Nausea, vomiting, and panic attacks in a 50-year-old woman
A 50-year-old woman presents to the emergency department because of repeated episodes of vomiting over the past 12 hours. She reports eight episodes of non-bloody, nonbilious emesis associated with palpitations and feelings of anxiety, but with no fever or diarrhea. She has not traveled recently and does not have any sick contacts.
She reports that she never had health problems until 6 months ago, when she began having panic attacks that woke her from sleep. The episodes first occurred once or twice per week, usually at night, and involved palpitations and feelings of anxiety that lasted 2 to 4 hours, but no other associated symptoms. After a month, the episodes began to occur more regularly during the day and were accompanied by a pounding headache that began in the back of her neck and extended up and over her head. Her primary care physician prescribed sertraline (Zoloft) and referred her to a neurologist to evaluate the headaches. The neurologic workup included brain magnetic resonance imaging and electroencephalography, both of which were normal.
After 8 weeks on sertraline, the episodes continued to increase in frequency and severity, and her physician switched her to paroxetine (Paxil) and added lorazepam (Ativan), which did not improve her symptoms. Over the past 2 months, during which time she has not been taking any medications, the episodes began to involve nausea and, more recently, vomiting, with episodes occurring as often as once or twice daily, and with intermittent symptom-free days. None of the prior episodes was accompanied by symptoms as severe as those she is currently experiencing.
She is otherwise healthy with no chronic diseases. Her surgical history includes resection of an angiolipoma from her right arm and dilation and curettage for endometrial polyps. She has no personal or family history of psychiatric illness.
PHYSICAL EXAMINATION
The patient is slender and tremulous but does not appear diaphoretic. Her blood pressure is 176/92 mm Hg, pulse 98, temperature 36.5°C (97.7°F), and respiratory rate 20 per minute. Oxygen saturation by pulse oximetry is 98% on room air. She has dry mucus membranes and orthostatic hypotension, but her physical examination is otherwise normal. Electrocardiography (ECG) shows a normal sinus rhythm with a prolonged QTc of 571 ms and peaked P and T waves.
LABORATORY VALUES
- Hemoglobin 15.6 g/dL (reference range 11.5–15.5)
- Hematocrit 47.2% (36.0–46.0)
- Platelet count 448 × 109/L (150–400)
- White cell count 18.65 × 109/L (3.70–11.00)
- Potassium 2.5 mmol/L (3.5–4.0)
- Chloride 97 mmol/L (98–110)
- Bicarbonate 21 mmol/L (23–32)
- Anion gap 20 mmol/L (0–15)
- Glucose 233 mg/dL (65–100).
Sodium, blood urea nitrogen, and creatinine levels are all within normal limits. Urinalysis suggests a urinary tract infection.
IS THIS A PANIC ATTACK?
1. Which of the following is not characteristic of a panic attack?
- Nausea and vomiting
- Onset during sleep
- Palpitations
- Chest pain or discomfort
- Headache
- Trembling or shaking
According to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV), the diagnosis of panic attack requires the presence of intense fear or discomfort and four or more other symptoms that may come from any of six domains:
- Cardiovascular: palpitations, pounding heart, tachycardia, and chest pain or discomfort
- Autonomic: sweating, chills or hot flushes, and trembling or shaking
- Pulmonary: shortness of breath or a smothering sensation
- Neurologic: dizziness or light-headedness and paresthesias
- Gastrointestinal: choking and nausea or abdominal distress
- Psychological: compass derealization, depersonalization, and the fear of losing control or “going crazy.”1
Two aspects of the patient’s history may be misinterpreted by those unfamiliar with the symptomatology of panic attack. First, although panic disorder carries an increased risk of many comorbidities, including migraine, headache is not typically associated with the panic attacks themselves.2 Second, while not a part of the diagnostic criteria, sleep disturbances are common in patients with panic disorder, and 30% to 45% of patients with the disorder experience recurrent nocturnal panic attacks.3 Therefore, the correct answer is headache.
