Approach Considerations

No invasive procedures are required to diagnose panic disorder, although they may be useful in eliminating other conditions in the differential diagnosis. As previously mentioned, history, collateral information, physical examination, and a mental status examination remain the diagnostic cornerstones for panic disorder.

Use electrocardiography (ECG) to assess 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 embolism require appropriate testing (e.g., determination of D-dimer level, spiral CT scanning, ventilation-perfusion [V/Q] scanning, duplex Doppler/ultrasonography, or pulmonary angiography).

Diagnostic 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, cannabis, cocaine, and phencyclidine in patients suspected of intoxication
D-dimer assay to exclude pulmonary embolism

Room air pulse oximetry values are usually 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.

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]; it is also a potential gene of risk for panic disorder.

Radiologic 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. However, positron emission tomography (PET) scanning has demonstrated increased flow in the right parahippocampal region and reduced serotonin type 1A receptor binding in the anterior and posterior cingulate and raphe of patients with panic disorder.^[15]Magnetic resonance imaging (MRI) has demonstrated smaller temporal lobe volume, despite normal hippocampal volume, in patients with panic disorder.^[19]

Treatment & Management

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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