Approach
Diagnose panic disorder based on self-reported patient history, clinical interview, and behavioral observation. Objective findings based on the physical examination or laboratory testing are not generally required during assessment.
History/clinical interview
Three key features are important in the differential diagnosis of panic disorder:[1]
Panic attacks are recurrent, with a history of occurring unexpectedly or "out of the blue," and peak within a few minutes.
The focus of the fear or apprehension is on having another panic attack and/or the misinterpretation of the mental and physical consequences of the panic sensations as being dangerous.
There may be avoidance or safety behaviors designed to minimize the experience of future panic episodes. Agoraphobia may also be a common consequence.
Panic attacks involve the sudden onset of intense physical and cognitive symptoms of anxiety. Typically a panic attack will reach a peak within minutes, and the person often feels the need to do something urgently (e.g., escape to a safe place).[4] Anxiety sensations may be a common presentation in primary care. The surge of anxiety experienced physiologically in a dangerous situation may be differentiated from a panic attack by an absence of "catastrophizing" cognitive symptoms.[4] For a diagnosis of panic disorder, the individual must experience an unexpected panic attack over the course of his or her lifetime that is followed by a 1-month period of worry over the recurrence of the attack or its consequences, and/or a maladaptive change in behavior because of the attack.[1]
Panic attacks are recurrent; note that nonrecurrent panic attacks are relatively common in the general population.[2][3] The frequency of panic attacks may vary considerably, with some individuals reporting brief clusters of several panic episodes in a short period of time, weekly panic attacks, or periodic attacks over the course of several months. Regardless of frequency, the person remains persistently concerned or anxious about the possibility of another attack and its consequences.[4]
Although panic attacks are common in other anxiety disorders, such as specific phobias, social anxiety disorder, and posttraumatic stress disorder, they do not necessarily constitute a diagnosis of panic disorder. In other anxiety disorders, the panic attacks are triggered by the anticipation of or direct exposure to feared situations (and can therefore be considered to be "expected" rather than "unexpected" as in panic disorder). Persistent concern or behavioral change because of fear of further panic attacks may differentiate panic disorder from panic attacks associated with other mental health conditions.[4]
Up to 70% of patients report a history of at least 1 nocturnal panic attack.[55] Individuals may present with symptoms suggestive of heightened sympathetic nervous system activity (e.g., palpitations, increased systolic blood pressure, hyperventilation, sweating, flushing). Other common symptoms include chest pain and discomfort, dizziness, and tingling or numbing sensations in the hands, feet, and facial areas. Gastrointestinal symptoms such as nausea and vomiting are more common in males. Actual fainting episodes are uncommon. However, panic disorder comorbid with blood, injection, or injury phobia may increase the risk for fainting given acute decreases in heart rate and blood pressure when exposed to blood-injury triggers.
Medical history tends to be unremarkable, although a history of asthma and of smoking in adolescence may be especially associated with increased risk for panic disorder.[50][56] A number of medical conditions, such as hyperthyroidism, hypoglycemia, orthostatic hypotension, and rarely pheochromocytoma, may mimic symptoms of panic. Assess for medical comorbidity, which is frequently found (e.g., respiratory disorders, cardiac arrhythmias, thyroid disease, chronic pain and cancer).[4] Assess for current medication and substance use (e.g., alcohol, nicotine, stimulants, benzodiazepines, opiates) as direct, adverse, and withdrawal effects may mimic panic symptoms.[4]
Cultural factors need to be taken into account when assessing panic attacks and panic disorder.[57] White people report predominantly cardiac and respiratory symptoms during panic episodes, whereas Cambodian refugees report symptoms focused on the head and neck and gastrointestinal areas.[8][58][59][60] Black patients commonly report intense sensations of numbing in their extremities, fears of dying, and thoughts of "going crazy."[61] Patients from Spain and India infrequently report cognitive symptoms, and Japanese patients rarely have depersonalization.[62][63][64]
Medical service utilization may be high among patients with a history of panic. Patients often seek help from medical specialists or emergency departments, and may be referred for unnecessary investigations to rule out medical causes of symptoms.[65]
Providers should assess the intensity and frequency of attacks. Levels of distress are typically high, with impairment on measures of quality of life seen compared to healthy controls, and an increased risk of suicide attempt.[66][67]
Functional impairments in personal, social, and occupational domains are common and become increasingly severe with increasing avoidance and safety-related behaviors.[68]
Routinely screen for other anxiety, mood, and substance-related disorders should be routinely conducted, due to high levels of comorbidity and association with worse outcomes.[8] In practice, given the high potential for co-existing diagnoses, there is often a need to assess and prioritize multiple mental health conditions.[12] Use of a timeline approach to onset of disorders may be helpful, and may help establish the primary disorder and assist with treatment planning and prioritization.[69] Suicide risk assesment is important.[4][70]
Assessment of panic and associated impairments can be augmented by self-monitoring and key informant interviews with family members.
