Case 3: A woman with attacks of palpitations and a fear of dying

01The case

Over the past three months a 29-year-old woman has had several brief attacks of dizziness, a pounding heart, difficulty breathing and what she calls "extreme weakness". During each one she felt she was about to die or to go mad. In those three months she has seen a cardiologist five times, and no heart disease has been found.

02Summary

Diagnosis

Panic disorder, one of the anxiety disorders.

What points to it

• The attacks start suddenly and are over quickly.
• A surge of autonomic symptoms: palpitations, breathlessness from overbreathing, dizziness, feeling faint.
• Intense fear during the attack, of dying or of losing her mind.
• Repeated normal cardiac assessments, so a heart cause is unlikely. Five visits in three months also show that she is not yet ready to consider a psychological explanation.

What else it could be

Exclude what can mimic panic: an arrhythmia, hyperthyroidism, hypoglycaemia, asthma, rarely a phaeochromocytoma or temporal lobe epilepsy, and caffeine, stimulants or withdrawal from alcohol or sedatives. After a normal cardiac work-up, an ECG, thyroid function and glucose are usually enough. Ask about low mood, since depression often comes with panic, and about avoiding places, which would suggest agoraphobia as well.

Management

• Build a working relationship and help her accept, without dismissing her symptoms, that the attacks are anxiety and not heart disease. Explain the circle of bodily sensation, fear and overbreathing.
• CBT for panic, the psychological treatment of first choice.
• An SSRI, an antidepressant, started low and raised slowly because panic can get worse in the first weeks, and continued for months after she is well. If no SSRI helps after 12 weeks, imipramine or clomipramine.
• Benzodiazepines are not a routine treatment.
• Ask about suicidal thoughts and alcohol: the risk rises when panic comes with depression or substance misuse.
• Agree a plan that limits emergency visits and further heart tests.

Outlook

Fair with treatment. Untreated, panic disorder tends to run a chronic course. Most people improve with CBT or an SSRI, but relapse is common when medication stops, and the outlook is worse with agoraphobia, depression or alcohol misuse.