As a panic disorder specialist, I take an active responsibility in helping my patients feel confident that their physical complaints have no organic etiology. My day is filled with my patient’s reporting symptoms of heart palpitations, shortness of breath, chest pressure, rubbery legs, lightheaded feelings, inner trembling, numbness and tingling in the extremities, lump in the throat, knot in the stomach and head pressure, to name a few. Each set of physical symptoms create a catastrophic health worry. For example, heart pounding and shortness of breath often prompt worry about heart disease. Numbness and tingling and head pressure create worry about neurological disease. Lump in throat and knot in the stomach set off worries about throat cancer and stomach cancer, respectively.
For decades, I have worked diligently to build a professional relationship with primary care doctors and the majority of my referrals come from primary care. Panic disorder patients often present to primary care and emergency medicine with an array unexplained somatic complaints. Because the physical symptoms seem to appear suddenly, out of the blue, for no apparent reason, the patient immediately wonders, “Why am I feeling this way? What is the matter? What could it be?” Uncertainties about the cause of panic symptoms lead the patient to entertain a series of false illness misattributions to account for their severe somatic distress.
A choice Point in the Delivery of Healthcare; the Initial Interface
The nature of the initial interface between panic patient and doctor can have a significant impact on the course of this condition. The physical symptoms of panic mimic organic illness and a thorough medical investigation must be undertaken. However, when the results of a battery of medical tests are within normal limits, a diagnosis of panic disorder for these somatic complaints is often overlooked. If physician reassurance is offered with no definitive diagnosis and explanation for why the patient is suffering with severe physical distress, the patient often doubts the doctor’s evaluation. The patient thinks “Maybe he did not take me seriously. Maybe the doctor missed something serious.” Panic patients seek a clear reasonable explanation for their somatic complaints. If they are told it is “Stress” or “Anxiety”, oftentimes, the patient thinks, “The doctor thinks it is all in my head.” Next, recycling with a new doctor, doctor shopping and increase in redundant medical utilization can occur.
Five Steps to Confirm a Diagnosis of Panic Disorder;
1) Rule out severe psychiatric illness such as major depression and psychosis.
2) Ask the patient to list the physical symptoms that are of most concern.
3) Ask the patient what specific thoughts or fears might arise when the specific physical sensation is present. The thoughts fall into three categories; (1) fear of medical illness, (2) fear of a nervous breakdown (3) worry what could it be and whether the symptoms will ever go away.
4) Ask the patient when he worries about the symptom what happens to the symptom (symptom reactivity). The mind-body connection occurs in panic disorder. Worry about the symptom causes the symptom to amplify or persist.
5) Ask the patient when very busy and distracted, how strong is the physical symptom. Most often with most panic symptoms, shifting attention away from the symptom leads to a reduction in symptom intensity.
When medical tests rule out organic illness, early diagnosis of panic disorder in medical settings can prevent chronic patient distress, enhance patient-doctor interactions, reduce redundant medical utilization and improve quality of care.