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In a panic disorder history taking station, it’s important to rule out other anxiety disorders. If attacks only occur in specific situations (e.g., only in crowds), consider another anxiety disorder.
Key Knowledge
ICD-11 defines panic disorder (6B01) as recurrent unexpected panic attacks that are not restricted to particular stimuli or situations. This must also be accompanied by persistent concern regarding the recurrence of a panic attack, or behaviours intended to avoid their recurrence, resulting in significant functional impairment.
A panic attack is a discrete episode of intense fear or apprehension accompanied by multiple characteristic symptoms including palpitations, sweating, trembling, shortness of breath, chest pain, nausea, dizziness, and psychological symptoms such as fear of dying or losing control.
Core features include:
●Recurrent panic attacks, at least some of which are unexpected (occur “out of the blue”)
●Attacks reach peak intensity rapidly, usually within minutes
●Rapid onset of several characteristic symptoms such as: palpitations, sweating, chest pain, dizziness, nausea, deperonsalisation, fear of immminent death etc.
●Persistent concern about having further attacks or their consequences (e.g., “I’m going to have a heart attack,” “I’m going to lose control”)
●Maladaptive behavioural change as a result (e.g., avoidance of situations, always carrying medication)
●Symptoms cause significant distress or functional impairment
●Individual panic attacks typically last for a few minutes. Frequency and severity can vary.
●The disorder is not better explained by another mental disorder (e.g., attacks occurring only in social situations would suggest social anxiety disorder) or by a medical condition.
Differential Diagnosis for Panic Disorder
1. Other anxiety disorders
Key distinctions: In specific phobia, social anxiety disorder, OCD, or agoraphobia, panic attacks occur predictably in response to specific triggers. In panic disorder, at least some attacks are unexpected. However, these conditions commonly coexist.
2. Generalised anxiety disorder (GAD)
Key distinctions: GAD involves persistent, excessive worry about multiple every day events and/or a general sense of apprehension. People with GAD may experience physical anxiety symptoms but not the sudden, intense episodes characteristic of panic disorder.
3. Post-traumatic stress disorder (PTSD)
Key distinctions: Panic attacks in PTSD are typically triggered by trauma reminders. There will be a clear trauma history and other PTSD symptoms (re-experiencing, avoidance, hypervigilance).
4. Substance use or withdrawal
Key distinctions: Stimulants (caffeine, cocaine, amphetamines) can cause panic-like symptoms. Alcohol or benzodiazepine withdrawal can present similarly. History is key.
5. Normality
Key distinctions: Panic attacks in response to real threats which are considered part of the normative continuum of reactions.
6. Menopause/perimenopause
Key distinctions: Panic attacks are driven by an overwhelming sense of doom, whereas menopausal symptoms are primarily physical, including clamminess and sweating, often without intense fear, and symptoms may typically last longer than a panic attack and are more common at night. Shortness of breath is not typically a menopausal symptom. Also consider the timing and age of the patient.
Risk Assessment in Panic Disorder
To self:
●Suicide risk – Particularly when comorbid with depression
●Substance misuse – Self-medication with alcohol or benzodiazepines may be present
●Avoidance and isolation – Severe restriction of activities, loss of employment, relationship breakdown
●Iatrogenic harm – Repeated A&E attendance, unnecessary investigations
●Accident risk – Attacks while driving or in dangerous situations
To others:
●Generally low, however there may be strain on family members providing reassurance or support
From others:
●Low
Communication Tips
Panic disorder CASC stations often involve explaining the diagnosis or taking a history, which should involve exploring triggers and screening for avoidance behaviour and comorbidity.
Exploring panic attacks:
●”Can you describe what happens during one of these episodes?”
●”How quickly do the symptoms come on? How long do they last?”
●”What physical symptoms do you experience?”
●”What thoughts go through your mind when this happens?”
Distinguishing panic disorder from other anxiety:
●”Do these episodes come completely out of the blue, or do they happen in particular situations?”
●”Can you predict when an attack might happen?”
●”Have you noticed any triggers or patterns?”
Impact and consequences:
●”How often are these attacks happening?”
●”How worried are you about having another attack?”
●”Do you avoid certain situations or activities because you’re afraid of having an attack?”
●”How has this affected your daily life, e.g. work, relationships, going out?”
Screen for avoidance:
“●Are there places you avoid because you’re worried about having a panic attack?”
●”How do you feel about crowds, public transport, open spaces, being away from home?”
Screen for comorbidities:
●Depression: mood, anhedonia, sleep, appetite, hopelessness
●Substance use: “Have you used alcohol or anything else to help cope with the anxiety?”
Medical screening:
●”Have you seen your GP? Have you had any physical health tests?”
●Ask about caffeine intake, prescribed medications (e.g. benzodiazepines, thyroid medications), and illicit substances
Understanding and insight:
●”What do you think is causing these episodes?”
●”Have you ever wondered whether anxiety might play a role?”
CASC Practice Scenarios
Scenario 1: History Taking
Candidate Instructions:
You are the SpR in the general adult psychiatry outpatient clinic. Ms Rachel Foster, a 28-year-old primary school teacher, has been referred by her GP following three attendances at A&E over the past six weeks with chest pain and palpitations. Troponin, ECG, and chest X-ray were normal on each occasion. She was discharged with advice to see her GP, who started propranolol 10mg three times daily two weeks ago but Ms Foster remains symptomatic. She has no past psychiatric history.
