Differential Diagnosis for a Patient with Panic Attacks and Skin Rashes

The patient's presentation of panic attacks, skin rashes, restlessness, palpitations, and fear suggests a complex interplay between psychological and physiological factors. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Panic Disorder with Comorbid Condition: The 10-year history of panic attacks is suggestive of panic disorder. The skin rashes could be related to stress or an independent condition such as urticaria, which can be triggered by stress and anxiety, commonly seen in patients with panic disorder.

• Other Likely Diagnoses

  • Anxiety Disorder with Dermatological Condition: Conditions like atopic dermatitis (eczema) or psoriasis can have a psychological component, with stress exacerbating symptoms. The patient's anxiety could be contributing to or worsening the skin condition.
  • Mastocytosis: A condition characterized by the accumulation of mast cells in one or more organs, which can cause a wide range of symptoms including skin lesions, anxiety, palpitations, and flushing due to the release of histamine and other mediators.
  • Thyroid Disorders: Hyperthyroidism can cause anxiety, palpitations, and skin changes, including rashes. The irregular intervals of symptoms could be related to fluctuations in thyroid hormone levels.

• Do Not Miss Diagnoses

  • Pheochromocytoma: A rare tumor of the adrenal gland that can cause episodic palpitations, anxiety, and skin manifestations like flushing due to the excessive release of catecholamines. Although rare, missing this diagnosis could be fatal.
  • Cardiac Conditions: Certain heart conditions, such as supraventricular tachycardia or mitral valve prolapse, can present with palpitations and anxiety. Skin rashes could be unrelated or indicative of an embolic phenomenon in the case of cardiac conditions.
  • Neurological Conditions: Conditions like multiple sclerosis or a seizure disorder could present with a wide range of symptoms including anxiety, skin manifestations, and neurological deficits.

• Rare Diagnoses

  • Systemic Mastocytosis with Associated Hematologic Disorder: While mastocytosis is considered in the likely diagnoses, a systemic form with an associated hematologic disorder (like myeloproliferative neoplasms) is rarer and could explain a broader range of symptoms.
  • Ehlers-Danlos Syndrome: A group of disorders that affect connective tissues supporting the skin, bones, blood vessels, and many other organs and tissues. Some types can cause skin hyperextensibility, joint hypermobility, and other systemic symptoms that might overlap with the patient's presentation.
  • Autoimmune Disorders: Certain autoimmune conditions, such as lupus or scleroderma, can cause a wide range of systemic symptoms including skin rashes, anxiety, and palpitations, although the combination of symptoms described would be unusual for these conditions.