Psychiatry · Easy
This case is fictional and exists for study. It describes no real patient.
28 years · female
A 28-year-old female presents to her general practitioner complaining of recurring episodes of overwhelming fear over the past two months. The episodes occur unexpectedly, reaching peak intensity within minutes, and are accompanied by palpitations, sweating, chest tightness, shortness of breath, and a sensation that she is 'going crazy' or dying. Between episodes, she experiences constant worry about when the next attack will happen, which has led her to avoid going out alone. Physical examination and neurological assessment are unremarkable. Blood tests, including thyroid function tests, and a 12-lead electrocardiogram are all within normal limits.
Vital signs
- HR
- 78 bpm
- BP
- 122/76 mmHg
- RR
- 16/min
- Temp
- 36.7 °C
- SpO₂
- 99%
Examination findings
- Cardiovascular and respiratory physical examinations are completely normal
- Neurological examination reveals no focal deficits
Investigations
| Thyroid Stimulating Hormone (TSH) | 1.8 mIU/L | reference: 0.4-4.0 |
| Haemoglobin | 13.2 g/dL | reference: 12.0-15.5 |
Question 1 of 3
What is the most likely diagnosis?
Panic disorder is characterized by recurrent, unexpected panic attacks that peak rapidly, accompanied by autonomic arousal symptoms and persistent concern (anticipatory anxiety) about future attacks. Generalized anxiety disorder involves persistent, excessive worry about multiple daily domains rather than discrete episodic attacks. Social anxiety disorder centers on fear of scrutiny in social or performance situations. Agoraphobia involves fear of places where escape might be difficult, but here her avoidance is secondary to panic attacks.
Teaching point: Panic disorder is diagnosed when recurrent unexpected panic attacks are followed by persistent worry about subsequent attacks.
Question 2 of 3
If psychological therapy is unavailable or declined, which of the following is the most appropriate first-line pharmacological treatment for this patient?
According to NICE guidelines, an SSRI (such as sertraline) is the first-line pharmacological treatment for panic disorder. Propranolol only treats somatic autonomic symptoms and is not recommended as primary maintenance therapy for panic disorder. Benzodiazepines like diazepam carry a high risk of dependence and tolerance and should not be used long-term. Haloperidol is a typical antipsychotic and is not indicated for uncomplicated panic disorder.
Teaching point: SSRIs are the first-line pharmacological treatment choice for panic disorder in UK practice.
Question 3 of 3
Which of the following non-pharmacological interventions is recommended as a first-line treatment for this patient according to national guidelines?
Individual Cognitive Behavioural Therapy (CBT) is recommended by NICE guidelines as a first-line psychological treatment for panic disorder. Psychoanalysis lacks high-quality evidence in panic disorder management. Exposure and Response Prevention (ERP) is specific to Obsessive-Compulsive Disorder (OCD). Interpersonal Psychotherapy (IPT) is primarily indicated for major depressive disorder.
Teaching point: Cognitive Behavioural Therapy (CBT) is the gold-standard evidence-based psychological therapy for panic disorder.
Key learning points
- Panic disorder presents with recurrent unexpected panic attacks and persistent anticipatory anxiety about future attacks.
- Organic causes (e.g., hyperthyroidism, arrhythmias, anaemia) should be excluded before confirming a diagnosis of panic disorder.
- First-line management options for panic disorder include cognitive behavioural therapy (CBT) or an SSRI.
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