Practitioners frequently encounter patients suffering from panic disorder symptoms. The symptoms may present in an obvious fashion or remain more subtle and hard to distinguish from common medical problems. The practitioner should always remain alert for the presentation of a patient with symptoms of panic disorder. The successful diagnosis and treatment of these patients is a deeply rewarding endeavor. DEFINITION According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR), panic disorder is defined as recurrent, unexpected panic attacks, which are episodes of intense fear and apprehension. The signs and symptoms of a panic attack include the following as listed in Table 7.1. Panic attack symptom onset is rather abrupt and may occur without warning. Episodes may occur outside the home environment leading to agoraphobia [1]. The episode may be falsely interpreted as a heart attack, seizure, or stroke. There may be a sense of being “paralyzed” and unable to move. Often, a visit to the emergency room is the result. Patients may hyperventilate to the point of fainting, only to resume consciousness on the way to the hospital. The typical panic attack develops in intensity over approximately 10 minutes. Attacks may be full or partial in severity and occur unexpectedly, “out of the blue.” This feature leads to anticipatory anxiety and avoidance of activities that might be associated with the attack [2]. Furthermore, life for the patient becomes disrupted and less satisfactory. The ramifications are quite considerable. INCIDENCE AND PREVALENCE Panic disorder is estimated to occur in 3.5% of the United States population. Females outnumber males by approximately 2:1. In the primary care setting, this disorder may exist in as many as 1 out of 10 patients [3] and may go unrecognized for long periods. The average age at onset of panic disorder is 20 to 30 years [3]. Approximately one third of patients recover with or without treatment and the remainder tends to relapse. Panic disorder patients utilize medical services considerably more than do non-panic patients. The perceived need by patients to seek medical attention for their symptoms leads to greater utilization of health care services. Anxiety disorders in general have been estimated to cost billions of dollars per year, including the cost of care, the utilization of services, and the loss of work productivity [1]. Many patients seek multiple evaluations by various specialists. Some patients transfer their care from practitioner to practitioner. When patients present with symptoms of panic disorder, they are often desperate. This disorder can be disabling and can shake their confidence. They look to the practitioner for help and empathy, but may not be able to express their symptoms openly. Embarrassment and a fear that the practitioner will think they are “crazy” may interfere with the open dialogue necessary to proceed with diagnosis and treatment. Some cultures do not recognize mental health issues or allow patients to speak to the practitioner about these issues. Thus, recognizing and addressing the problem are major hurdles to overcome for the primary care practitioner. There is an understandable apprehension among many practitioners that mental health issues, including panic disorder in particular, will take much more time than they can afford to allot for one patient. Usually, it is simply the recognition and validation of the patient’s concerns and apprehension that constitutes the practitioner’s first duty. Once this is accomplished, the way is paved for pursuing a good treatment outcome. FURTHER HISTORY: IMPORTANT AREAS TO CONSIDER DURING THE WORKUP Since there are no specific tests or scans to confirm or deny a diagnosis of panic disorder, the practitioner must rely on an accurate and complete history in order to develop a clinical impression. Table 7.2 lists the important parts of the history to consider in patients suspected of having a panic disorder.