How to Distinguish Panic Disorder from Panic Attacks

APRIL 22, 2014
Shirah Vollmer, MD

You see a 26-year-old woman who has suffered recurrent episodes of chest pain and palpitations over the past 4 weeks, which have caused her to grow increasingly fearful of going out in public alone. The patient’s attacks begin with her suddenly getting scared and are followed by the rapid development of chest pain, palpitations, and a sense of feeling smothered.
 
The most recent attack occurred 4 days ago while she was in a shopping mall. It was so severe that her friends took her to an emergency room when she told them she thought she was going to die. The emergency room physician ordered several tests, including an electrocardiogram, and told her she had hyperventilated.

What is the most likely diagnosis? 

The most likely diagnosis is panic disorder. After a cardiac disorder has been excluded, the reasonable conclusion is that she is having recurrent panic attacks, which yields a diagnosis of panic disorder. She does not have agoraphobia, because although she is fearful about going out in public alone, she still manages to do that.

To say that she hyperventilated is not quite accurate, as it is important to convey to this young woman that she does have a medical diagnosis, though it is not cardiac in origin. Anxiety disorders are second only to disorders involving substance abuse as the most common psychiatric conditions in the United States.   
 
Are panic attacks synonymous with panic disorder?
 
No, a panic attack is like a headache in that it is a cluster of symptoms. When panic attacks occur on a regular basis and the person becomes preoccupied with having a panic attack, then a panic disorder is diagnosed.

More specifically, to quote the DSM-5, “the essential feature of panic disorder is the presence of recurrent, unexpected panic attacks followed by at least one month of persistent concern about having another panic attack, worry about the possible implications or consequences of the panic attacks, or a significant behavioral change related to the attacks.” In other words, panic attacks are common, but by themselves, they are not a disorder. When the attacks become the focal point of one’s mental life — when there is significant time and energy concerned about the next panic attack — then the diagnosis of panic disorder is appropriate. 

What other diagnoses might be considered, and what diagnostic tests should be done?
 
Very rarely, a pheochromocytoma can present with panic attacks. Loss, or unresolved grief, is often a contributing factor to the panic attack, so the physician should probe for recent changes. The “why now” question is critical. Since she also complains of feeling smothered, a pulmonary workup might also be a consideration.

In terms of psychiatric diagnosis, one might consider a personality disorder. Cluster B personalities tend to tilt towards dramatic presentations, and as such, one must consider whether this patient’s symptoms are in the context of other unstable behaviors. Depression is often comorbid with panic disorder, and so a thorough evaluation of her mood is mandated. It is also essential to rule out bipolar disorder, as she is at an age when panic attacks could be the first manifestation of a manic episode. Bipolar disorder is an important diagnosis not to miss, since prescribing her a selective serotonin re-uptake inhibitor (SSRI) without a mood stabilizer could exacerbate her manic symptoms.

Post-traumatic stress disorder (PTSD) might also be considered, as it is conceivable that she is being triggered by memories of painful experiences, and if her traumatic past is bubbling up, then this requires a different management program. Social anxiety would also be a consideration if her symptoms are precipitated when faced with meeting new people or people she is not very comfortable with. Substance abuse might also be considered, as it is important to determine that her symptoms are not related to detoxification.

As with all menstruating women, it would also be important to determine if her symptoms are related to her menstrual cycle and components of a premenstrual dysphoric disorder (PMDD) syndrome. Finally, given her age, a pregnancy test would also seem prudent.

What treatment options are available for managing panic disorder?
 
There are both pharmacological and non-pharmacological interventions. Pharmacologically, SSRIs are commonly prescribed, as are dual serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine. Either of these 2 classes of agents is indicated when there is significant impairment in daily functioning. These agents should be given for one year, or 6 months after symptoms have subsided.

For cases that are refractory to these interventions, mood stabilizers and/or atypical antipsychotics can be considered. These agents are ordinarily prescribed by a psychiatrist, and would be a possible indication for referral.

Non-pharmacologically, cognitive behavior therapy (CBT) and mindfulness-based stress reduction can both be useful. Promoting a healthy lifestyle with a good diet, withholding caffeine, and engaging in exercise will also help. As with all mental health-related diagnoses, stressing good sleep and hygiene is an essential part of the management program.

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