Getting to the heart of panic disorder
Mr. P suffers anxiety spells and feels faint, breathless, and near collapse. Numerous doctors could not find the cause. Are these episodes panic attacks, or something more serious?
During a routine visit, Mr. P tells us that he recently suffered an intense ‘panic’ episode—consisting of shortness of breath, dizziness, diaphoresis, chest pain, palpitations, and near syncope—less than 15 minutes after he started clearing brush in his backyard. We notice marked clubbing on Mr. P’s fingers, a physical sign seen in congenital heart disease, infective endocarditis, pulmonary fibrosis, and numerous other diseases.4
The clubbing prompts us to ask about his occupational history in detail, as work-related exposure to chemicals or fumes may result in pulmonary fibrosis. We then learn that for approximately 20 years before joining the aircraft company, Mr. P welded without wearing protective equipment—all that time inhaling noxious fumes while working.
We refer Mr. P to an internist, who finds clubbing of the fingers, decreased breath sounds, and increased pulmonic second heart sound (P2) on auscultation. The internist then orders:
- ECG, which reveals right axis deviation, incomplete right bundle branch block, and right ventricular hypertrophy (RVH)
- Pulmonary function tests, which show decreased diffusing capacity. Subsequent heart catheterization reveals RVH and concentric left ventricular hypertrophy.
The authors’ observations
Panic attacks often mimic symptoms of cardiac or pulmonary disease. By the same token, symptoms of an underlying cardiac or pulmonary disease can be mistaken for panic disorder, particularly in patients whose past episodes appear to meet DSM-IV-TR panic attack criteria (Table 2).5
Table 2
Panic attack symptoms that may suggest a cardiopulmonary disease
| Panic attack symptom | Possible cardiopulmonary disorder |
|---|---|
| Palpitations, chest discomfort, feeling faint | Cardiac arrhythmia |
| Breathlessness, fatigue, weakness | Heart failure |
| Weakness, nausea, diaphoresis, feelings of hot/cold associated with diaphoresis, paresthesias, lightheadedness, fear of dying | Cardiac or neurologic syncope |
| Intense, escalating chest pain/discomfort; may be accompanied by nausea, diaphoresis, dizziness, feelings of hot/cold associated with diaphoresis | Acute myocardial infarction |
| Shortness of breath, fatigue, weakness, feeling of choking | Pulmonary congestion* |
| * Because the lung parenchyma and visceral pleura lack pain fibers, pulmonary abnormalities related to these structures can be advanced before symptoms are noticed. | |
| Source: reference 5 | |
To avoid unnecessary referrals, psychiatrists need to quickly and accurately discern:
- when a medical problem is causing the patient’s symptoms
- how far to carry the medical evaluation, particularly for patients with palpitations, chest pain, or shortness of breath.
Also, a psychiatric patient whose mental disorder or comorbid axis II pathology compromises speech or cognitive function may have trouble communicating potentially serious medical problems to other clinicians. Mr. P’s guarded demeanor and obsession toward his physical problems may have kept him from accurately describing his symptoms in a clinical setting. Alternately, he might have misinterpreted his pulmonologist’s explanation of pulmonary fibrosis, thus believing the disorder was not serious.
Finally, patients with panic disorder are more aware of their heartbeats and physiologic responses than are persons without panic disorder,8 thus further complicating diagnosis.
UNCOVERING A MEDICAL CAUSE
Suspect an underlying heart or lung problem when panic symptoms affect breathing or resemble a heart attack.
Check for predisposing risk factors for cardiac disease. Ask the patient detailed questions about past and current medical problems, including:
- smoking
- hyperlipidemia
- diabetes
- heart problems
- pulmonary disease
- family history of any medical problems
- work-related exposure to any metal that may increase risk of cardiopulmonary disease.
Review medical treatment history. Mentally ill persons are more likely than those without a mental illness to receive inadequate general medical and preventative care.9 Patient, provider, and health care system issues—such as lack of insurance or the patient’s inability to recognize or describe symptoms—may impede medical care delivery to the mentally ill.9
Review overall history. A deeper look into Mr. P’s work and diagnostic history uncovered numerous possible causes of right heart failure, including:
- pulmonary fibrosis secondary to inhalational injury
- possible pulmonary vasculitis as indicated by his positive ANA and RF.
