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].

• Chills

  Four most common symptoms associated with a panic attack were that of palpitations, trembling/shaking, nausea or abdominal distress, and chills or hot flushes. [ncbi.nlm.nih.gov]

  Your hands may tingle or feel numb, and you might feel flushed or chilled. You may have chest pain or smothering sensations, a sense of unreality, or fear of impending doom or loss of control. [bu.edu]

  You may also have physical symptoms, such as Fast heartbeat Chest or stomach pain Breathing difficulty Weakness or dizziness Sweating Feeling hot or a cold chill Tingly or numb hands Panic attacks can happen anytime, anywhere, and without warning. [fpnotebook.com]

• 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]

• Dyspnea

  A 34-year-old woman with a 9-year history of unprovoked attacks of anxiety and dyspnea associated with symptoms of depersonalization and derealization is presented. [ncbi.nlm.nih.gov]

  An episode of intense fear accompanied by symptoms such as heart palpitations, sweating and chills or hot flushes, a sensation of dyspnea, chest pain, abdominal distress, depersonalization, fear of going crazy, and fear of dying. [icd10data.com]

  The DSM-V defines panic disorder (PD) as the recurrent onset of sudden fear accompanied by somatic symptoms like palpitations, excessive sweating, and dyspnea. [symptoma.com]

  Symptoms experienced during a panic attack include dyspnea or sensations of being smothered; dizziness, loss of balance or faintness; choking sensations; palpitations or accelerated heart rate; shakiness; sweating; nausea or other form of abdominal distress [fpnotebook.com]

• 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]

• Choking

  ’ or ‘going mad’ increased heart rate difficulty breathing (feeling that there is not enough air) feeling choked excessive perspiration dizziness, light-headedness or feeling faint. [beyondblue.org.au]

  […] dizziness, or feeling faint or unsteady fear of dying fear of losing control feelings of choking feelings of not being part of your environment flushing or chills nausea, stomach ache, or diarrhea numbness or tingling racing heart sweating trembling [medbroadcast.com]

  Signs of Panic Disorder At least four of the following symptoms: palpitations sweating trembling and shaking shortness of breath choking sensation chest pain or discomfort nausea or abdominal distress dizziness, lightheadedness feeling detached from oneself [healthychildren.org]

  […] in their life, many people will have a panic attack, which involves one or more of the following: a feeling of imminent danger or doom the need to escape heart palpitations sweating trembling shortness of breath or a smothering feeling a feeling of choking [anxietyannarbor.com]

• Abdominal Pain

  Fast or pounding heartbeat Sweating, trembling, or shaking Shortness of breath or trouble breathing Feeling of choking or having a lump in your throat Chest pain or discomfort Nausea or abdominal pain Feeling dizzy, unsteady, lightheaded, or faint Feeling [drugs.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]

  pain, or being extremely nauseous Feeling detached, feeling as if one is about to die, or just feeling that one is losing control Many individuals who experience repeated panic attacks or even first-time panic attacks may think they are having a heart [americanaddictioncenters.org]

  These symptoms include rapid heart rate, sweating, shaking, shortness of breath, hot flashes, and lightheadedness—as well as a sense of impending doom, chills, nausea, abdominal pain, chest pain, headache, and numbness or tingling. [psycom.net]

• Chest Pain

  CONCLUSIONS: The prevalence of panic disorder was low in patients presenting to an Australian ED with chest pain. [ncbi.nlm.nih.gov]

  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]

  Lipsitz, Panic Disorder in Children and Adolescents with Noncardiac Chest Pain, Child Psychiatry & Human Development, 44, 6, (742), (2013). Alexander H. [doi.org]

• Palpitations

  Koenig, The Teenager with Palpitations, Pediatric Clinics of North America, 61, 1, (63), (2014). [doi.org]

  Palpitations, chest pain, faintness, and trembling/shaking were the most frequent PD symptoms. In comparison with the other groups, youths with PD were significantly slightly older, Caucasian, and have more comorbid bipolar disorder. [ncbi.nlm.nih.gov]

  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]

• 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]

• Tinnitus

  Medication: mianserin 30mg daily, started after onset of tinnitus; carbamazepine recently added with no effect on tinnitus. Case 4: Female, aged 70. Duration of benzodiazepine usage: 20 years. [benzo.org.uk]

• Fear

  Fear of heights and fear of crossing bridges are examples of simple phobias. [web.archive.org]

  A therapeutic focus on fear of death and dying via cognitive interventions and exposure is recommended. [ncbi.nlm.nih.gov]

• Depersonalization

  CONCLUSIONS: PD patients scored higher on items suggesting common forms of derealization and depersonalization, perhaps suggesting "secondary" and defensive psychological processes, while lacking indicators of more profound ipseity disturbance. [ncbi.nlm.nih.gov]

