The DSM-V [1] defines panic disorder (PD) as the recurrent onset of sudden fear accompanied by somatic symptoms like palpitations, excessive sweating, and dyspnea. Other criteria include persistent anxiety about recurrence and its consequences or inappropriate behavioral changes. In order to diagnose PD, it is important to exclude medical illnesses, substance abuse, and other psychiatric disorders as the cause of the panic attacks.

The clinical presentation of panic attacks and PD can mimic the symptoms of coronary heart disease [2] and cardiomyopathies [2], making it difficult to differentiate between the conditions clinically [3]. For example, symptoms like chest pain, palpitations, sweating, discomfort, and dyspnea are common to PD as well as myocardial infarction (MI), angina pectoris and pulmonary embolism. Other somatic symptoms of PD include cold clammy hands, headache, diarrhea, insomnia, weakness, intrusive thoughts, and ruminations. The attacks in PD are often related to certain places or situations. Patients develop anxiety about the recurrence of the attack and start avoiding these situations and places resulting in agoraphobia [4]. This can further lead to the development of safety behaviors like dependence on anxiolytic medications and avoiding being alone [4].

Although no gender differences have been observed in the expression of PD symptoms in children and adolescents, a higher incidence of PD has been observed amongst girls. Children and adolescents experience somatic symptoms similar to those seen in adults and these include palpitations, dyspnea, sweating, chest pain, nausea, abdominal discomfort, dizziness, restlessness and a sense of losing control [5] [6] [7].

• Fatigue

  In fact, panic disorder often coexists with unexplained medical problems, such as chest pain not associated with a heart attack or chronic fatigue. [web.archive.org]

  The long list of symptoms include everything from feelings of restlessness or having difficulty concentrating to muscle tension, fatigue, and sleep problems. [rd.com]

  It normally develops between the ages of 18-45 and commonly occurs with other illnesses like depression as well as: 1 Chronic obstructive pulmonary disorder (a lung disorder) Irritable bowel syndrome Migraine headache Restless leg syndrome Fatigue Heart [healthyplace.com]

• Noncompliance

  Among the 8 noncompliant patients was 1 patient receiving imipramine alone who violated protocol by using benzodiazepines at rates exceeding those allowed, and 1 patient receiving CBT who began nonprotocol antidepressant treatment during acute treatment [doi.org]

• Non-Cardiac Chest Pain

  Anxiety and hypervigilance to cardiopulmonary sensations in non-cardiac chest pain patients with and without psychiatric disorders. [doi.org]

• Nausea

  Agoraphobia is not a component of this disorder An episode of intense fear and anxiety that may be accompanied by one or more of the following symptoms: heart palpitations, sweating, shortness of breath, chest pain, nausea, dizziness, and trembling. [icd9data.com]

  Tarbell, Vomiting and Nausea in the Pediatric Patient, Nausea and Vomiting, 10.1007/978-3-319-34076-0_13, (175-190), (2016). Andrea M. Victor, Alexandra D. Zagoloff and Gail A. [doi.org]

  Nausea and tiredness were more common with fluvoxamine (p 0.02 and p 0.01, respectively). Because inositol is a natural compound with few known side effects, it is attractive to patients who are ambivalent about taking psychiatric medication. [ncbi.nlm.nih.gov]

  Some of the features of a panic attack do in fact mimic those of a heart attack: palpitations, chest pain, shortness of breath, sweating, dizziness and nausea. [healthychildren.org]

• Tachycardia

  The event started suddenly and was associated with diaphoresis, chest pain, tachycardia, and tachypnea. Troponins and ECG are within normal limits. [step2.medbullets.com]

  […] flashes Visual disturbances Fear of dying Fear of losing control or impending doom [1] [2] [4] [6] [13] [14] [15] Effects of symptoms Symptoms of panic disorder have physical, behavioral and cognitive effects: [13] Physical: Tachycardia Palpitations [physio-pedia.com]

  Definition (CSP) specific psychological phenomenon characterized by sudden onset of anxiety (often unrelated to objective events), accompanied by autonomic symptoms such as tachycardia, paresthesia, flushing, and sweating. [fpnotebook.com]

  Specific psychological phenomenon characterized by sudden onset of anxiety (often unrelated to objective events), accompanied by autonomic symptoms such as tachycardia, paresthesia, flushing, and sweating. [icd10data.com]

• Skin Patch

  The development of a new MAOI skin patch may decrease these risks. MAOIs can also react with SSRIs to produce a serious condition called “ serotonin syndrome ”. [web.archive.org]

• Obsessive Thoughts

  Some OCD sufferers may only have obsessive thoughts without the related rituals. [uhs.umich.edu]

  thoughts; Anxiety must be limited to at least two of the following situations (or mainly to occur only in them): crowds, public places, travel from home, or unaccompanied travel by another person; Avoiding the phobic situation A single panic attack may [intechopen.com]

  Not all of the patients who respond to SSRI treatment are the ones in whom the condition seems attributable to anxious or obsessive thought patterns, so it appears likely that there is some set of patients for whom these medications correctly target some [panic411.com]

