24 Panic Disorder

Kenneth Lakritz

Clinical Vignette

A 33-year-old woman was referred to a psychiatric clinic after presenting to a hospital emergency department (ED) on four consecutive nights, complaining of chest pain, dyspnea, and faintness. Each time a careful cardiac and pulmonary examination was unremarkable, and the patient was sent home with a benzodiazepine prescription and reassurance from the ED staff that she was not ill.

She reported similar attacks since childhood, but not as frequently as recently. She felt a desperate need to have help available if an attack occurred and rarely left home unaccompanied. This lady worried that she would lose consciousness during an attack or lose control of her bowels but admitted that neither had ever happened.

Recently she had given up both driving and air travel. She worked at an undemanding job near home. Her lack of any substantive social life was something that significantly troubled her, but despite such she felt helpless to socialize any more. Caffeine made her feel “wired,” and she presented the psychiatrist with a long list of medications to which she was “allergic.” She acknowledged occasional excess alcohol consumption in order to lessen her anxiety.

Emergency department (ED) staff frequently encounter and diagnose patients with panic disorder. These individuals experience unpredictable and sudden bouts of intense anxiety and frightening physical symptoms, leading them to fear they are having a heart attack, stroke, or other medical emergency. This vignette is a classic illustration of a panic disorder. Typically, these patients require a combination of anxiolytic pharmacologic agents and behavioral psychotherapy.

Clinical Presentation

Patients with panic disorder are invariably focused on the details of their bodily sensations and tend to reach catastrophic conclusions based on minor aches, palpitations, and shortness of breath (Fig. 24-1

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