p155: differential diagnosis of panic attacks: using a decision tree

panic attacks are discrete episodes of intense fear or discomfort accompanied by symptoms such as palpitations, shortness of breath, sweating, trembling, derealization and a fear of losing control or dying. although panic attacks are required for a diagnosis of panic disorder, they also occur in association with a host of other disorders listed in the 5h version of the diagnostic and statistical manual of mental disorders. this paper presents the steps in making a differential diagnosis of panic attacks. detailed explanations with appropriate examples are provided to illustrate each of the decision-making process. the first step in the differential for a panic attack is to rule out the presence of etiological substance or medication use. when taken in high enough doses or during substance withdrawal, a number of substances and medications can lead to a panic attack. next, possible etiological general medical conditions such as hyperthyroidism or pheochromocytoma, should be considered. once it is clear that panic attacks are not the direct physiological consequence of a substance or medical condition, the next step is to determine the relationship between the panic attacks and a possible situational trigger. finally, panic attacks triggered by a realistic event do not warrant a diagnosis of a mental disorder. an illustrative flow chart which will facilitate the differential diagnosis of panic attacks is provided in this review.