• Low Self-Esteem

  It can cause: Low self-esteem Poor school performance Problems with peer and family relationships Social isolation Sleep problems Depression Drug or alcohol use Agoraphobia (fear of visiting crowded places) What causes panic attacks and panic disorder [youngmenshealthsite.org]

  self-esteem, frustration, and resentment prior to PD onset. [scielo.br]

  HeartSpeak - a novel method for reducing stress and other stress-related conditions such as anxiousness, depression, and low self-esteem.[69] Depending on the situation, all of these coping mechanisms may be adaptive, or maladaptive. [en.wikipedia.org]

• Headache

  Other somatic symptoms of PD include cold clammy hands, headache, diarrhea, insomnia, weakness, intrusive thoughts, and ruminations. The attacks in PD are often related to certain places or situations. [symptoma.com]

  Common side effects of SSRIs include: nausea headaches low sex drive (loss of libido) blurred vision diarrhoea or constipation dizziness dry mouth loss of appetite sweating feeling agitated insomnia (sleep problems) abdominal pain When you first start [nhsinform.scot]

  Chronic obstructive airways disease and migraine headaches are also present in a larger proportion of sufferers than chance would suggest, as are functional disorders such as irritable bowel syndrome and tension-type headache. [patient.info]

  N Engl J Med 327:1109–1114 PubMed Google Scholar Sjaastad O, Bakketeig LS (2004) Caffeine-withdrawal headache: the Vaga study of headache epidemiology. [doi.org]

  Headaches, discomfort and lightheadedness are also common. When the panic-related anxiety becomes a chronic issue, the person starts to experience detrimental long-term effects. [psychguides.com]

Diagnosis of PD can be challenging as its clinical presentation resembles that of several serious acute conditions. Therefore the diagnosis is often based on the exclusion. History, physical examination and mental status examination are the pillars of PD diagnosis. An electrocardiography (ECG) should be obtained early during the workup to rule out myocardial ischemia and conduction abnormalities in all patients presenting with palpitations, chest pain, dyspnea, and sweating. Pulse oximetry will usually show either normal or slightly higher oxygen levels. Arterial blood gas analysis is performed to exclude metabolic acidosis and hypoxemia. In patients with a history of a syncopal event, ambulatory Holter monitoring should be considered. A D-dimer test, spiral computed tomography (CT scan), lower limb Doppler or ventilation-perfusion (V/Q) scanning is indicated to exclude pulmonary embolism especially in those at risk. Electroencephalography may be required to differentiate PD from partial complex seizures.

Laboratory studies should be performed to exclude substance abuse and other medical conditions. These include complete blood count, hemoglobin, urine toxicology, serum electrolytes, serum glucose, cardiac enzymes and, thyroid-stimulating hormone.

Orexin or hypocretin has been shown to play a role in the pathogenesis of panic in rats [8] and elevated levels have been observed in the cerebrospinal fluid of individuals with panic attacks.

Functional magnetic resonance imaging is not routinely recommended in the workup of PD although increased flow in the right parahippocampal region with decreased serotonin type 1A receptor binding in the anterior and posterior cingulate and raphe of patients with panic disorder has been noticed on positron emission tomography (PET) scanning [9]. Patients with PD have also been observed to have smaller temporal lobe volume on magnetic resonance imaging [10].

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.
2. Tully PJ. A good time to panic? Premorbid and postmorbid panic disorder in heart failure affects cardiac and psychiatric cause admissions. Australas Psychiatry. 2015;23:124 –7.
3. Tully PJ, Cosh SM, Baumeister H. The anxious heart in whose mind? A systematic review and meta-regression of factors associated with anxiety disorder diagnosis, treatment and morbidity risk in coronary heart disease.J Psychosom Rese. 2014;77:439 –48.
4. Roy-Byrne PP, Craske MG, Stein MB. Panic disorder. Lancet. 2006;16:1023-32
5. Masi G, Favilla L, Mucci M, Millepiedi S. Panic disorder in clinically referred children and adolescents. Child Psychiatry Hum Dev. 2000;31:139-51.
6. Ehlers A. Somatic symptoms and panic attacks: a retrospective study of learning experiences. Behav Res Ther. 1993;31:269-78.
7. Diler RS, Birmaher B, Brent DA, et al. Phenomenology of panic disorder in youth. Depress Anxiety. 2004;20:39-43.
8. Johnson PL, Truitt W, Fitz SD, et al. A key role for orexin in panic anxiety. Nat Med. Jan 2010; 16(1):111-5.
9. Neumeister A, Bain E, Nugent AC, et al. Reduced serotonin type 1A receptor binding in panic disorder. J Neurosci. Jan 21 2004; 24(3):589-91.
10. Vythilingam M, Anderson ER, Goddard A, et al. Temporal lobe volume in panic disorder--a quantitative magnetic resonance imaging study. Psychiatry Res. Aug 28 2000; 99(2):75-82