  Depersonalization is a feeling of being outside your own body while derealization is a feeling that the world is not real. [study.com]

  Panic Disorder At least four of the following symptoms: palpitations sweating trembling and shaking shortness of breath choking sensation chest pain or discomfort nausea or abdominal distress dizziness, lightheadedness feeling detached from oneself ( depersonalization [healthychildren.org]

  […] danger or doom the need to escape heart palpitations sweating trembling shortness of breath or a smothering feeling a feeling of choking chest pain or discomfort nausea or abdominal discomfort dizziness or lightheadedness a sense of things being unreal, depersonalization [anxietyannarbor.com]

• 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]

• Hot Flushes

  Four most common symptoms associated with a panic attack were that of palpitations, trembling/shaking, nausea or abdominal distress, and chills or hot flushes. [ncbi.nlm.nih.gov]

  flushes If these symptoms seem relevant to you, we can help. [bu.edu]

  flushes The presence of fewer than four of the above symptoms may be considered a limited-symptom panic attack. [verywellmind.com]

• Dizziness

  Dizziness is one of the most frequent complaints in both primary and specialized medical care facilities. Many dizzy patients, without a known organic cause, considered as having idiopathic dizziness, may have a psychiatric disorder. [ncbi.nlm.nih.gov]

  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]

  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]

• Headache

  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]

• Paresthesia

  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]

  […] accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering Feelings of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, light-headed, or faint Chills or heat sensations Paresthesia [adaa.org]

  Paresthesias (numbness or tingling sensations). Derealization (feelings of unreality) or depersonalization (being detached from oneself). Fear of losing control or “going crazy.” Fear of dying. [youtube.com]

• Tremor

  These can include: intense fear or discomfort; nausea; feeling short of breath; choking sensations; chest pain or discomfort; dizziness or light-headedness; rapid ‘thumping’ heartbeat; sweating; numbness or tingling sensations; tremor (shaking); and fear [mydr.com.au]

  Signs There are no specific physical signs associated with the condition, unless the patient is seen during a panic attack, when increased sympathetic outflow may manifest as tachycardia, hypertension, tremors, sweating, etc. [patient.info]

  […] disorders, and dysfunction of the mitral valve of the heart can mimic anxiety while medications such as codeine, calcium channel blockers, ACE inhibitors, statins, and benzodiazepines can cause anxiety-like symptoms such as agitation, dizziness, flushing, tremors [rd.com]

• Giddiness

  Symptoms of hyperventilation include light-headedness, giddiness, shortness of breath, heart palpitations, and feelings of weakness. "Yes," said Kathy, "I feel like I can't breathe!" [uncommonhelp.me]

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].

In addition to treatment efficacy, other factors should be considered when recommending treatment, including patient preference, treatment history, severity of illness, and presence of comorbid disorders. [web.archive.org]

Articles were identified through PsycLIT, PsyINFO, and MEDLINE (1985 to 2006) using the terms panic disorder, psychotherapy, psychosocial treatment, treatment, and pharmacotherapy. [ncbi.nlm.nih.gov]

Prognosis The literature is contradictory about prognosis. In one study the panic disorder had a long course lasting several years [ 9 ]. [patient.info]

Prognosis Patients with panic disorder have a poor prognosis particularly if untreated. Patients often relapse when they attempt to discontinue treatment. [minddisorders.com]

Sarcoidosis is a systemic disease of unknown etiology, in which granulomas develop in various organs, including the skin, lungs, eyes, or heart. [ncbi.nlm.nih.gov]

Considering alcohol and drug dependence, 14% met the criteria for only alcohol dependence, and 11% for drug dependence.12 ETIOLOGY Several factors have been identified as part of the etiology of PD, and both genetic and environmental factors seem to contribute [scielo.br]

Etiology The exact cause of panic disorder has yet to be determined, however, several factors are thought to play a role in the development of this disorder. [physio-pedia.com]

Epidemiologic data from EU countries were critically reviewed to determine the consistency of prevalence estimates across studies and to identify the most pressing questions for future research. [ncbi.nlm.nih.gov]

Kessler RC Epidemiology of psychiatric comorbidity. In:Tsuang MTTohen MZahner GEPeds. Textbook in Psychiatric Epidemiology. New York, NY John Wiley & Sons1995;179- 197 Google Scholar 33. [doi.org]

Although accumulating evidence suggests that some inflammatory processes play a role in the pathophysiology of mental disorders, very few studies have evaluated cytokine levels in patients with PD. [ncbi.nlm.nih.gov]

This study points out the need of early antidepressant treatment for panic disorder to prevent further ED. Copyright 2016 Elsevier Ireland Ltd. All rights reserved. KEYWORDS: Antidepressants; Erectile dysfunction; Panic disorder; Taiwan [ncbi.nlm.nih.gov]

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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