Genet B Neuropsychiatr Genet. 2012 Apr. 159B(3):274-80. [QxMD MEDLINE Link].
Lonsdorf TB, Ruck C, Bergstrom J, et al. The COMTval158met polymorphism is associated with symptom relief during exposure-based cognitive-behavioral treatment in panic disorder. BMC Psychiatry. 2010 Nov 26. 10:99. [QxMD MEDLINE Link].
Schumacher J, Kristensen AS, Wendland JR, Nothen MM, Mors O, McMahon FJ. The genetics of panic disorder. J Med Genet. 2011 Jun. 48(6):361-8. [QxMD MEDLINE Link].
American Psychiatric Association. Practice guideline for the treatment of patients with panic disorder. 2nd ed. Washington, DC: American Psychiatric Association; 2009.
National Collaborating Centre for Mental Health, National Collaborating Centre for Primary Care. Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults. Management in primary, secondary and community care. London, UK: National Institute for Health and Clinical Excellence; 2011.
US Food and Drug Administration. Celexa (citalopram hydrobromide) - Drug safety communication: revised recommendations, potential risk of abnormal heart rhythms [press release]. March 28, 2012. [Full Text].
Roberson-Nay R, Kendler KS. Panic disorder and its subtypes: a comprehensive analysis of panic symptom heterogeneity using epidemiological and treatment seeking samples. Psychol Med. 2011 Nov. 41(11):2411-21. [QxMD MEDLINE Link].
Deckert J, Catalano M, Syagailo YV, et al. Excess of high activity monoamine oxidase A gene promoter alleles in female patients with panic disorder. Hum Mol Genet. 1999 Apr. 8(4):621-4. [QxMD MEDLINE Link].
Buckley PF, Miller BJ, Lehrer DS, Castle DJ. Psychiatric comorbidities and schizophrenia. Schizophr Bull. 2009 Mar. 35(2):383-402. [QxMD MEDLINE Link].
National Institute of Mental Health. Panic disorder among adults. [Full Text].
Noyes R Jr, Clancy J, Woodman C, et al. Environmental factors related to the outcome of panic disorder. A seven-year follow-up study. J Nerv Ment Dis. 1993 Sep. 181(9):529-38. [QxMD MEDLINE Link].
Noyes R Jr, Hoehn-Saric R. Panic disorder and agoraphobia. In: Noyes R Jr, Hoehn-Saric R, eds. The Anxiety Disorders. Cambridge, England: Cambridge University Press. 1998. 86-157.
Hasler G, Gergen PJ, Kleinbaum DG, et al. Asthma and panic in young adults: a 20-year prospective community study. Am J Respir Crit Care Med. 2005. 171:1224-30. [QxMD MEDLINE Link].
Beghi E, Allais G, Cortelli P, et al. Headache and anxiety-depressive disorder comorbidity: the HADAS study. Neurol Sci. 2007 May. 28 suppl 2:28 suppl 2. [QxMD MEDLINE Link].
Tellez-Zenteno JF, Patten SB, Jette N, Williams J, Wiebe S. Psychiatric comorbidity in epilepsy: a population-based analysis. Epilepsia. 2007 Dec. 48(12):2336-44. [QxMD MEDLINE Link].
Cox BJ, Norton GR, Swinson RP, Endler NS. Substance abuse and panic-related anxiety: a critical review. Behav Res Ther. 1990. 28(5):385-93. [QxMD MEDLINE Link].
Kaplan HI, Sadock BJ. Panic disorder and agoraphobia. In: Millet KC, ed. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 8th ed. Baltimore, Md: Williams & Wilkins; 1998. 594-603.
Johnson J, Weissman MM, Klerman GL. Panic disorder, comorbidity, and suicide attempts. Arch Gen Psychiatry. 1990 Sep. 47(9):805-8. [QxMD MEDLINE Link].
Fleet RP, Marchand A, Dupuis G, Kaczorowski J, Beitman BD. Comparing emergency department and psychiatric setting patients with panic disorder. Psychosomatics. 1998 Nov-Dec. 39(6):512-8. [QxMD MEDLINE Link].

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Author

Mohammed A Memon, MD Psychiatrist/Geriatric Psychiatrist, Carolina Center for Behavioral Health; Assistant Professor of Psychiatry, Virginia Commonwealth University School of Medicine

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

Disclosure: Nothing to disclose.

Chief Editor

Randon S Welton, MD Associate Professor of Psychiatry, Director of Residency Training, Department of Psychiatry, Wright State University, Boonshoft School of Medicine

Randon S Welton, MD is a member of the following medical societies: American Association of Directors of Psychiatric Residency Training, American Psychiatric Association, Dayton Psychiatric Association, Ohio Psychiatric Physicians Association

Disclosure: Nothing to disclose.

Acknowledgements

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