Panic Disorder

Question 1

A 28 year old woman has short episodes of chest pain, dizziness and breathlessness. She has had 2 similar episodes in the past 4 months. Medical investigations have excluded cardiac pathology. How would you assess and manage?

Answer 1

Impression
Given the exclusion of any medical pathology in the setting of these acute episodes of chest pain and breathlessness, this presentation likely represents panic disorder, particularly given the repeated episodic nature of the presentation.

DDx
Organic cause
- ACS
- other respiratory illness
Other related anxiety disorder
- Panic attack
- Agoraphobia
- social phobia
- GAD
other psych/co-morbid
- somatic symptom disorder/illness anxiety disorder
- SUD
- withdrawal (Alcohol, other substances)

Conduct complete psych assessment in order to determine diagnosis and appropriate treatment approach

Question 2

Panic Disorder - History

Answer 2

History

• Sx: ascertain sx of panic attacks; chest pain, diaphoresis, sob, anxiety, palpitations, choking, shaking, dizziness, loc, etc. time duration (avg ~14 minutes)
• STUDENTS FEAR the 3 C’s
• Ascertain underlying cognitions/fears - fear of having panic attacks, in public, fear of social settings, or isolated events with no impairment in function due to fear of recurrence
• ask about other anxiety disorder features: OCD, GAD, social, agoraphobia, etc
• Screen depressive, manic, suicide/self-harm, violence, personality
• FamHx, MedHx - characterise cardiovascular risk factors, past MI/stroke etc
• Rest of psych history

Question 3

Panic Diorder - Examination

Answer 3

Examination:

• Cardiorespiratory
• MSE
• Case formulation

Question 4

Panic Disorder - Investigations

Answer 4

Investigations:
Want to rule out organic causes of this presentation
- Bedside: ECG, VBG urine drug screen
- Bloods: serial trops, FBC, UEC, CRP/ESR
- Imaging: CXR, ECHO, ?coronary angio +/- therapeutic intervention as required

Question 5

Panic disorder - Management

Answer 5

Management:
Mainstay of acute management is psychoeducationa and reassurance, can also utilise de-arousal/relaxation/mindfulness strategies in the acute setting as well (slow breathing, etc)
- consider use of benzodiazepines in the acute setting, although panic attach usually over before drug starts working.

Long-term treatment
Biological
- SSRI or SNRI
- TCA (if 1st line ineffective)

Psychological

• CBT
• Psychoeducation
• De-arousal techniques (a part of CBT anyway)

Social
- Social supports, psychoeducation for family