MBBS IV Block C PBL Case 5: Panic Disorder

PBL Case 5: Panic Disorder

I. Human Biology in Health and Disease
1. Discuss the different pathophysiological causes of chest discomfort

II. Professional skills: Diagnostic, problem solving, effective communication and

clinical management
1. Discuss the approaches of assessing a patient with non-specific symptoms

2. Differentiate life threatening and non-life threatening conditions from

undifferentiated symptoms

3. Recognize the importance of understanding the patient as a person, and the

possible association between patient’s symptoms and psychosocial background

III. Population health, health services, economics and policy

1. Know the prevalence of panic attack and panic disorder

IV. Medical Ethics, Professional Attitudes and behaviour

1. Discuss the ethical issues relating to the management of a patient with panic
disorder
MBBS IV Block C PBL Case 5: Panic Disorder

Page 1
2-3 days of on and off chest pain and SoB

 Fever(?)
o Cough, sputum production, GI symptoms, headache
 Characteristics of chest discomfort
o Exertional? Local? Progression?
 Aggravating factors
o Exacerbation recently?
 3 months: sub-acute condition
 Reason for consultation
 Past medical history
 Family history
 Social history such as pet and living environment
 Risk factors
o Smoking, diet
 Cardiac dyspnoea vs respiratory dyspnoea
 Ddx
o Vascular: heart failure
o Infection: TB,
o COPD, pulmonary fibrosis
o Asthma
o Neoplasm: lung cancer
o Trauma: rib fracture, costochondritis
o GI problems: esophagus, stomach
o Iatrogenic
o Endocrine: hyperthyroidism, adrenal gland
 FM ddx
o Common: menopause, anxiety
 PE
o CVS and Respiratory
o Thyroid
Page 2
Chest discomfort for 3 days, sudden onset, episodic, dizziness, numbness of fingers

Fast heart pounding: arrhythmia

Many symptoms match with anxiety
Palpitation for 3 months: not likely to be arrhythmia due to long time
Numbness of finger: tissue perfusion poor due to tachycardia(?)
Hyperventilated, hypoxaemia/poor perfusion->dizziness
Caffeine: stimulating effect
Psychiatric Ix: GAD7, social history important e.g. life events, work
 Most likely: anxiety
 Systemic: hyperthyroidism, adrenal gland
 Less likely: AMI, arrhythmia
24 hour ecg for arrhythmia
 PE sign
o Pulses regularity
o Central cyanosis, pallor
o Neck mass
o Toxicology test
MBBS IV Block C PBL Case 5: Panic Disorder

 Chinese herbs
 Ix: GAD7,ecg, LFT, RFT,CBC,廿四味 (24 hour urine catecholamine collection)
 DSM-5 criteria for anxiety ddx
o Six months
 Types of anxiety
o Panic disorder, separation anxiety, adjustment disorder, specific phobia
o Symptoms: tachycardia, sweating, increase breath rate(phobic symptoms)

Page 3
All PE normal, afraid to go to Tibet again

Specific phobia disorder: afraid of high altitude

Worry and uncertain about the future
Somatic form disorder(?)
Family member score for cardiac disease
Refer to cardiologist? Psychiatrist?
Advice on dealing with sudden anxiety
MBBS IV Block C PBL Case 5: Panic Disorder

Give sick certificates now?

High altitude sickness
OVER Ix: false positive, make her anxiety worse
24 hr ecg

Page 4

 Agoraphobia: fear to go to place or situation that make you panic

o Must be related to crowdedness, public space, travel away or travel alone

HDL low, LDL and total cholesterol high

Ten year CVS death risk: 0.6%

Adjustment anxiety: more related to life event like death of family or work change

MOST PROBABLE ddx: Panic disorder

Major biopsychosocial problem:

 Fear when leading tour to China
o Refer to clinical psychologist
o Prophylaxis of high altitude sickness
 Fear of cardiac disease
o Monitor of blood lipid profile
 Lifestyle modification: coffee, alcohol

3 aspects of psychiatric disease:

1. Predisposing
2. Precipitating
3. Perpetuating factors

Prevalence of common mental disorders among Chinese adults aged from 16 to 75 was 13.3%.
The most common disorders were mixed anxiety and depressive disorder (6.9%), followed by
generalised anxiety disorder (4.2%), depressive episode (2.9%), and other anxiety disorders
including panic disorders, all phobias and obsessive compulsive disorder (1.5%).
MBBS IV Block C PBL Case 5: Panic Disorder

