A 42-year-old woman comes to the office due to repeated episodes of chest pain, dizziness, and shortness of breath over the past 3 months. She says, "I am worried that I have some kind of heart condition. I can be fine and relaxing at home and then all of a sudden I start sweating, my heart starts pounding, and I feel like I can't get any air. Now I feel anxious all the time because I never know when it will happen again. At work, I'm afraid to give presentations because I had an episode while giving a talk. I even stopped driving to work for fear that it will happen while I'm driving and I'll lose control of the car." The patient has a history of hypertension that is well controlled. Her medications include hydrochlorothiazide and multivitamins. She does not use tobacco, alcohol, or illicit drugs. She lives with her husband. Family history is significant for hypertension and coronary artery disease in her father. She was seen in the emergency department 2 months ago for similar symptoms, and her ECG and cardiac enzymes were normal. Vital signs, physical examination, and routine laboratory results are within normal limits. The patient says, "I am really concerned that I could have heart disease like my father." Which of the following is the most likely explanation for the patient's symptoms?

Question

A 42-year-old woman comes to the office due to repeated episodes of chest pain, dizziness, and shortness of breath over the past 3 months.  She says, "I am worried that I have some kind of heart condition.  I can be fine and relaxing at home and then all of a sudden I start sweating, my heart starts pounding, and I feel like I can't get any air.  Now I feel anxious all the time because I never know when it will happen again.  At work, I'm afraid to give presentations because I had an episode while giving a talk.  I even stopped driving to work for fear that it will happen while I'm driving and I'll lose control of the car."  The patient has a history of hypertension that is well controlled.  Her medications include hydrochlorothiazide and multivitamins.  She does not use tobacco, alcohol, or illicit drugs.  She lives with her husband.  Family history is significant for hypertension and coronary artery disease in her father.  She was seen in the emergency department 2 months ago for similar symptoms, and her ECG and cardiac enzymes were normal.  Vital signs, physical examination, and routine laboratory results are within normal limits.  The patient says, "I am really concerned that I could have heart disease like my father."  Which of the following is the most likely explanation for the patient's symptoms?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1ab_1d7f_8f63_ab48afaeb796_MD0005_00 Patients with panic disorder will often seek medical evaluation due to prominent physical symptoms. This patient's recurrent episodes of chest pain, sweating, dizziness, and shortness of breath are most likely due to panic disorder. Other characteristic symptoms include gastrointestinal distress, paresthesias, derealization, and feelings of losing control. These patients characteristically experience some unexpected panic attacks (as in this patient, with sudden onset of symptoms while relaxing at home) and develop anticipatory anxiety of additional attacks. Avoidance behavior, typically involving situations in which the patient fears having a panic attack (eg, while driving), can develop. (Choice A) Generalized anxiety disorder is characterized by persistent anxiety or worry about multiple issues lasting for at least 6 months and would not explain this patient's episodic panic attacks. Although this patient has chronic anxiety, it is related to her fears of having another attack. (Choice B) Illness anxiety disorder is characterized by persistent preoccupation and disproportionate anxiety about having a serious illness, while having mild or no somatic symptoms. This patient has multiple somatic symptoms, and is concerned about having heart disease as she has not yet been accurately diagnosed with panic disorder. Illness anxiety disorder is not diagnosed when the illness-related preoccupation is better explained by another mental disorder, such as panic disorder. (Choice D) 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. (Choice E) In specific phobia, panic-type symptoms are always triggered by the feared object (phobic stimulus). This patient's history of unexpected attacks is more characteristic of panic disorder. Educational objective: Patients with panic disorder have recurrent, unexpected anxiety attacks associated with multiple somatic symptoms. They exhibit anticipatory anxiety about additional attacks and/or significant changes in behavior due to the attacks. References: Diagnosis and management of generalized anxiety disorder and panic disorder in adults. (http://www.ncbi.nlm.nih.gov/pubmed/25955736)

A 42-Year-Old Woman Comes to the Office Due to Repeated