What is the diagnosis for a patient who has had a panic attack?

Diagnosis of a Patient with a Panic Attack

A single panic attack does not constitute a diagnosis of Panic Disorder; the diagnosis requires recurrent unexpected panic attacks plus at least one month of persistent concern about additional attacks, worry about their implications, or significant behavioral changes related to the attacks. 1, 2

Understanding the Distinction: Panic Attack vs. Panic Disorder

A panic attack is a symptom or syndrome, not a diagnosis in itself. It represents a discrete episode of intense fear with abrupt onset of physical symptoms (palpitations, chest pain, dyspnea, dizziness, sweating) and psychological symptoms (fear of dying, feeling of going mad, sense of losing control). 2, 3

Diagnostic Criteria for Panic Disorder

To diagnose Panic Disorder, the following must be present 1, 2:

• Recurrent unexpected panic attacks (not just a single episode)
• At least one month of one or more of the following:
  • Persistent concern or worry about having additional panic attacks
  • Worry about the implications or consequences of the attacks (e.g., "I'm having a heart attack," "I'm going crazy")
  • Significant maladaptive behavioral changes related to the attacks (avoidance of exercise, unfamiliar situations, or being alone)

The key evolution in diagnostic thinking: Modern criteria (DSM-IV onward) shifted from simply counting panic attacks to recognizing Panic Disorder as a chronic anxiety condition focused on the fear of future attacks and autonomic dysregulation symptoms. 2

Alternative Diagnoses When Panic Attacks Occur

If Panic Attacks Are Expected or Situationally Triggered

Panic attacks can occur in multiple psychiatric conditions without warranting a Panic Disorder diagnosis 4:

• Social Anxiety Disorder: Panic attacks triggered by social evaluation situations (being called on in class, meeting strangers) 5
• Specific Phobia: Panic attacks occurring only in response to a specific feared object or situation 4
• Agoraphobia: Panic attacks feared in situations where escape might be difficult; requires at least two trigger situations (public transportation, open spaces, enclosed spaces, crowds, being outside home alone) 6
• PTSD: Panic attacks triggered by trauma reminders or reexposure to trauma-related stimuli 4
• Separation Anxiety Disorder: Panic attacks related to separation from attachment figures 1

Critical diagnostic pitfall: If a patient attributes all panic attacks to specific triggers (social situations, trauma reminders, specific phobias), Panic Disorder should not be diagnosed—the primary disorder is the condition causing the expected attacks. 4

Cultural Considerations in Diagnosis

Cultural syndromes significantly affect whether panic attacks are perceived as "unexpected" 4:

• Ataque de nervios (Latin America): Panic-like episodes triggered by interpersonal arguments
• Khyâl attacks (Cambodia): Episodes triggered by specific exertions like standing up
• Trung gió attacks (Vietnam): Episodes attributed to atmospheric wind exposure

In these contexts, patients may not consider their attacks "unexpected" even when they meet Western diagnostic criteria, potentially leading to underdiagnosis and lack of treatment. 4

Medical Conditions That Must Be Excluded

Before diagnosing any anxiety disorder, systematically rule out medical mimics 1, 6, 5:

• Cardiac: Arrhythmias, mitral valve prolapse (45% of panic disorder patients may have MVP) 4
• Endocrine: Hyperthyroidism, hypoglycemia, pheochromocytoma
• Respiratory: Asthma, chronic obstructive pulmonary disease
• Neurological: Seizure disorders, vestibular dysfunction
• Substance-related: Caffeine excess, stimulant use, alcohol or benzodiazepine withdrawal

Comorbidity Assessment

When a patient presents with panic attacks, assess for common comorbid conditions 1, 5:

• Depression (frequently co-occurs and increases suicide risk) 2, 7
• Substance use disorders (often develop as self-medication) 7
• Other anxiety disorders (generalized anxiety, social anxiety)
• Agoraphobia (develops in many patients with Panic Disorder) 7, 8

Clinical Severity and Functional Impact

Panic Disorder is a severe condition that causes major suffering, significant quality of life impairment, disruption of social functioning and interpersonal relationships, and is considered a risk factor for suicide. 2 Healthcare utilization is high because patients typically interpret symptoms as serious somatic disease (heart attack, stroke). 9

Practical Diagnostic Algorithm

1. Confirm panic attack features: Abrupt surge of intense fear with ≥4 physical/cognitive symptoms peaking within minutes 1, 3
2. Determine if attacks are unexpected or expected: Ask specifically about triggers and anticipatory anxiety 4
3. Assess for one-month persistence criterion: Ongoing worry, concern about implications, or behavioral changes 2
4. Rule out medical conditions: Obtain targeted history, physical exam, and appropriate testing (TSH, ECG, glucose) 1, 6
5. Identify primary disorder: If attacks are consistently triggered by specific situations, diagnose the primary anxiety disorder (social anxiety, specific phobia, agoraphobia) rather than Panic Disorder 4, 5
6. Screen for comorbidities: Depression, substance use, other anxiety disorders 1, 7

Bottom line: A single panic attack warrants clinical attention and medical workup, but the specific diagnosis depends on recurrence pattern, expectedness, associated persistent anxiety, and functional impact. Do not reflexively diagnose Panic Disorder without meeting full criteria. 2, 8