Behavioral observation
When interviewing patients, they may become noticeably anxious and nervous when describing their panic sensations.
Individuals with recurring panic attacks will cope with their anxiety through behavioral avoidance, safety-seeking, or use of substances, especially nicotine. Individuals may also report avoiding certain activities, such as exercising, based upon fears of triggering panic sensations.
The patient will have an increased reliance on safety cues, such as trusted companions and use of medication when entering social situations. The focus of the anxiety is mainly due to fears of experiencing panic sensations rather than fears of being negatively evaluated by others.
Physical exam
Objective findings from the physical exam are not generally found when examining a patient with panic attacks. Cardiorespiratory evaluations are typically within normal limits. Some studies have found that approximately 25% of patients presenting with palpitations suffer from recurring panic attacks.[71] Chest pain is common in medical populations, with non-anginal chest pain associated with panic disorder.[72] Respiratory variability may be a potential risk factor for panic disorder.[51]
Signs of heightened sympathetic nervous system activity, such as tachycardia, increased systolic BP, hyperventilation, sweating, and flushing, may be present in intense panic attacks. Muscle trembling or shaking in extremities may contribute to fears of imbalance.
Laboratory tests
Laboratory testing or imaging studies may be indicated to help rule out organic causes that may be contributing to the clinical presentation.
Where there is potential for an organic underlying cause, a reasonable minimum panel of blood tests includes:[4]
Thyroid function tests
Blood chemistries
Complete blood count
Blood glucose levels.
Toxicology screening may be indicated to determine whether illicit substances are contributing to the clinical presentation. An ECG is required in all patients presenting with chest pain or other cardiac symptoms (e.g., arrhythmias), to exclude cardiac causes.[4]
Screening tools
The PRIME-MD panic screen contains four "yes or no" questions to assess the presence of panic attacks within the last 4 weeks. Responding "yes" to all 4 questions indicates likely presence of panic disorder. The panic screen also includes 11 somatic and cognitive symptoms, with endorsement of at least 4 of these symptoms indicative of likely panic disorder.[73]
The Panic Disorder Severity Scale (PDSS) is a 7-item measure assessing the frequency, avoidance, degree of distress, and functional impairment of panic attacks. Items are scored on a 0-4 scale, with higher scores indicative of greater panic severity. Among patients with panic disorders without agoraphobia, scores of 0-1 are considered normal, 2-5 borderline ill, 6-9 slightly ill, 10-13 moderately ill, 14-16 markedly ill, and 17+ severely ill.[74]
The GAD-7 is a brief self-report measure for assessing anxiety severity in primary care. In total, 7 items are scored on a 0 to 3 scale, with a cut score of ≥10 indicative of a likely anxiety disorder.[10][75] Although designed as a measure of generalized anxiety, the GAD-7 is sensitive in detecting panic-related symptoms.
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