Panic disorder

Diagnosis

 Symptoms
 Presentation
 Psychiatric rating scales

Symptoms

Establishing the diagnosis of Panic disorder (PD) may often be complicated, although a thorough history, physical examination and other tests can usually provide the correct diagnosis. Fundamental to the diagnosis of PD is the occurrence of discrete panic attacks. These attacks consist of distinct periods of intense fear or discomfort in which at least four of the symptoms noted below develop abruptly and reach a crescendo within 10 minutes, typically lasting 15 minutes. However, attacks may recur rapidly, and once the symptoms abate, a severely anxious state may not remit for several hours. Symptoms include:

• shortness of breath or choking
• dizziness, unsteady feelings, or faintness
• palpitations or accelerated heart rate (tachycardia)
• trembling or shaking
• excessive perspiration
• nausea or abdominal distress
• numbness or tingling sensations (paresthesias)
• flushes or chills
• chest pain (angina)
• depersonalisation and derealisation
• fear of going crazy or doing something uncontrolled
• fear of myocardial infarction or dying.

Factsheet: Diagnosis of mental disorders

Presentation

Taking these symptoms into account it can be seen why PD can often present as several other physical illnesses, causing many physicians to perform extensive medical check-ups as they unsuccessfully evaluate cardiac, gastrointestinal, pulmonological endocrinological or neurological sources of a patient's symptoms. As a result of these complicating physical symptoms, many newly diagnosed patients report having previously contacted physicians before the correct referral and diagnosis are made. These examinations delay the confirmation of the correct diagnosis.

Due to this often-extended process, and the helplessness associated with the panic attacks, these patients are at particular risk of developing secondary depression. As many as 30% of patients suffering from PD may develop major depression during or after the onset of panic disorder (Angst, 1997).

A correct and timely diagnosis is therefore dependent on a detailed clinical assessment of the presenting complaints and history. A full physical examination is often essential to rule out other conditions. Other relevant information should be a history of possible substance abuse as many substances, in states of intoxication and withdrawal, mimic panic attacks. Alcohol, marijuana, opiates, hallucinogens, cocaine, over-the-counter drugs (nasal sprays and diet tablets), ß (beta)-agonists, caffeine and benzodiazepines can all be associated with panic attacks.

A complete psychological assessment should also be considered as part of the diagnostic process. As many as 70% of patients with panic disorder may have a comorbid psychological or psychiatric condition that will need to be addressed when planning treatment.

Psychiatric Rating Scales

There are many rating scales used for measuring the severity of disorders in psychiatry.

Hamilton Anxiety Rating Scale (Ham-A)

This scale consists of 14 items, each defined by a series of symptoms. As one of the first rating scales developed to measure the severity of anxiety symptomatology it has become a widely used and accepted outcome measure for the evaluation of anxiety in clinical trials. The scale was introduced by Max Hamilton in 1959 and measures the severity of anxiety symptoms such as anxiety, tension, depressed mood, palpitations, breathing difficulties, sleep disturbances, restlessness and other physical symptoms (Hamilton, 1959).

Global Assesment of Functioning (GAF)

The reporting of overall function on Axis V (5) of the DSM-IV is performed using the Global Assessment of Functioning (GAF) Scale. The GAF scale may be particularly useful in tracking the clinical progress of individuals in global terms, using a single measure. The GAF scale is to be rated with respect only to psychological and occupational functioning.

Clinical Global Impression (CGI)

The CGI refers to the global impression of the patient and requires clinical experience with the syndrome under assessment. The concept of improvement refers to the clinical distance between the patient's current condition and that prior to the start of treatment. The CGI improvement-scale can be completed only following or during treatment. There are seven categories of severity ranging from 'Not ill' to 'Extremely severe'.

Factsheet: Rating scales