What is the diagnostic approach for an adult patient with a history of trauma, stress, or anxiety disorders, presenting with recurrent panic attacks, palpitations, sweating, trembling, and fear of losing control or dying?

Diagnostic Approach for Panic Disorder

Panic disorder is diagnosed when a patient experiences recurrent, unexpected panic attacks followed by at least one month of persistent concern about additional attacks, worry about their implications, or significant behavioral changes related to the attacks. 1, 2

Core Diagnostic Criteria

A panic attack must include four or more of the following symptoms that develop abruptly and peak within 10 minutes: 1, 2, 3

• Palpitations, pounding heart, or accelerated heart rate 1, 2
• Sweating 1, 2
• Trembling or shaking 1, 2
• Sensations of shortness of breath or smothering 1, 2
• Feeling of choking 1, 2
• Chest pain or discomfort 1, 2
• Nausea or abdominal distress 1, 2
• Feeling dizzy, unsteady, lightheaded, or faint 1, 2
• Derealization (feelings of unreality) or depersonalization (being detached from oneself) 1, 2
• Fear of losing control or "going crazy" 1, 2, 3
• Fear of dying 1, 2, 3
• Paresthesias (numbness or tingling sensations) 1, 2
• Chills or hot flushes 1, 2

Essential Diagnostic Steps

1. Establish Pattern of Panic Attacks

Document the presence of recurrent, unexpected panic attacks that are not better explained by another mental disorder or medical condition. 1, 2 The attacks must be "unexpected" rather than triggered exclusively by specific situations (which would suggest specific phobia or social anxiety disorder). 4

2. Assess Post-Attack Sequelae

At least one panic attack must be followed by one month or more of:

• Persistent concern or worry about having additional panic attacks 1, 2
• Worry about the implications or consequences of the attacks (e.g., "losing control," "having a heart attack," "going crazy") 1, 2
• Significant maladaptive behavioral change related to the attacks (e.g., avoidance of exercise, unfamiliar situations, or being alone) 1, 2

3. Screen for Agoraphobia

Determine whether the patient avoids situations due to fear that escape might be difficult or help unavailable if panic symptoms occur. 2 Approximately 30-50% of patients with panic disorder develop agoraphobia. 4 Common avoided situations include crowds, public transportation, open spaces, enclosed spaces, or being outside the home alone. 4

4. Rule Out Medical Causes

Before attributing symptoms to panic disorder, systematically exclude medical conditions that mimic panic attacks: 5

• Cardiac: Arrhythmias, coronary artery disease, mitral valve prolapse 5
• Endocrine: Hyperthyroidism, hypoglycemia, pheochromocytoma 5
• Respiratory: Asthma, chronic obstructive pulmonary disease 5
• Neurological: Seizure disorders, vestibular dysfunction 5

5. Identify Substance-Induced Presentations

Screen for substances that can provoke panic-like symptoms: 5

• Caffeine excess (>400 mg/day) 5
• Stimulant medications or illicit drugs (amphetamines, cocaine) 5
• Withdrawal from alcohol, benzodiazepines, or other sedatives 5
• Certain medications (bronchodilators, corticosteroids, thyroid supplements) 5

6. Assess for Comorbid Psychiatric Conditions

Screen systematically for commonly co-occurring disorders: 6

• Major depressive disorder: Use PHQ-9 or assess for depressed mood, anhedonia, sleep disturbance, and suicidal ideation 6, 5
• Generalized anxiety disorder: Use GAD-7 to assess for chronic, pervasive worry about multiple life domains 6, 5
• Social anxiety disorder: Determine if panic symptoms occur specifically in social evaluation situations 4
• Post-traumatic stress disorder: Assess for trauma history and re-experiencing symptoms 6
• Substance use disorders: Directly ask about alcohol and drug use, as these frequently complicate anxiety disorders 6, 7

7. Evaluate Functional Impairment and Safety

Assess how panic disorder impacts daily functioning: 6, 5

• Work performance and attendance 6, 5
• Social relationships and activities 6, 5
• Ability to complete household responsibilities 5
• Quality of life and overall distress 6

Screen immediately for safety concerns: 5

• Suicidal ideation or self-harm thoughts (panic disorder increases suicide risk) 6, 5
• Intent to harm others 5
• Severe agitation or psychotic symptoms requiring emergency evaluation 6, 5

8. Consider Cultural Variations in Presentation

Recognize that panic attack presentation varies across cultural contexts. 6, 4 European Americans commonly report heart-focused panic attacks, while Southeast Asian populations (particularly Cambodian and Vietnamese refugees) more often express somatic-focused panic attacks related to beliefs about blocked wind or chi, with prominent neck pain and dizziness. 6, 4 These represent the same underlying panic phenomenon with different symptomatic expression. 4

Distinguishing Panic Disorder from Generalized Anxiety Disorder

Panic disorder features discrete episodes of intense fear peaking within 10 minutes, whereas GAD involves chronic, pervasive worry about multiple topics without discrete panic attacks as the defining feature. 4, 8 However, patients with GAD may experience occasional panic attacks, and the two disorders frequently co-occur. 6 The key distinction is that panic disorder centers on fear of the panic attacks themselves and their consequences, while GAD centers on excessive worry about everyday life circumstances. 4, 8

Common Diagnostic Pitfalls

• Missing comorbid depression: Always screen with PHQ-9 or direct questioning, as major depression co-occurs in up to 50-60% of panic disorder cases 6
• Overlooking substance use: Alcohol and benzodiazepine dependence often develop as patients attempt to self-medicate panic symptoms 6, 9
• Attributing all symptoms to anxiety: Cardiac and endocrine conditions can coexist with panic disorder and require concurrent treatment 5
• Ignoring cultural context: Somatic presentations are more common in non-Western populations and should not be dismissed as "atypical" 6, 4
• Failing to assess suicide risk: Panic disorder significantly increases suicide risk, particularly when comorbid with depression 6