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A 41-year-old female presents with recurrent episodes of severe palpitations, diaphoresis, tremor, chest tightness, and a sense of impending doom occurring 2-3 times weekly for 3 months. She was diagnosed with panic disorder by her primary care provider and started on sertraline, with no improvement after 8 weeks at therapeutic dose. On further evaluation, the PMHNP notes the episodes are not triggered by specific situations or cognitive patterns. The patient reports severe headaches accompany each episode. Her blood pressure during an in-office episode is 210/120 mmHg, and between episodes she is consistently normotensive. Which finding is most suggestive that this presentation is not primary panic disorder?
Explanation
Pheochromocytoma is a must-know medical mimic of panic disorder. Both cause episodic palpitations, diaphoresis, and a sense of doom. The distinguishing features are paroxysmal severe hypertension (not seen in panic), episodic headaches accompanying the adrenergic surge, and treatment resistance to standard anxiolytics. The screening test is plasma free metanephrines or 24-hour urine catecholamines.
Key Takeaway
Paroxysmal severe hypertension with episodic headache, diaphoresis, and palpitations should prompt evaluation for pheochromocytoma before attributing symptoms to panic disorder.