Your tasks are to:
●Take a psychiatric history
●Perform a risk assessment
Scenario Summary:
Rachel Foster is a 28-year-old teacher experiencing recurrent panic attacks that began two months ago following a stressful period at work. She has had multiple A&E attendances with cardiac symptoms, all physically investigated and cleared. The attacks occur both predictably (crowded places, staff meetings) and unpredictably (at home, while driving). She has developed significant avoidance of supermarkets and public transport. She is not depressed but is exhausted and worried she has an undiagnosed heart condition. There is no substance use. She lives with her partner James and feels supported but guilty about her limitations.
Actor Brief:
You are Rachel Foster, a 28-year-old primary school teacher living with your partner James, who works as a software developer. Two months ago, you started having terrifying episodes where you felt like you were having a heart attack. The first one happened during a staff meeting, you suddenly felt your heart racing, couldn’t breathe, felt dizzy and sick, and were convinced you were dying. You had to leave the room. Since then, it’s happened at least ten or twelve times. Sometimes it comes completely out of the blue, for example you’ll be sitting at home watching TV and suddenly it starts. Other times it’s in crowded places like the supermarket or on the train.
When these episodes happen, your heart pounds so hard you can feel it in your throat. You get chest pain, your hands tingle and go numb, you feel like you can’t get enough air, and you’re absolutely terrified you’re going to die or collapse. They usually last about ten minutes, though it feels like forever. Afterwards, you’re exhausted and shaky for hours.
You’ve been to A&E three times because you were certain it was your heart. Each time they did tests including blood tests, heart tracings, chest X-rays, and told you everything was fine. You want to believe them, but it feels so physical that you’re worried they’ve missed something. Your GP started you on propranolol two weeks ago, which has helped a tiny bit with the physical symptoms, but the attacks keep happening.
You’re now avoiding quite a lot. You won’t go to big supermarkets anymore, instead you use the corner shop or order online. You’ve stopped getting trains, and only drive on familiar routes. You’re dreading the staff meeting next week. You haven’t taken time off work yet, but you’re struggling to concentrate and feel on edge all day. You’re constantly monitoring your heart rate and breathing and recently bought an apple watch to monitor this more, but it makes you more anxious.
You’re not depressed. You still enjoy things when you’re not having an attack, you sleep reasonably well (though you sometimes wake up panicking), and your appetite is normal. You drink maybe a glass of wine once or twice a week and have not tried using alcohol to numb your worries, nor have you tried any recreational drugs. You have no past psychiatric problems. Your mum has always been an anxious person but never had treatment. You drink one coffee a day and this has been the same habit for the last 10 years, caffeine doesn’t make you anxious.
You do not have any significant past medical history and if asked specifically about your thyroid you say the GP checked that and it was normal.
James has been supportive but doesn’t really understand, he thinks you just need to “push through it” and that avoiding things makes it worse. You feel guilty that you’re not pulling your weight and he’s had to do all the shopping and you’ve cancelled plans with friends several times.
You’re tearful when describing the attacks because they’re so frightening, but you’re cooperative and willing to talk. You’re desperate for help because you feel like your life is shrinking. If asked directly whether you’ve thought about harming yourself, you say no and that you want to get better, not give up. You have never self harmed or ever had suicidal thoughts. You’re open to the idea that this might be anxiety-related, though part of you still worries something physical has been missed.
Feedback for Scenario 1
Knowledge & Clinical Skills
A good candidate will:
●Systematically explore the phenomenology of panic attacks, eliciting the characteristic rapid onset, physical symptoms and time course (peaking within minutes, lasting 10-30 minutes)
●Distinguish between situationally-triggered and unexpected panic attacks, and assess the pattern of occurrence to differentiate panic disorder from other anxiety disorders
●Thoroughly explore avoidance behaviours and their impact on functioning, recognising the development of agoraphobic avoidance secondary to panic attacks
●Conduct a comprehensive risk assessment that includes not just suicidal ideation but also risks specific to panic disorder: driving during attacks, occupational impairment, and the risk of developing depressive symptoms or substance misuse.
Communication
A good candidate will:
●Validate the patient’s fear and distress.
●Demonstrate empathy for the impact on daily functioning and relationships, explicitly acknowledging how frightening and disabling panic attacks are.
●Ask open questions and allow patient time to express herself.
Video Example
Our video on panic disorder can be found here! Panic Disorder History | CASC Video – PsychPanda
Authors/Reviewers
Dr Damir Rafi is a Psychiatry Speciality registrar in forensics, currently working in London.
Dr Rebecca Goodall is a Psychiatry Specialty Registrar, specialising in children & adolescents.
Dr Molly Beazley is a Psychiatry Speciality Registrar specialising in forensics.
References and Resources
World Health Organization. (2019). International classification of diseases for mortality and morbidity statistics (11th ed.). https://icd.who.int/browse11/l-m/en
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
National Institute for Health and Care Excellence. (2011). Generalised anxiety disorder and panic disorder in adults: Management (CG113). https://www.nice.org.uk/guidance/cg113
Disclaimer:
This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.
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