What is the likely diagnosis for a patient presenting with palpitations, paresthesia, and anxiety, with no known medical history or current medications?

Panic Disorder with Somatic Manifestations

This clinical presentation of palpitations, paresthesias (tingling all over body), and uneasiness strongly suggests panic disorder, which is characterized by discrete episodes of intense fear accompanied by these exact physical symptoms. 1, 2, 3

Diagnostic Criteria Match

The patient's symptom triad precisely matches the DSM-IV criteria for panic disorder, which requires four or more of the following symptoms developing abruptly within 10 minutes: 4, 1, 2, 3

• Palpitations or accelerated heart rate (present in this patient) 1, 2, 3
• Paresthesias (numbness or tingling sensations) (present as "tingling all over body") 1, 2, 3
• Anxiety/uneasiness (present as "uneasiness") 1, 2, 3

Additional panic disorder symptoms to assess include: sweating, trembling, shortness of breath, feeling of choking, chest pain, nausea, dizziness, derealization/depersonalization, fear of losing control, fear of dying, and chills or hot flushes. 1, 2, 3

Critical Red Flags to Exclude First

Before confirming panic disorder, you must immediately rule out life-threatening cardiac conditions. The following red flags mandate urgent cardiac evaluation: 5

• Syncope or pre-syncope with palpitations - requires immediate hospitalization 5
• Chest pain accompanying palpitations - requires urgent evaluation for ischemia 5
• Dyspnea or severe symptoms - warrants immediate cardiology referral 5
• Pre-excitation (delta waves) on ECG - indicates WPW syndrome with sudden death risk 5
• Wide complex tachycardia - requires immediate specialist referral 5

Essential Diagnostic Workup

Obtain a 12-lead ECG immediately to exclude: 4, 5

• Pre-excitation patterns (WPW syndrome) - particularly critical if palpitations are irregular, as this suggests atrial fibrillation with sudden death risk 4, 5
• QT prolongation - suggests risk of torsades de pointes 5
• Arrhythmias during symptoms 4

Common diagnostic pitfall: Many patients with panic disorder report palpitations when continuous ambulatory ECG monitoring shows no arrhythmias, but this does not exclude serious underlying pathology. 4, 5 Never assume benign etiology without ECG documentation. 5, 6

Bidirectional Relationship Between Cardiac and Psychiatric Symptoms

Recognize that 45% of patients with panic disorder have mitral valve prolapse (MVP), and many MVP patients experience palpitations as part of panic attacks despite no documented arrhythmias on monitoring. 4, 5 This creates diagnostic complexity where:

• Anxiety can cause palpitations through increased adrenergic tone 6
• Cardiac conditions can trigger anxiety symptoms 6
• Both may coexist 4

Definitive Treatment Recommendations

First-Line Pharmacotherapy

Selective serotonin reuptake inhibitors (SSRIs) are the treatment of choice for panic disorder due to their established efficacy, favorable safety profile, and effectiveness for both panic attacks and anticipatory anxiety. 7, 8

Specific SSRI options with FDA approval for panic disorder: 2, 3

• Sertraline - FDA-approved for panic disorder with or without agoraphobia 2
• Fluoxetine (Prozac) - FDA-approved for panic disorder 3

Expected response timeline: 7

• Statistically significant improvement begins at week 2 7
• Clinically significant improvement expected by week 6 7
• Maximum therapeutic benefit achieved by week 12 or later 7

Role of Benzodiazepines

Benzodiazepines like alprazolam are FDA-approved for panic disorder but should be reserved for short-term use only (4-10 weeks maximum) due to risks of dependence, tolerance, and withdrawal symptoms. 7, 1, 9, 10

Alprazolam is specifically indicated for: 1

• Management of anxiety disorder with symptoms including palpitations, accelerated heart rate, paresthesias, and dizziness 1
• Treatment of panic disorder with or without agoraphobia 1

Critical safety consideration: If benzodiazepines are used, gradual reduction of 25% of the dose every two weeks is essential to minimize withdrawal symptoms. 7

Psychological Treatment

Cognitive-behavioral therapy (CBT) specifically designed for panic disorder is the psychological treatment of choice, with or without combination with SSRIs. 7, 8

Structured CBT protocol: 7

• 12-14 individual sessions of 60-90 minutes each 7
• Conducted over approximately 3-4 months 7
• Components include psychoeducation, cognitive restructuring, gradual exposure, relaxation techniques, and relapse prevention 7

The combination of CBT with SSRIs provides superior results compared to either treatment alone for patients with moderate to severe panic disorder. 7 CBT demonstrates large effect sizes (Hedges g = 1.01) for generalized anxiety disorder. 7, 8

Treatment Duration

Continue SSRI treatment for 12 months before tapering to prevent relapse. 10 The physician should periodically reassess the usefulness of the drug for the individual patient. 1, 2, 3

When to Refer

Immediate referral to cardiology/arrhythmia specialist is indicated for: 4, 5

• Documented sustained ventricular arrhythmias 5
• Syncope with palpitations 5
• Wide complex tachycardia of unknown origin 4, 5
• Pre-excitation on ECG (WPW syndrome) 4, 5
• Severe symptoms such as syncope or dyspnea during palpitations 4