One has to ask the right question in order to get the answer.
The chief complaint on the encounter form said ‘panic attack’ and a quick review of the chart before I entered the room showed a healthy 28 year old woman with no health or emotional issues who came in every year for a routine birth control visit. She told me she had had a ‘panic attack’ the day before and was sure there was nothing serious wrong, but came in at the insistence of a colleague. “It’s probably a waste of time, but Seeley made me promise to come.”
She gave a well organized history of the event. On her way to work as an ed tech she suddenly felt that something awful was about to happen and then felt cold and clammy and had the sensation that time was going slowly for her but racing for everyone else and that she was ‘not part of anything.’ Her hands and lipids began to tingle, her heart was racing and felt like it would jump out of her chest, and she couldn’t get a good breath. Her stomach felt queasy and she thought she might need to move her bowels. She pulled over and it seemed to pass after 2-3 minutes, but resumed as she was driving and when she got to work she felt shaky and started to cry for no reason. Seeley, a friend and co-worker, sat with her until it passed - about 45 minutes - and she was sent home.
A patient of one of my partners, I had never met her before. After she described her panic attack, we began with basics. She was healthy, taking no medications, with a good job she enjoyed, a good relationship with her parents who lived locally, and happy with her boy friend of two years with whom she lived and with whom she planned to start a family in a few years. She did not smoke. She gardened actively but had no formal exercise program. She had no family or personal history of thyroid disease, heart disease, or mental illness, including anxiety or panic. There had been no recent stressors or life changes. In fact, she said, it made no sense to have a panic attack, because life had never been better.
Her chart had no other clues and her exam was entirely normal. Her last period had been normal and on time and her pregnancy test was negative.
I told her I agreed that this was a typical panic attack, and complimented her on her diagnostic acumen. I explained the physiology involved in panic attacks, so she would understand the biologic basis of her symptoms, and reviewed the two general forms that panic takes: (1) situational and related to some form of trigger; or (2) purely biologic, essentially a false alarm of the stress response system. I suggested we check a couple simple things (blood count, thyroid hormone and EKG) to reassure ourselves we were not missing something unusual and unlikely.
During the visit I had been plagued by a growing discomfort, a sense that I was missing something important. As I began to talk about management options, I realized what was bothering me. On the one hand, this was quite straight forward: she was a healthy young woman with no personal or family factors to suggest cardiac, endocrine or psychiatric disease who had had classic symptoms of a panic attack. On the other hand, there was nothing in her history or demeanor to suggest a situational stress issue to trigger a panic attack, and it is unusual to have biologic panic disorder present at age 28 with no family history and with no previous anxiety or panic issues.
When in doubt, ask the patient.
“Is there anything else you can think of, something we haven’t talked about, that might be causing you some stress?”
“No. Like I said. It’s weird. Everything is great.”
“Have you ever had that panic feeling before?”
“I’ve never had a panic attack, but I felt that way once before. Last year, after my accident.”
“Accident?”
“Yes. I had a car accident last year. Actually, exactly a year ago, the first week in April, my boy friend’s birthday. A lady pulled out of a parking lot and hit my car. I didn’t see her at all. I had some bumps and bruises and a sore wrist, but I wasn’t really hurt. The car was totaled and they had to cut, you know, use this big thing to cut me out. The next day when I went to get my stuff from the car, my heart raced and I got all shaky and sweaty, just like yesterday. It lasted all day and then went away. I had nightmares for a couple nights. I’d forgotten all about it until you asked.”
“Interesting. You said you were driving. What else do you remember about that day?”
“I was on my way to work. Oh my god. The accident was at the same place my panic attack started yesterday.”
We still did the lab work and EKG, which were normal. But she and I both felt much more satisfied with our deeper understanding. And she told me that next year she is going to take a different route to work on her boy friend’s birthday.