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Panic disorder manifests with a wide variety of symptoms that mimic other major medical problems.

Clinical Features

Panic disorder is defined as recurrent panic attacks followed by 1 month or more of persistent worry of future episodes or maladaptive changes in behavior related to the attack. Episodes begin unexpectedly; severity peaks within 10 minutes and symptoms last for up to 1 hour. Symptoms of panic attacks include palpitations, sweating, shortness of breath, trembling or shaking, choking sensation, chest pain or discomfort, nausea or abdominal distress, dizziness or light-headedness, paresthesias, chills or hot flashes, fear of losing control, fear of dying, and derealization or depersonalization.

Diagnosis and Differential

Panic disorder is a diagnosis of exclusion because its symptoms and signs mimic those of many potentially life-threatening disorders. A thorough history and physical examination and, when indicated, other tests help rule out these life-threatening disorders. The differential diagnosis of panic attacks is listed in Table 186-1.

Table 186-1

Medical Differential Diagnosis of Panic Attacks

Emergency Department Care and Disposition

  1. After excluding life-threatening causes of symptoms, educate and reassure the patient that panic disorder is an illness that can be treated effectively.

  2. Benzodiazepines, such as alprazolam 0.25 to 1 mg PO or lorazepam 0.5 to 1 mg PO/IV, are used to control acute symptoms. Antidepressants, such as selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI), are preferred for maintenance therapy. Ideally, follow up should be in place if sending the patient out with a benzodiazepine or SSRI/SNRI prescription. Caution should be used in prescribing benzodiazepines to certain populations, such as drug abusers, geriatric patients, and those with respiratory disorders.

  3. Ask the patient about suicidal thoughts, as the patient may require psychiatric consultation and hospitalization.

  4. Most patients can be discharged. Refer to outpatient psychiatry for continuation or initiation of pharmacotherapy.


Clinical Features

Patients with conversion disorder develop voluntary motor or sensory function deficits. The symptoms are not consciously produced by the patient and are usually in response to a stressor or conflict. The symptoms or deficits are not explained by a known organic etiology or ...

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