Lance H. Hoffman
PANIC DISORDER
EPIDEMIOLOGY
Panic disorder has a national lifetime prevalence of 3.5%.
Women are two to three times more likely than men to be afflicted with this disorder.
Symptoms usually begin in the second to fourth decades of life.
CLINICAL FEATURES
The patient experiences acute, recurrent episodes of intense anxiety and fear, resulting in a persistent fear regarding the implications of having another such episode.
Most episodes begin unexpectedly. Symptom severity peaks within 10 minutes of symptom onset and lasts for up to 1 hour.
Different somatic and cognitive symptoms dominate the panic attacks (Table 188-1).
Tachycardia and mild hypertension are common physical examination findings.
TABLE 188-1 Symptoms of a Panic Attack
DIAGNOSIS AND DIFFERENTIAL
Panic disorder is a diagnosis of exclusion because its symptoms and signs mimic those of many potentially life-threatening disorders.
Multiple medical diagnoses should be considered in the differential for panic disorder (Table 188-2).
Victims of intimate partner violence or sexual abuse or assault may present similarly to a patient with panic disorder.
TABLE 188-2 Medical Differential Diagnosis of Panic Attacks
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Life-threatening causes of the patient’s symptoms must first be excluded.
Benzodiazepines are the mainstay of therapy for controlling symptoms acutely. Alprazolam 0.25 to 0.5 milligram PO or lorazepam 1 to 2 milligrams PO or IV is effective.
The patient should be questioned specifically about suicidal thoughts and depression because patients with panic disorder and depression have a lifetime suicide risk of 19.5%.
Referral to a psychiatrist for outpatient cognitive behavioral therapy and pharmacotherapy is warranted if symptoms are controlled and suicidality is lacking. Otherwise, psychiatric consultation for admission is necessary.
CONVERSION DISORDER
EPIDEMIOLOGY
Conversion disorder is rare, but affects women approximately four times more often than men.
CLINICAL FEATURES
Conversion disorder is a somatoform disorder in which a person unconsciously and acutely produces a symptom suggestive of a physical disorder that results in a change or loss of physical functioning as a response to a stressor or conflict.
The symptom cannot be explained by a known organic etiology or culturally sanctioned response pattern, and it cannot be limited to pain or sexual dysfunction.
The symptom typically involves a loss of neurologic functioning.
DIAGNOSIS AND DIFFERENTIAL
An organic explanation for the patient’s symptom must be excluded before the diagnosis of conversion disorder can be made.
A variety of physical examination maneuvers have been described to assist the clinician in differentiating neurologic symptoms caused by a psychological etiology from an organic etiology (Table 188-3).
A high index of suspicion must be maintained for organic etiologies that might explain the symptom, including systemic lupus erythematosus, polymy- ositis, multiple sclerosis, Lyme disease, and drug toxicity.
TABLE 188-3 Testing Techniques for Conversion Disorder
EMERGENCY DEPARTMENT CARE AND DISPOSITION
An organic etiology to the symptom must first be excluded.
After presenting the normal test results, reassure the patient that a serious medical illness is not present as directly confronting the patient that the symptom has no organic etiology may worsen the symptom.
The physician should suggest to the patient that the symptom often spontaneously resolves in cases in which the test results are normal.
Psychiatric or neurologic consultation in the ED is warranted if the symptom does not resolve and precludes discharging the patient home. Otherwise, outpatient psychiatric referral is mandatory as repetitive reassurance may be needed before full function returns.
For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 287, “Panic Disorder,” by Linda M. Nicholas and Elizabeth Shumann, and Chapter 288, “Conversion Disorder,” by Gregory Moore and Kenneth Jackimczyk.