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Clinical Scenario
A 28-year-old female receptionist presents to her GP with a 3-month history of recurrent episodes of sudden, intense fear that "come out of nowhere". Each episode lasts about 10 minutes, peaks rapidly, and is accompanied by palpitations, sweating, trembling, dyspnoea, choking, chest tightness, dizziness, paraesthesia in her fingers and around her mouth, and an overwhelming fear that she is having a heart attack and is going to die. She has had 6 such attacks in the last month. The first occurred while she was watching television. She now avoids taking the underground to work (where her last attack occurred), avoids the supermarket, and will not exercise because exercise raises her heart rate and "sets it off". She has stopped going out with friends. She checks her pulse 30 times a day and has attended the ED twice with normal ECG, troponin and TSH. She drinks 6 cups of coffee per day and a bottle of wine on Saturday. Her father was treated for depression. GAD-7 = 14. She scores 17 on the PDSS. She has no medical history and is not on medication. She is suicidal ideation free.
Questions
a) What is the diagnosis and what two DSM-5-TR criteria support it? (2 marks)
Diagnosis: Panic disorder (with agoraphobic avoidance).
DSM-5-TR criteria:
- Recurrent, unexpected panic attacks — abrupt surge of intense fear peaking within minutes with at least 4 of 13 symptoms (she has 9: palpitations, sweating, trembling, dyspnoea, choking, chest pain, dizziness, paraesthesia, fear of dying). The first attack was unexpected ("watching television"), satisfying the unexpected requirement.
- At least 1 month of persistent concern about further attacks plus maladaptive behaviour change — pulse-checking 30 times a day, avoidance of the underground, supermarket and exercise, two ED attendances.
Additional: not attributable to substance (caffeine is provoking but the unexpected attack excludes caffeine as sole cause) or medical condition (normal ECG, troponin, TSH). Not better explained by another mental disorder.
b) List the organic causes of panic-like symptoms you must exclude, naming two specific tests for each. (3 marks)
- Cardiac (ACS, arrhythmia, MVP) — 12-lead ECG (looking for ST changes, QTc, SVT, WPW); high-sensitivity troponin if chest pain.
- Hyperthyroidism — TSH (suppressed); free T4 / free T3 (raised).
- Phaeochromocytoma — 24-hour urine fractionated metanephrines; plasma free metanephrines.
- Hypoglycaemia — capillary glucose during attack; fasting glucose / insulin (insulinoma).
- Substance-induced / withdrawal — urine drug screen (cannabis, cocaine, amphetamines); CIWA-Ar and detailed alcohol history.
- Pulmonary embolism — D-dimer; CTPA if Wells score intermediate/high.
c) Outline the first-line management plan. (3 marks)
- Cognitive-behavioural therapy (CBT) — high-intensity, 12 to 15 weekly sessions; components: psychoeducation (cognitive model — bodily sensations are catastrophically misinterpreted, completing a vicious cycle), cognitive restructuring (challenge "I'm dying"), interoceptive exposure (spinning, hyperventilating to induce sensations and learn tolerance) and in-vivo exposure (graded return to underground, supermarket, exercise). CBT alone gives 60 to 80% response and prevents relapse.
- SSRI — sertraline 25 mg OD for week 1, then 50 mg OD, titrate weekly to 100 to 200 mg OD. Start low and titrate slowly to avoid jitteriness; onset 4 to 6 weeks, full effect 8 to 12 weeks; continue at least 12 months after remission; withdraw over at least 4 weeks. Counsel re initial worsening of anxiety, GI upset, sexual dysfunction.
- Psychoeducation and lifestyle — explain the diagnosis and benign prognosis; reduce caffeine to under 200 mg/day (currently 6 cups = about 600 mg/day); reduce alcohol (alcohol causes rebound anxiety); regular aerobic exercise; sleep hygiene. Refer to NHS Talking Therapies (IAPT) Step 3.
d) Name two pharmacological options if first-line treatment fails after 12 weeks, and the dose of each. (2 marks)
- Switch to venlafaxine XR 75 mg OD, titrate to 225 mg OD (SNRI; NICE alternative first-line; monitor BP at higher doses), OR switch to escitalopram 10 to 20 mg OD.
- Add pregabalin 150 mg/day in divided doses, titrate to 300 to 600 mg/day (binds α2δ calcium-channel subunit in the amygdala; rapid onset within 1 week; useful adjunct in GAD and treatment-resistant panic).
Not appropriate: long-term benzodiazepines (dependence within 4 to 6 weeks); beta-blockers alone (do not treat the core panic); antipsychotics (no evidence).
Examiner Notes
- Common error: prescribing benzodiazepines chronically — dependence and withdrawal are major problems. Benzodiazepines are for short-term (2 to 4 weeks) rescue only, e.g. while waiting for SSRI onset.
- Common error: starting sertraline at 50 mg OD in panic — risk of jitteriness; start at 25 mg OD and titrate weekly.
- Common error: attributing the case to "just caffeine" — the unexpected attack while watching TV is the diagnostic clue; caffeine is provoking but the patient meets full panic disorder criteria.
- PDSS = 17 = moderate-to-severe panic disorder (thresholds: 0 to 5 remission, 6 to 10 mild, 11 to 15 moderate, 16 to 21 moderate-to-severe, 22 to 28 severe).
- GAD-7 = 14 = moderate (5 to 9 mild, 10 to 14 moderate, 15 to 21 severe); confirms clinically significant anxiety warranting treatment.
- Always screen for depression and suicidality in any anxious patient — comorbidity is common and suicide risk is independent of comorbid depression.