Chapter 186. Panic and Conversion Disorders

Panic Disorder

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.

Table 186-1 Medical Differential Diagnosis of Panic Attacks

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Table 186-1 Medical Differential Diagnosis of Panic Attacks

Cardiovascular

Angina

Myocardial infarction

Mitral valve prolapse

Congestive heart failure

Tachyarrhythmias: premature atrial contractions, supraventricular tachycardia

Pulmonary

Hyperventilation

Asthma

Pulmonary embolus

Endocrine

Hyperthyroidism

Hypoglycemia

Hyponatremia

Pheochromocytoma

Carcinoid syndrome

Cushing syndrome

Neurologic

Migraine headache

Ménière disease

Complex partial seizures

Transient ischemic attacks

Drug induced

Caffeine

Cocaine

Sympathomimetics

Theophylline

Thyroid preparations

Selective serotonin reuptake inhibitors

Cannabis

Corticosteroids

β-Agonists

Triptans

Nicotine

Yohimbine

Hallucinogens

Anticholinergics

Drug withdrawal

Alcohol

Barbiturates

Benzodiazepines

Opiates

β-Antagonists

Psychiatric

Post-traumatic stress disorder

Depressive disorders

Other anxiety disorders

Psychosocial

Partner violence

Sexual abuse or assault

Other situational stressors

Emergency Department Care and Disposition

After excluding life-threatening causes of symptoms, educate and reassure patients that panic disorder is an illness that can be treated effectively.
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.
Ask patients about suicidal thoughts. Patients who are suicidal or so incapacitated that they cannot care for themselves require psychiatric consultation and hospitalization.
Most patients can be discharged. Refer to a psychiatrist for outpatient cognitive behavioral therapy and initiation of pharmacotherapy.

Conversion Disorder

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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 may help test for true neurologic deficits.

Table 186-2 Testing Techniques for Conversion Disorder

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Table 186-2 Testing Techniques for Conversion Disorder

Function

Technique

Sensation

Yes/no test

Patient closes eyes and responds yes or no to touch stimulus. No response in numb area favors conversion disorder.

Bowlus and Currier test

Patient extends and then crosses the arms, with thumbs pointed down and palms facing together. Fingers (but not thumbs) are then interlocked, and then the hands are rotated inward toward chest. Sharp stimuli are applied to each finger in turn and the patient is asked to indicate normal or abnormal sensation in each digit. Patients with conversion disorder make mistakes and are inconsistent with responses.

Strength test

Patient closes eyes. Test “strength” by touching finger to be moved. True lack of sensation would not allow patient to ascertain finger to be moved.

Pain

Gray test

With abdominal pain due to psychological factors, the patient will close eyes during palpation. In pain of organic basis, the patient is more likely to watch the examiner's hand to anticipate pain.

Motor

Drop test

When a patient with paralysis of nonorganic etiology lifts a thumb, the affected limb will drop more slowly or fall with exaggerated speed as compared with the unaffected limb. In addition, an extremity dropped from above the face will miss it.

Thigh adductor test

Examiner places hands against both inner thighs of the patient who is told to adduct the “good” leg against resistance. With pseudoparalysis, the adductor muscles of “bad” leg will also adduct.

Hoover test

Examiner's hands cup both heels of the patient who is asked to elevate the “good” leg. With pseudoparalysis the “bad” leg will push downward. When the patient is asked to lift the “bad” leg, if there is no downward pressure in the “good” leg, the patient is not trying.

Sternocleidomastoid test

Contraction of normal sternocleidomastoid muscle causes face to rotate away from side of the contracted muscle. Patient with conversion hemiplegia cannot turn head to the weak side.

Coma

Corneal reflex

Corneal reflexes remain intact in an awake patient.

Bell phenomenon

Eyes divert upward when lids are opened, whereas eyes remain in neutral position in true coma.

Lid closing

In true coma, lids when opened close rapidly initially and then more slowly as lids descend. Awake patients will have lids stay open, snap shut, or flutter.

Seizures

Corneal reflex

Usually intact in pseudoseizure.

Abdominal musculature

Palpation of abdominal musculature reveals lack of contractions with pseudoseizure.

Blindness

Opticokinetic drum

Rotating drum with alternating black and white stripes or piece of tape with alternating black and white sections pulled laterally in front of a patient's open eyes will produce nystagmus in a patient with intact vision.

Emergency Department Care and Disposition

Listen

Direct confrontation stating that symptoms have no organic etiology may worsen the condition. After excluding an organic cause for symptoms, gently reassure the patient that a serious medical illness has not been identified.
Suggest to the patient that symptoms often spontaneously.
Consult with a neurologist or psychiatrist if symptoms do not resolve and preclude discharge. Otherwise, refer for outpatient psychiatric treatment as repetitive reassurance may be needed before full function returns.

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Panic Disorder

Clinical Features

Diagnosis and Differential

Emergency Department Care and Disposition

Conversion Disorder

Clinical Features

Diagnosis and Differential

Emergency Department Care and Disposition

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Clinical Features

Diagnosis and Differential

Emergency Department Care and Disposition

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Clinical Features

Diagnosis and Differential

Emergency Department Care and Disposition

Further Reading

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