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Panic disorder is a common, often chronic illness characterized by recurrent, spontaneous panic attacks. These are short-lived episodes of anxiety or intense fear and are accompanied by a range of somatic symptoms, which may include tachycardia, tachypnea, dyspnea, chest tightness, weakness, nausea, dizziness, and paresthesias. Panic disorder may occur with or without agoraphobia, a condition typified by avoidance of places or situations associated with anxiety. Panic disorder with agoraphobia may be severely disabling, and patients may be incapable of functioning socially or occupationally.

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Because many of the symptoms of panic disorder overlap with those of acute medical illness, the initial point of contact for patients with panic disorder is often the ED.

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When compared with patients with other psychiatric or medical problems, patients with panic disorder have the highest rates of use of ED services.1 Increased use can precede the diagnosis of panic disorder by up to 10 years.2 Although progress has been made in diagnosis and treatment, up to half of those who have the disorder remain undiagnosed.

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Panic disorder is relatively common, with national lifetime and 12-month prevalences of 3.5% and 2.5%,3 respectively, and a cross-national lifetime prevalence of 1.6% to 2.2%.4 The age of onset is typically from late adolescence to the mid-30s. The incidence may have a bimodal distribution, with the first peak in late adolescence, followed by a second, smaller peak in the mid-30s.5

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Women are two to three times more likely than men to develop panic disorder. There is some evidence that panic attacks may remit during pregnancy, only to be exacerbated in the postpartum period.6 Cultural factors may play a role in the presentation of panic disorder. Sleep paralysis is a common symptom of panic disorder in the black population,7 and orthostatic-induced dizziness is a common trigger for panic attacks in Vietnamese refugees.8 Ataque de nervios is an anxiety syndrome in Hispanic cultures that, at times, has a similar presentation to panic disorder.9

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The etiology basis of panic disorder is unknown. It is most likely multifactorial in origin, with genetic, behavioral, and biologic underpinnings.10

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Genetic or Familial

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First-degree relatives of patients with panic disorder have a four- to sevenfold increased risk of developing the disorder, and monozygotic twins have a higher concordance than dizygotic twins for panic disorder.6,11

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Behavioral

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Theorists in cognitive behavioral therapy (CBT) have proposed that panic disorder is a response to internal cues. Heightened sensitivity of body functions and/or cognitive misinterpretation of these cues are postulated to trigger a conditioned fear response. For example, a person with panic disorder can be more aware than others that his or her heart rate has increased. He or she then may misinterpret this cue as “I’m having a heart attack” and become fearful. CBT theorists also hypothesize that anticipatory anxiety ...

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