A 32-year-old man with no significant medical history comes to the office with concerns about recurrent episodes of sudden heart pounding, shortness of breath, chest pain, dizziness, shaking, and tingling in his extremities over the past several months. The episodes last about 10 minutes and are associated with feelings of unreality and detachment from his body. The patient fears having episodes while at work or driving and worries that he may have a heart condition or a serious undiagnosed disease. He has seen other physicians, who performed extensive medical workups but found nothing wrong. His worry has progressively worsened, and he now feels anxious all the time. The patient does not use alcohol or illicit drugs. Routine laboratory testing, ECG, and physical examination show no abnormalities. Which of the following is the most likely diagnosis?

Question

A 32-year-old man with no significant medical history comes to the office with concerns about recurrent episodes of sudden heart pounding, shortness of breath, chest pain, dizziness, shaking, and tingling in his extremities over the past several months.  The episodes last about 10 minutes and are associated with feelings of unreality and detachment from his body.  The patient fears having episodes while at work or driving and worries that he may have a heart condition or a serious undiagnosed disease.  He has seen other physicians, who performed extensive medical workups but found nothing wrong.  His worry has progressively worsened, and he now feels anxious all the time.  The patient does not use alcohol or illicit drugs.  Routine laboratory testing, ECG, and physical examination show no abnormalities.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d7dd_d8f7_bc81_f7306c5c4431_MD0003_00 The unexpected and abrupt onset of symptoms in this otherwise healthy patient with repeated negative medical workups is suggestive of panic disorder. Patients with panic disorder frequently have cardiorespiratory symptoms and may fear they are having a heart attack and repeatedly seek medical care. Other symptoms may include gastrointestinal distress, paresthesias, and dissociative symptoms such as derealization and depersonalization. Patients typically develop anticipatory anxiety about subsequent attacks and may develop chronic anxiety. They may reasonably become preoccupied with their symptoms and fears of having an undiagnosed condition, making it difficult to differentiate panic disorder from a somatic symptom disorder. (Choice A) Conversion disorder (functional neurological symptom disorder) involves development of a neurological symptom that is inconsistent with recognized neurological disease. (Choice B) This patient's feelings of derealization and depersonalization are associated symptoms of his panic attacks. Depersonalization/derealization disorder should not be diagnosed when the symptoms occur only during panic attacks that are part of panic disorder. (Choice C) In factitious disorder, patients intentionally falsify symptoms in order to assume the sick role. (Choice D) This patient has become chronically anxious because he fears recurrent panic attacks. His anxiety is restricted to fears surrounding his panic symptoms, and he does not have the excessive worries about multiple issues required for a diagnosis of generalized anxiety disorder. (Choice E) In illness anxiety disorder, patients experience excessive anxiety about having or acquiring a serious illness and have few or no somatic symptoms. This patient has multiple somatic symptoms, and he is concerned that they are due to a medical illness because he has not yet been accurately diagnosed. Illness anxiety disorder is not diagnosed when the illness-related preoccupation is better explained by another mental disorder, such as panic disorder. (Choice G) Multiple physical symptoms, high health care use, and a preoccupation with symptoms are seen in both panic disorder and somatic symptom disorder. However, in somatic symptom disorder, physical symptoms are persistent over time. This patient's acute physical symptoms are characteristic of panic disorder and do not persist between panic attacks. Educational objective: Patients with panic disorder may be misdiagnosed with a somatic symptom disorder due to preoccupation with unexplained symptoms and a history of high health care use. The recurrent abrupt onset of characteristic physical symptoms that resolve within minutes should raise clinical suspicion for panic disorder. References: Understanding and treating panic disorder in the primary care setting. (http://www.ncbi.nlm.nih.gov/pubmed/15842183) Panic disorder subtypes: deceptive somatic impersonators. (http://www.ncbi.nlm.nih.gov/pubmed/19763206)

A 32-Year-Old Man with No Significant Medical History Comes to the Office