Below is a brief summary of the phenomenology and epidemiology of panic attacks, followed by 3 patient cases focused on the differential diagnosis and medical work-up of panic attacks.
What is a panic attack?
Panic attacks are characterized by a surge of intense fear or intense discomfort that reaches a peak within minutes and is accompanied by at least four somatic or cognitive symptoms (APA 2013). The somatic symptoms include chest pain, racing heartbeat or palpitations, feeling breathless, shaking, sweating, chills or heat sensations, dizziness or feeling faint, derealization (feeling of unreality) or depersonalization (feeling of being outside one’s body), paresthesias, feelings of choking, nausea, or stomach discomfort (APA 2013). The cognitive symptoms include the fear of losing control or “going crazy” and a fear of dying.
Panic attacks are common: roughly 1 in 10 people in the US will experience a panic attack in a given year (Culpepper 2004). Panic attacks can occur in isolation or in association with other psychiatric diagnoses (i.e. PTSD with panic attacks, social anxiety with panic attacks). Panic attacks are the sine qua non of panic disorder (recurrent, unexpected panic attacks with maladaptive behavioral changes aimed at preventing future panic attacks). Multiple medical problems can also be misdiagnosed as panic attacks.
With “panic attack” in the lay lexicon, it is crucial to ask patients what they mean when they say they have panic attacks. Can you describe your most recent panic attack in detail? When was it? Where were you? What happened first? And then? And then what? How long did it take to reach its most severe? How long did it take to resolve? During this history collection, I am listening carefully for the typical elements of a panic attack. Sometimes patients are describing classic panic attacks. Often they are episodes of severe anxiety. On occasion, there are atypical features that suggest the need for further medical evaluation.
The 3 cases below explore the differential diagnosis of panic attacks.
Are these panic attacks? Or something else?
Case #1
Selma is a 22-year-old woman who has migraines and asthma. She uses albuterol after exercise. Last week, during a jog, she experienced the sudden onset of chest discomfort, palpitations, and shortness of breath, and was afraid she might die. Her albuterol inhaler did not help. The symptoms peaked in 5-10 minutes and self-resolved within 30 minutes once she started walking. In general, she has been feeling well and doesn’t use tobacco, alcohol, or any drugs. She drinks 2 cups of coffee daily. She has felt palpitations before, at night, while lying in bed, but the chest pain is new. Her vital signs and physical exam are normal. Her GAD-7 is 5, and her PHQ9 is 3. A CBC, TSH and BMP from 1 month prior are all WNL.
What work-up would you recommend at this time? (choose all that apply)
EKG
Ziopatch
Echo
PFTs
Urine toxicology
CXR
No further work up
You order an in-clinic EKG (normal sinus rhythm), and a Ziopatch to take home for 2 weeks of heart rhythm monitoring.
Selma returns a month later. She has had 2 more similar episodes of chest pain, palpitations, shortness of breath, and fear of dying without a clear precipitant. The Ziopatch was on during both events and did not show any arrhythmias. The episodes were not associated with eating or migraines. You ask more about her current stressors. You learn that 3 months ago, her younger sister was intubated after an asthma exacerbation. Selma was frequently in the emergency room for asthma as a child. Because she is worried about her episodes of chest pain, Selma has started to avoid leaving her house.
You broach the possibility of recurrent panic attacks with Selma. With the associated fear of leaving the house, this may be developing into panic disorder. Panic disorder is more common in people with a recent life stressor, chest pain with negative cardiac testing, obstructive lung disease, migraines, and history of palpitations (Katon 2006). You refer Selma to a therapist to begin treatment.
Case #2
Barbara is a 50-year-old woman with hypothyroidism on levothyroxine, diabetes on glipizide, and seasonal allergies on PRN decongestants. Two days ago, for the first time, Barbara experienced an episode of sweating, nausea, and shakiness. She drank ginger ale to calm her stomach, and her symptoms fully resolved within 30 minutes. Barbara did not lose consciousness or experience any transient neurologic deficit. She had no chest pain, palpitations, or shortness of breath. Barbara has been taking her glipizide with food and levothyroxine as prescribed. Her seasonal allergies have been well controlled, without the need for decongestants. She does not smoke cigarettes, drink alcohol or use any drugs. She is not feeling depressed or anxious in general, but was intensely anxious during this episode. Her vital signs, cardiovascular, and neurologic exam are normal. Three months ago, her A1c was 7.5 and TSH was 2.
What work-up would you recommend? (choose all that apply)
EKG
Ziopatch
POCT blood glucose
TSH
BMP
24-hour blood pressure cuff
You consider episodes of hypotension, hypertension, hypoglycemia, arrhythmia, cardiac ischemia, electrolyte disturbance and panic attacks as possible etiologies for her symptoms. An in-clinic EKG shows normal sinus rhythm and POCT blood glucose is 80. You provide reassurance despite not having a clear diagnosis for this event. You order a BMP for electrolyte disturbance, send her home with a prescription for a blood pressure cuff and ask Barbara to carry her glucometer with her when she is out to evaluate for hypoglycemia.
