Chapter 186. Panic and Conversion Disorders

Clinical Features

The cardinal features of panic disorder are recurrent acute episodes of intense anxiety and fear and persistent worry about having another such episode. Symptoms include palpitations, sweating, shortness of breath, trembling or shaking, choking sensation, chest pain or discomfort, dizziness or light-headedness, paresthesias, chills or hot flashes, fear of losing control, fear of dying, derealization, and depersonalization. Episodes begin unexpectedly; severity peaks within 10 min and symptoms last for up to 1 hour.

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 to rule out these life-threatening disorders. The differential diagnosis of panic attacks is listed in Table 186-1.

Emergency Department Care and Disposition

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

2. Benzodiazepines, such as alprazolam 0.25 to 0.5 milligrams PO or lorazepam 1 to 2 PO/IV are used to control acute symptoms. Antidepressants, such as selective serotonin reuptake inhibitors and serotonin/norepinephrine reuptake inhibitors, are preferred for maintenance therapy.

3. Ask patients about suicidal thoughts. Patients who are suicidal or so incapacitated that they cannot care for themselves require psychiatric consultation and hospitalization.

4. Most patients can be discharged. Refer to a psychiatrist for outpatient cognitive behavioral therapy and initiation of pharmacotherapy.

Clinical Features

Patients with conversion disorder unconsciously develop symptoms that suggest a physical or neurologic disorder. The symptoms are not consciously produced by the patient, are usually in response to a stressor or conflict, are not limited to pain or sexual dysfunction, and are not explained by a known organic etiology or culturally sanctioned response pattern. Organic disease may be concurrently present.

Diagnosis and Differential

An organic explanation for the patient's symptoms must be excluded before the diagnosis of conversion disorder can be made. The differential diagnosis is broad and includes stroke, multiple sclerosis, polymyositis, infectious disorders, as well as drug ingestions or poisonings. The examination techniques listed in Table 186-2...