Patients with panic disorder frequently present to the emergency department (ED) with chest pain or dyspnea, fearing that they are dying of myocardial infarction. They commonly report a sudden unexpected and spontaneous onset of fear or discomfort, typically reaching a peak within 10 minutes. DSM-5 criteria for panic disorder include the experiencing of recurrent panic attacks, with 1 or more attacks followed by at least 1 month of fear of another panic attack or significant maladaptive behavior related to the attacks. A panic attack is an abrupt period of intense fear or discomfort accompanied by 4 or more of the following 13 systemic symptoms:
During the episode, patients have the urge to flee or escape and have a sense of impending doom (as though they are dying from a heart attack or suffocation). Other symptoms may include headache, cold hands, diarrhea, insomnia, fatigue, intrusive thoughts, and ruminations.
Patients with panic disorder have recurring episodes of panic, with the fear of recurrent attack resulting in significant behavioral changes (eg, avoiding situations or locations) and worry about the implications of the attack or its consequences (eg, losing control, going crazy, dying).
Panic disorder may result in changes in personality traits, characterized by the patient becoming more passive, dependent, or withdrawn.
Assess precipitating events, suicidal ideation or plan, phobias, agoraphobia, and obsessive-compulsive behavior. Exclude involvement of alcohol, illicit drugs (eg, cocaine, amphetamine, phencyclidine, amyl nitrate, lysergic acid diethylamide [LSD], yohimbine, 3,4-methylenedioxymethamphetamine [MDMA, or ecstasy]), cannabis, and medications (eg, caffeine, theophylline, sympathomimetics, anticholinergics).