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Panic disorder

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Panic disorder

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USMLE® Step 1 style questions USMLE

2 questions
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A 30-year-old woman comes to the physician for a follow-up appointment. One month ago, the patient had an episode for which she presented to the emergency department because she thought “she was going to die.” The episode began while the patient was giving a presentation at work. At that time, she had intense chest pain, palpitations, sweating, and shortness of breath. ECG and laboratory evaluation were normal at the time, and the symptoms resolved without any intervention. She had experienced a similar  episode 3 months ago while she was at home watching TV with no identifiable stressor. The patient tells the physician that she has been afraid of another attack since then, and she has avoided going out with friends in fear that another episode may happen when outside her home. Past medical history includes a prior diagnosis of alcohol use disorder; she has since been sober for 7 years. Which of the following is the most likely diagnosis for this patient’s current condition?

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Content Reviewers:

Rishi Desai, MD, MPH

Contributors:

Tanner Marshall, MS

At some point you’ve probably heard someone say or joke about “having a panic attack,” but panic attacks are very real situations where someone experiences a sudden period of intense fear or discomfort, believing that something bad’s going to happen and that there’s some imminent threat or danger.

These feelings are often so intense that they’re accompanied by physiological symptoms like heart palpitations, dizziness, or shortness of breath.

These symptoms peak within the first 10-20 minutes, but some might last hours.

Sometimes patients having a panic attack might feel as though they’re having a heart attack or some other life-threatening illness.

Panic attacks can happen even in familiar places where there are no real threats, which makes them unpredictable, which can further increase anxiety about when the next panic attack is going to happen.

The DSM-5 outlines the specific criteria required for diagnosis of a panic attack.

Patients need to experience the abrupt onset of at least four of the following 13 symptoms: pounding heart or fast heart rate; chest pain or discomfort; sweating; trembling; shortness of breath; nausea; dizziness; chills; numbness; feelings of choking; feelings of being detached from oneself; fear of losing control; and fear of dying.

Admittedly, some of these symptoms might naturally occur together, so they can be very hard to tease apart.

For example, it would be unusual for a person who’s sweating, feeling dizzy, and feeling chills to also not be trembling.

It’s also important to note that some of these are physical symptoms whereas others are mental, like specific thoughts and ideations.

Panic attacks can happen in the context of several mental disorders including depressive disorders, posttraumatic stress disorder, and substance abuse disorders.

They can also, however, happen in the context of a panic disorder, which is basically identified in someone who has panic attacks that are recurrent—meaning 2 or more—and unexpected.

In addition, the DSM-5 says that for somebody to be diagnosed with a panic disorder, they also need to experience persistent worrying or changes in behavior due to their panic attacks.

Also, the panic attacks can’t be related to the effects of some substance, like an illicit drug or medication.

Finally, for panic disorder to be diagnosed, the associated panic attacks can’t be better explained by some other anxiety disorder, like agoraphobia or social anxiety disorder.

Patients with a panic disorder can’t predict where the panic attack will happen next, so it’s important to seek treatment before patients develop something called avoidance, which is when they actively avoid the places where a panic attack previously occurred.

They might stop doing activities that they think might trigger the attacks, like going to the park, riding in elevators, or driving.

Summary

Panic disorder is a type of anxiety disorder characterized by recurrent and unexpected panic attacks, which typically peak within the first 10-20 minutes though some might last hours. A panic attack is a sudden episode of intense fear or discomfort that can include physical symptoms such as heart palpitations, chest pain, sweating, shaking, and difficulty breathing.

Sometimes panic disorder gets so bad that the person stops engaging in activities that they think could trigger an attack, severely hampering their ability to function in day-to-day life.

The management may involve a combination of psychotherapy and medication. Cognitive-behavioral therapy is the most effective psychotherapy for panic disorder. Medications such as antidepressants and anti-anxiety medications can also be helpful.

Sources
  1. "Robbins Basic Pathology" Elsevier (2017)
  2. "Harrison's Principles of Internal Medicine" McGraw Hill Education/ Medical (2018)
  3. "Pathophysiology of Disease: An Introduction to Clinical Medicine 8E" McGraw-Hill Education / Medical (2018)
  4. "Anxiety" The Lancet (2016)
  5. "Short- and long- term efficacy of cognitive behavioral therapy for DSM-IV panic disorder in patients with and without severe psychiatric comorbidity" Journal of Psychiatric Research (2011)
  6. "Phenomenology of panic disorder in youth" Depression and Anxiety (2004)