About This Page
This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- Panic attacks are abrupt surges of fear/discomfort peaking within minutes
- Panic disorder requires recurrent unexpected attacks plus >=1 month worry or maladaptive behavior
- Rule out MI/arrhythmia, PE, asthma, hyperthyroidism, pheochromocytoma, stimulant intoxication, and withdrawal when suggested
- First-line long-term treatment: CBT and SSRI/SNRI
- Agoraphobia can coexist but is separately defined
Overview
Panic disorder involves recurrent unexpected panic attacks and persistent concern about future attacks or consequences, or maladaptive avoidance. Panic attacks themselves can occur in many psychiatric and medical conditions. Step 2 CK stems often describe repeated ED visits for chest pain, palpitations, paresthesias, fear of dying, and negative cardiac workup.
Epidemiology
Panic disorder often begins in late adolescence or early adulthood and is associated with depression, other anxiety disorders, alcohol use disorder, and high health-care use. Anticipatory anxiety and avoidance can lead to agoraphobia and disability.
Clinical Features
Symptoms
Abrupt intense fear with palpitations, sweating, trembling, dyspnea, chest pain, dizziness, paresthesias
Fear of dying, losing control, or having a heart attack
Attacks peak within minutes and resolve within 20-30 minutes
Persistent fear of future attacks or avoidance of exercise/driving/crowds
Syncope, exertional chest pain, hypoxemia, focal deficits, or abnormal ECG
Signs
Tachycardia, hyperventilation, tremor, diaphoresis during attack
Normal examination between attacks
Stimulant intoxication, thyrotoxicosis, asthma, PE, or arrhythmia signs require medical workup
Investigations
First-line
Clinical assessmentConfirm recurrent unexpected attacks plus >=1 month worry/behavior change
Rule out emergencies when indicatedECG/troponin, pulse oximetry, pregnancy test, D-dimer/CTPA, TSH, glucose, toxicology based on history/exam
Suicide/depression screenAssess comorbid depression and substance use
Second-line
Panic severity scale or diaryTracks frequency, triggers, avoidance, response
Medication reviewStimulants, caffeine, decongestants, thyroid hormone, albuterol, steroids, withdrawal
Specialist
CBT referralCBT with interoceptive exposure is highly effective
Specialty referralOnly for red flags or abnormal testing suggesting medical disease
1
Acute attack
- Reassure after medical danger is excluded; coach slow breathing and grounding
- Avoid repeated low-yield testing after appropriate negative evaluation
- Short-acting benzodiazepines may relieve severe acute symptoms but are not long-term first-line
2
Long-term treatment
- CBT with interoceptive exposure and cognitive restructuring
- SSRI/SNRI such as sertraline, fluoxetine, paroxetine, escitalopram, or venlafaxine; start low
- Continue medication 6-12 months after remission before slow taper
3
Agoraphobia/avoidance
- Use graded exposure to avoided situations
- Reduce safety behaviors such as always needing a companion
- Treat alcohol/benzodiazepine misuse if present
Complications
- Agoraphobia:
- Depression and suicide risk:
- Alcohol or benzodiazepine misuse:
- Repeated ED visits/testing:
- Occupational and social impairment:
USMLE Step 2 CK Exam Tips
- 1Panic attacks peak within minutes; GAD is chronic worry over months
- 2Unexpected recurrent attacks + 1 month worry/avoidance = panic disorder
- 3Best long-term treatment is CBT and/or SSRI, not chronic benzodiazepines
- 4Panic-like exertional syncope or abnormal ECG is not panic until medically evaluated
- 5Pheochromocytoma distractor: episodic headache + sweating + hypertension
- 6Hyperventilation can cause perioral/finger paresthesias
practicetest your knowledge on panic disorderApply what you've learnt with USMLE Step 2 CK-style questions from the iatroX Q-Bank — psychiatry and beyond.
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