Case 16: A woman with sudden crises who fears a heart attack

Case 16: A woman with sudden crises who fears a heart attack

A 26-year-old woman, referred after visits to many specialists, with sudden spells of palpitations and sweating in which she fears a heart attack.

  • 2 min read
  • Checked 01 Nov 2026

The case

After seeing one specialist after another, a 26-year-old woman is referred for a psychiatric opinion. She has sudden crises of tension, palpitations and sweating, in which she feels unreal and is afraid she is having a heart attack. Each lasts a few minutes, and over the past month they have come four or five times a week. Between them she feels tense and is almost always waiting for the next one, so she has started going out less.

Summary

Diagnosis

Panic disorder, one of the anxiety disorders, with anticipatory anxiety and early agoraphobic avoidance.

What points to it

  • Sudden attacks lasting minutes, with many autonomic signs: palpitations, sweating, tension.
  • Feeling unreal during the attack (depersonalisation, or derealisation if it is the surroundings that seem unreal).
  • Fear of impending death, here of a heart attack.
  • Repeated visits to specialists to find a physical cause, which is very common in panic disorder.
  • Between attacks, constant fear of the next one, and avoidance of going out, the start of agoraphobia.

What else it could be

Physical illness that mimics panic (an arrhythmia, hyperthyroidism, hypoglycaemia, asthma), caffeine, stimulant drugs, and withdrawal from alcohol or sedatives. Panic attacks also occur within other disorders, such as depression or a phobia, where they come only in the feared situation.

Management

  • Explain the diagnosis plainly, as a common and treatable condition, and agree to stop further tests that are not needed.
  • CBT: education about panic, breathing control, challenging the catastrophic reading of bodily sensations, and graded exposure to the places she has begun to avoid. Relaxation techniques help alongside.
  • An SSRI, an antidepressant, started low and raised slowly. If no SSRI helps after 12 weeks, imipramine or clomipramine.
  • Benzodiazepines are not part of routine treatment.
  • Ask about suicidal thoughts, low mood and alcohol.

Outlook

Fair with treatment. The earlier the avoidance is tackled, the better. Untreated, the attacks and the avoidance tend to spread and become chronic.