A 24-year-old woman comes to the office due to recurrent episodes of chest pain, palpitations, and shortness of breath over the past few months. During some episodes, she experiences dizziness, diaphoresis, and paresthesias of the hands. The episodes last 5-10 minutes, and the patient constantly worries about when and where she will have another one. She says, "This keeps happening and no one has been able to tell me why. I'm scared something might be seriously wrong with me." The patient has been to the emergency department twice in the past month for similar episodes; prior evaluation, including complete metabolic profile, thyroid function tests, arterial blood gas analysis, ECG, cardiac enzymes, and chest x-ray, showed no abnormalities. Vital signs are within normal limits. Physical examination is unremarkable. Which of the following is the most likely diagnosis?

Question

A 24-year-old woman comes to the office due to recurrent episodes of chest pain, palpitations, and shortness of breath over the past few months.  During some episodes, she experiences dizziness, diaphoresis, and paresthesias of the hands.  The episodes last 5-10 minutes, and the patient constantly worries about when and where she will have another one.  She says, "This keeps happening and no one has been able to tell me why.  I'm scared something might be seriously wrong with me."  The patient has been to the emergency department twice in the past month for similar episodes; prior evaluation, including complete metabolic profile, thyroid function tests, arterial blood gas analysis, ECG, cardiac enzymes, and chest x-ray, showed no abnormalities.  Vital signs are within normal limits.  Physical examination is unremarkable.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_3635_8086_9249_0759e5a1c845_MD0001_00 Recurrent episodes of chest pain, palpitations, shortness of breath, sweating, dizziness, and paresthesia lasting <10 minutes in a young, otherwise healthy patient are characteristic of panic disorder. Onset of panic attacks is unexpected and sudden, accompanied by an abrupt surge in anxiety and fear. Patients with panic disorder worry about recurrent attacks and frequently avoid situations due to fears of having another attack. Panic disorder is characterized by prominent, paroxysmal, physical symptoms (eg, cardiorespiratory, gastrointestinal), and patients may not receive an accurate diagnosis until repeated medical workups are negative. Due to delays in diagnosis, some patients may become preoccupied with fears of having an undiagnosed condition, resulting in high health care use (eg, recurrent emergency department visits). (Choice A) Conversion disorder (also called functional neurological symptom disorder) involves development of a neurological symptom that is inconsistent with a known neurological disease. This patient's dizziness and paresthesia occur only in the context of abrupt-onset and episodic cardiorespiratory symptoms, which is characteristic of panic disorder. (Choice B) In factitious disorder, patients intentionally falsify symptoms to assume the sick role; evidence of falsification is necessary for diagnosis. There is no indication that this patient is fabricating her symptoms. (Choice C) Generalized anxiety disorder is characterized by persistent worry about multiple issues (eg, work, finances, health) and lasts ≥6 months. Although this patient has chronic anxiety, it is specifically related to her fears of having another attack and not having received a diagnosis. (Choice D) In illness anxiety disorder, patients experience excessive anxiety about having or acquiring a serious illness and have few or no physical symptoms. This patient has multiple physical symptoms, and she is concerned that they are due to a medical illness because she has not been accurately diagnosed. (Choice F) Both panic disorder and somatic symptom disorder feature multiple physical symptoms and high health care use. In somatic symptom disorder, patients experience physical symptoms persistently (eg, daily, unrelenting fatigue) whereas in panic disorder, physical symptoms are unexpected, episodic, and of short duration, typically lasting <10 minutes. Educational objective: Panic disorder is characterized by recurrent anxiety attacks associated with prominent somatic symptoms. Abrupt onset of characteristic physical symptoms that resolve within minutes and a negative medical workup should raise suspicion for panic disorder.

A 24-Year-Old Woman Comes to the Office Due to Recurrent