A 40-year-old woman comes to the emergency department fearing she is having a heart attack. While clutching her chest and breathing heavily, she says, "I feel like I'm dying." Temperature is 37.2 C (99 F), blood pressure is 125/86 mm Hg, pulse is 110/min and regular, and respirations are 18/min. The patient's pulse oximetry shows 98% on room air. Laboratory evaluation and ECG show no abnormalities. The pain resolves within 10 minutes without treatment, and the patient reports, "I was taking the bus home from work when my chest started feeling really tight. I'm lucky my friend was there and able to help me get to the hospital. What if she's not there next time?" She describes experiencing similar episodes at random places and times that are characterized by a pounding heart, trembling, dizziness, and sweating. She drinks alcohol socially and does not use any medications. This patient is most likely to develop which of the following disorders as a result of her current condition?
Panic disorder | |
Clinical |
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Treatment |
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SNRI = serotonin norepinephrine reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor. | |
This patient likely has panic disorder, which presents with distressing cardiopulmonary/neurologic symptoms that reach their peak level of intensity in 10 minutes or less and then subside. Due to the intensity of the symptoms and their tendency to mimic a heart attack, patients may fear they are dying and seek treatment in the emergency department.
Patients with panic disorder often develop agoraphobia, which is characterized by anxiety about and avoidance of multiple situations where they may feel trapped and helpless in the event of a panic attack (eg, crowds, enclosed spaces, public transportation). For example, this patient may start avoiding bus rides due to fears of recurrent panic attacks. In severe cases of agoraphobia, patients may restrict their activities to the point that they leave home only with a companion or they become completely housebound.
Agoraphobia is a distinct condition and can be diagnosed with or without the presence of panic disorder.
(Choice A) In acute stress disorder, exposure to a life-threatening trauma results in symptoms of reexperiencing (ie, intrusive memories, flashbacks), avoidance of reminders, negative mood, dissociation, and hyperarousal. This patient does not have a history of experiencing a traumatic event.
(Choice C) Although patients may have the fear of "going crazy" while experiencing a panic attack, they are not at greater risk of developing psychotic symptoms (eg, delusions, hallucinations, disorganized speech and/or behavior). Acute psychotic symptoms would be more indicative of brief psychotic disorder.
(Choices D and F) This patient is fearful of leaving home unaccompanied due to a concern about future panic attacks rendering her helpless. In dependent personality disorder, individuals have a lifelong pattern of seeking out relationships due to feeling helpless when alone. Separation anxiety disorder in adults consists of ≥6 months of excessive and distressing anxiety due to separation from a significant attachment figure (eg, spouse, child), unrelated to a fear of being debilitated by panic attack symptoms.
(Choice E) Generalized anxiety disorder is characterized by persistent and excessive worry about multiple issues (eg, work, health, finances). This patient's anxiety is focused on her panic symptoms and future attacks.
Educational objective:
Panic disorder consists of recurrent and unexpected panic attacks characterized by an abrupt surge of anxiety and distressing cardiopulmonary/neurologic symptoms. Agoraphobia, a common comorbid disorder, results in anxiety about and avoidance of situations where patients may feel trapped and helpless in the event of a panic attack (eg, crowds, enclosed spaces, public transportation).