What is the management approach to panic disorder in the emergency department?

Updated: Mar 21, 2018
  • Author: Mohammed A Memon, MD; Chief Editor: Randon S Welton, MD  more...
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Patients with chest pain, dyspnea, palpitations, or near-syncope should be placed on oxygen and in a supine or Fowler position. Monitor the patients with pulse oximetry, electrocardiography (ECG), and frequent determination of vital signs (including one set of orthostatic vital signs, when possible).

A major component of therapy involves educating the patient that their symptoms are neither from a serious medical condition nor from a psychotic disorder, but rather from a chemical imbalance in the fight-or-flight response. This alone may account for the significant placebo response rate noted in clinical trials. [34]

Patients with panic disorder may require frequent reassurance and explanation. Many may benefit from social service intervention, which may provide supportive discussions and explore resources for outpatient care. The emergency department staff must listen effectively and remain empathic and nonargumentative. Statements made by healthcare staff, such as, "It's nothing serious" and "It's related to stress" are frequently misinterpreted by the patient as implying a lack of understanding and concern.

Instituting treatment for panic disorder in the emergency department is appropriate in a very limited subset of patients who are highly motivated and cooperative, who possess an understanding of the psychological nature of their disorder, and whose symptomatology is elicited as a response to a temporary stress. In such cases, pharmacotherapy with an oral benzodiazepine for a brief duration (approximately 1 wk) may be appropriate.

Intravenous (IV) medication (e.g., lorazepam at 0.5 mg IV q20min) may be necessary in patients with panic disorder who, as a result of subsequent poor impulse control, pose a risk to themselves or to those around them. However, patients with panic disorder are probably best served by referral to a psychiatrist before beginning anxiolytic medications. A psychiatrist can establish a constructive rapport with patients and follow their needs on a long-term basis.

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