Panic Attacks Masquerading as Intractable Vomiting

Panic attacks are characterized as abrupt and intense episodes of fear or discomfort that reach their peak within a few minutes, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. These episodes are typically accompanied by a combination of physical and psychological symptoms such as palpitations; pounding heart or accelerated heart rate; sweating; trembling or shaking; sensations of shortness of breath or feeling smothered; feelings of choking, chest pain, or discomfort; nausea or abdominal distress; feeling dizzy, unsteady, light-headed, or faint; chills or heat sensations; numbness or tingling sensations (paresthesias); feeling detached from oneself or experiencing a sense of unreality (derealization); fear of losing control or going crazy; and fear of dying.¹ In clinical practice, identifying the underlying cause of physical symptoms that coincide with panic attacks can be challenging, especially when the symptoms are seemingly unrelated.² This case report elucidates a perplexing and atypical manifestation of panic attacks presenting as intractable vomiting.

Case Report

A 19-year-old patient presented with recurrent episodes of vomiting commencing at the age of 16 years, coinciding with his transition to a new school environment. Despite returning home, the vomiting persisted, evolving to include hematemesis after prolonged retching. Preceding the vomiting episodes, the patient experienced symptoms such as nausea, palpitations, shivering, sweating, and a general sense of fear, which would subside only to recur intermittently. Symptomatic management with antiemetics proved ineffective, leading to a significant disruption in the patient’s daily life, including irregular attendance at school and social withdrawal over a span of 2 years. Extensive medical evaluations, including routine blood investigations, electroencephalography, abdominal ultrasonography, and endoscopy, revealed no organic abnormalities, prompting consideration of an underlying functional etiology. Consequently, psychiatric consultation was sought, with no history of mood disturbances identified during the evaluation. The patient’s mental status examination yielded an anxious mood but was otherwise within normal limits, with no notable deficits in higher mental functions or significant findings upon systemic examination.

A diagnosis of panic disorder was considered, and symptom reduction was achieved with a starting dose of 12.5 mg of paroxetine and 0.25 mg of clonazepam. Clonazepam was tapered and stopped in the next 3 weeks. Paroxetine was gradually titrated to 25 mg, resulting in the cessation of vomiting episodes and the resumption of normal school attendance. However, upon discontinuation of medication by the patient’s parents after 9 months of symptom remission, a recurrence of vomiting episodes with identical features ensued soon. Reintroduction of paroxetine successfully alleviated symptoms once again.

Discussion

The aim of this report is to present a rare case in which panic attacks manifested as intractable vomiting, leading to diagnostic complexities and delays. Given the strong correlation between various gastrointestinal complaints such as abdominal pain, nausea, vomiting, constipation, and diarrhea with anxiety disorders, it is imperative to highlight this atypical presentation.³ A study by Lydiard et al⁴ revealed a significant prevalence of gastrointestinal complaints among individuals with panic disorder, with 28.3% experiencing stomach bloating and nausea and 11.3% reporting frequent vomiting. We started the patient on paroxetine controlled release formulation. Paroxetine was the first US Food and Drug Administration–approved selective serotonin reuptake inhibitor for the treatment of panic disorder. Although paroxetine is commonly associated with gastrointestinal side effects, its slow titration, administration with food, and use of the controlled-release preparation are helpful in attenuating these side effects. Also, it is known that these adverse effects lessen gradually. The controlled-release formulation of the drug also ensures convenient once-daily dosing.⁵ Through this report, we emphasize the importance of considering panic attacks as a potential differential diagnosis in patients presenting with unexplained gastrointestinal symptoms.

Article Information

Published Online: August 22, 2024. https://doi.org/10.4088/PCC.24cr03744
© 2024 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord 2024;26(4):24cr03744
Submitted: March 16, 2024; accepted May 23, 2024.
To Cite: Zain AA, Mittal T, Haridas NJ. Panic attacks masquerading as intractable vomiting. Prim Care Companion CNS Disord. 2024;26(4):24cr03744.
Author Affiliations: Government Medical College, Kozhikode, Kerala, India (Zain); Department of Psychiatry, Government Medical College, Kozhikode, Kerala, India (Mittal, Haridas).
Corresponding Author: Tanvi Mittal, MBBS, Department of Psychiatry, Government Medical College, Kozhikode, Kerala, India 673008 (tmpsymd@gmail.com).
Relevant Financial Disclosure: None.
Funding/Support: None.
Patient Consent: Consent was obtained from the patient to publish the case report, and information has been de identified to protect anonymity.
ORCID: Ajzal A. Zain: https://orcid.org/0009-0008-6930-2839; Tanvi Mittal: https://orcid.org/0009-0009-4608-6413; Nishanth Jalaja Haridas: https://orcid.org/0000-0002-2517-2031