A 32-year-old woman presents to the psychiatry outpatient clinic with a 6-month history of recurrent, unexpected panic attacks characterized by palpitations, dyspnea, chest discomfort, and fear of dying. She reports 4 attacks in the past month, each lasting 20–30 minutes. Between attacks, she worries constantly about having another one and has begun avoiding crowded places and public transport. Physical examination and cardiac workup (ECG, troponin, echocardiography) are normal. She denies substance use or medical comorbidities. What is the most appropriate next step in management?

Explanation

## Diagnosis and Initial Assessment **Key Point:** This patient meets DSM-5 criteria for Panic Disorder: recurrent unexpected panic attacks, persistent worry about future attacks, and behavioral changes (avoidance, agoraphobia-like features). **High-Yield:** Once organic causes (cardiac, neurological, endocrine) are excluded by appropriate investigations, the diagnosis is psychiatric and requires evidence-based psychological and pharmacological intervention. ## First-Line Management of Panic Disorder | Intervention | Role | Evidence | Duration | |---|---|---|---| | SSRI (paroxetine, sertraline, escitalopram) | First-line pharmacotherapy | Gold standard; FDA-approved | 4–6 weeks to effect, 12+ weeks for full response | | Cognitive-Behavioral Therapy (CBT) | First-line psychotherapy | Highly effective; addresses catastrophic thoughts and avoidance | 12–20 sessions | | Benzodiazepines | Adjunct only, short-term | Rapid symptom relief but risk of dependence; not monotherapy | 2–4 weeks max | | Tricyclic antidepressants (TCAs) | Alternative if SSRI fails | Second-line; more side effects than SSRIs | Weeks to months | **Clinical Pearl:** The combination of SSRI + CBT is superior to either alone. CBT specifically targets panic-related catastrophic cognitions and interoceptive conditioning. **Warning:** Benzodiazepines should NOT be used as monotherapy in panic disorder because they: - Do not address underlying anxiety disorder - Carry high risk of dependence (especially with long-term use) - May paradoxically worsen avoidance behavior - Are reserved for acute crisis or short-term bridge therapy (2–4 weeks) while SSRI takes effect ## Why Brain MRI and Cardiac Monitoring Are Not Indicated **Key Point:** Investigations are already complete (normal ECG, troponin, echo). Panic attacks mimic cardiac emergencies but do not cause structural cardiac or neurological disease. Unnecessary investigations reinforce health anxiety and delay appropriate psychiatric treatment. ## Management Algorithm ```mermaid flowchart TD A[Panic Disorder diagnosed]:::outcome --> B{Cardiac/organic causes ruled out?}:::decision B -->|No| C[Investigate: ECG, troponin, echo, TSH, glucose]:::action B -->|Yes| D[Start SSRI + refer for CBT]:::action D --> E[Review at 4-6 weeks]:::action E --> F{Response adequate?}:::decision F -->|Yes| G[Continue SSRI + CBT, taper avoidance]:::action F -->|No| H[Increase SSRI dose or switch agent]:::action H --> I[Reassess at 12 weeks]:::action ``` **Mnemonic:** **SSRI-CBT** = **S**elective **S**erotonin **R**euptake **I**nhibitor + **C**ognitive **B**ehavioral **T**herapy — the gold-standard combination for panic disorder.