I. Human Biology in Health and Disease

1. Discuss the different pathophysiological causes of chest discomfort
MBBS IV Block C PBL Case 5: Panic Disorder

Panic disorder
 Panic attack: period of intense fear with autonomic symptoms that develops
rapidly, peak in 10 minutes, lasting no longer than 20-30 minutes
 Panic disorder: recurrent panic attacks, not secondary to substance, medical or
psychiatric disorder, lasting for at least 1 month
 Epidemiology
o Bimodal peak at young and middle aged, female predominant
 Pathophysiology
o Neurochemistry
 Serotonin: exaggerated post synaptic receptor response to synaptic
serotonin
 Noradrenergic: increase adrenergic activity with hypersensitivity of
presynaptic a2 receptors
 GABA: reduce inhibitor receptor sensitivity
 Cholecystokinin-pentagastrin: increase pentagastrin causing dose
dependent panic attack
o Genetics
 Moderate heritability (25-50%)
 E.g. CCK gene polymorphisms
 Need environmental critical stressor to develop full blown disorder
 Types
o Spontaneous: no specific situation
o Situational: on situation where attacks have occurred previously
o Nocturnal: during sleep
 Etiology
o Injury
o Illness
o Adverse life event
o Substance abuse: cannabis, stimulants
o SSRI discontinuation syndrome
 Symptoms
o Episodic:
 Acute onset, peak at few minutes
 Short duration (20-30 minutes)
 Recurrent, spotnaeous trigger
 Autonomic symptoms (4 out of the following)
 1. SYM: sweating, tremor, hypertension, blushing
 2. CVS: palpitation, tachycardia, atypical chest pain (relieved by
exercise, nitrates are ineffective)
 3. RESP: SOB, tachypnea, wheezing
 4. ABDOMEN: nausea, gastric discomfort, choking, urgency
 5. NEURO: dizziness, unsteadiness, paresthesia,
derealization/depersonalization, fear of going crazy/dying
o Psychological/behavioural change
 Persistent worry about additional/consequences of another attack
 Maladaptive behavioural hange (e.g. phobic avoidance of
situations/places)
 Duration: ?1 month
MBBS IV Block C PBL Case 5: Panic Disorder

 Complications
o 1. Hyperventilation syndrome (50-60%)
 Hypocapnia: reduction in CO2, reduce cerebral BF  dizziness,
confusion, agitation
 Hypocalcemia and respiratory alkalosis: paresthesia, carpopedal spasm,
weakness
o 2. Agoraphobia: a type of anxiety disorder in which you fear and avoid places
or situations that might cause you to panic and make you feel trapped, helpless
or embarrassed
o 3. Social phobia: anxiety during social situations
o 4. Depression
o 5. Alcohol and substance misuse
o 6. Impulsive risk of suicide
o 7. Medical conditions
 Other ddx
o GAD, agoraphobia and social phobia
o Alcohol and substance intoxication
o Bipolar affective disorder
o ARDS, pulmonary embolism, asthma, MI
 Diagnosis
o Clinical: provocation test (demonstrate due to hyperventilation)
o Blood tests
 CBC
 RFT: reduction in Ca
 ABG: increase pH, reduce PaCo2, reduce HCO3 (resp alkalosis)
 D-dimer: exclude PE
 Glucosse: exclude DKA
o Imaging
 ECG: prolong QT, acute ST, T changes
 CXR: exclude lung problems
 VQ scan: exclude PE
 Treatment
o Acute
 Resuscitation: vitals, O2 therapy, IV access
 Slow breathing technique
 Benzodiazepine (reduce agitation and anxiety)
o Long term
 Anti-depressants
 SSRI: fluoxetine, paroxetine (1st line)
 TCA: imipramine, clomipramine (GAD, agoraphobia, panic
disorder, PTSD< OCD)
 Benzodiazepine
 Psychotherapy
 CBT: educate body’s response to panic
 Psychodynamic: emotion focused treatment
MBBS IV Block C PBL Case 5: Panic Disorder

Anxiety symptoms

 GAD
MBBS IV Block C PBL Case 5: Panic Disorder

Generalized anxiety disorder

II. Professional skills: Diagnostic, problem solving, effective communication and

clinical management
1. Discuss the approaches of assessing a patient with non-specific symptoms

2. Differentiate life threatening and non-life threatening conditions from

undifferentiated symptoms

3. Recognize the importance of understanding the patient as a person, and the

possible association between patient’s symptoms and psychosocial background
MBBS IV Block C PBL Case 5: Panic Disorder

Framingham risk score (estimates the risk of heart attack in 10 years)

Considers
 Age
 Sex
 Smoker
 Total cholesterol
 HDL cholesterol
 Systolic BP
 Blood pressure treated with medications

III. Population health, health services, economics and policy

1. Know the prevalence of panic attack and panic disorder

IV. Medical Ethics, Professional Attitudes and behaviour

1. Discuss the ethical issues relating to the management of a patient with panic
disorder