Her BMP is normal. 1 month later, she sends you a message that she had another episode and her blood glucose was 40. You schedule a follow up to discuss her diabetes management.
Case #3
Richie is a 32-year-old man whose wife is pregnant with their first child. He has a history of generalized anxiety disorder and insomnia. He recently experienced the sudden onset of a racing heartbeat, shortness of breath, tingling on his face that spread to his hand, and blurred vision. The episode lasted 2 minutes and then stopped abruptly. During the event, Richie never lost consciousness. He has been drinking more caffeine during the day (3 cups of coffee now instead of 1). A GAD-7 in the clinic today is 15, indicating severe anxiety. His vital signs and a cardiovascular, respiratory and neurologic exam are all normal.
You think that this episode is most likely a panic attack. You discuss starting an SSRI for generalized anxiety disorder and recommend a maximum of 1 cup of coffee per day.
Richie returns for routine follow-up 6 weeks later. He has been taking sertraline 50 mg daily and his baseline anxiety is a bit better. He has had 2 more episodes that were identical to the initial one: 2 minutes of racing heartbeat, shortness of breath, tingling of his face then hand, and blurred vision, with an abrupt onset and resolution. Once again, his exam is normal. His vision is 20/20.
What work-up would you recommend? (choose all that apply)
EKG
Peripheral neuropathy panel – B12, HIV, RPR, A1c, TSH
POCT blood glucose
BMP
Brain MRI
An EKG shows normal sinus rhythm. You order a peripheral neuropathy panel, POCT blood glucose, and chemistry panel, which are all WNL. You increase his sertraline to 100 mg daily and ask him if it is OK to send an e-consult to Neurology. There is something atypical about these episodes – panic attacks typically last longer than 2 minutes, on average 30 minutes, and are less likely to have a stereotyped presentation (Fraser-Rini 2020). The neurologist recommends a brain MRI, which shows a temporal lobe lesion. You tell Richie about these results and urgently refer him to neurology to discuss the possibility of temporal lobe seizures.
Differential Diagnosis for Panic Attacks
- MI
- Arrhythmia
- Mitral valve prolapse
- Hypertension, hypotension
- Pulmonary Embolism
- Obstructive lung diseases – COPD, asthma
- Hyperthyroidism, hypothyroidism
- Hypoglycemia
- Pheochromocytoma
- Transient Ischemic Attack
- Migraines
- Temporal lobe seizure
- Vestibular dysfunction
- Substances, such as caffeine, albuterol, levothyroxine, steroids, and decongestants
- Substance withdrawal (alcohol, benzodiazepines)
(Culpepper 2004, Locke 2015, Katon 2006).
Key Points
1) Panic attacks are characterized by a surge of intense fear or discomfort that reaches a peak within minutes and with at least four symptoms: chest pain, racing heartbeat or palpitations, feeling breathless, shaking, sweating, chills or heat sensations, dizziness or feeling faint, derealization or depersonalization, paresthesias, feelings of choking, nausea or stomach discomfort, fear of losing control and ‘going crazy,’ or a fear of dying.
2) Ask specific details about a patient’s “panic attack,”: what happened before, what happened during the event, how long did it take to reach its most severe form, and how long did it take to resolve.
3) The differential diagnosis for panic attacks is broad; make sure to consider psychiatric medical conditions, co-existing medical illness, medication side effects, substance toxicity or withdrawal, or a new medical diagnosis.
References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington, DC: American Psychiatric Association; 2013.
Culpepper, L. (2004). Identifying and Treating Panic Disorder in Primary Care. Identifying and Treating Panic Disorder in Primary Care. Journal of Clinical Psychiatry 65[suppl 5]:19–23.
Fraser-Rini, J., & Ochoa, J. (2020). Panic Attack as the Sole Manifestation of Epilepsy Localized to the Nondominant Temporal Region. The Journal of Neuropsychiatry and Clinical Neurosciences, 32(3), 309–311.
Guaiana, G., Meader, N., Barbui, C., Davies, S. J., Furukawa, T. A., Imai, H., Dias, S., Caldwell, D. M., Koesters, M., Tajika, A., Bighelli, I., Pompoli, A., Cipriani, A., Dawson, S., & Robertson, L. (2023). Pharmacological treatments in panic disorder in adults: A network meta-analysis. Cochrane Database of Systematic Reviews, 2023(11).
Katon, W. J. (2006). Panic Disorder. New England Journal of Medicine 354(22), 2360-7.
Locke, A. B. (2015). Diagnosis and Management of Generalized Anxiety Disorder and Panic Disorder in Adults. 91(9).