Anxiety OSCE - Panic Disorder

Case Overview

• Age/Sex: 19/F
• Occupation: University student (first year, studying biochemistry)
• Setting: Student health clinic, during exam period
• Chief complaint: "I've been feeling anxious and on edge, and I've had several really scary attacks where I felt like I couldn't breathe."

Patient Script

Who I Am

I'm a 19-year-old university student living in a shared flat while studying for my end-of-year exams.

What Brings Me In

I've been having sudden terrifying episodes where my heart races and I feel like I'm choking — they're happening more and more and I can't concentrate on studying.

My Story

About three weeks ago I had my first really bad episode: I suddenly felt an intense wave of fear, my heart was pounding, I was breathing fast and felt like I might faint. Since then I've had several attacks, at first every few days but now they're happening every day, sometimes more than once. The worst was three days ago in the library — I felt lightheaded, sweaty and I thought I might be having a heart attack, so I left and sat outside for ages. Since that day I avoid the library and crowded lecture halls because I'm worried another one will happen.

The attacks come on suddenly without any obvious trigger. They last about 5–20 minutes, and afterwards I'm very shaky and exhausted and keep worrying about when they'll happen again. I've been sleeping badly for about two weeks, waking up early and lying awake thinking about getting through the day. I used to go to morning lectures but lately I've been cancelling because I'm scared something will happen there.

I started drinking more coffee and energy drinks while revising — probably 3–4 cups or energy drinks a day. I vape socially once or twice a week, and I smoke cannabis occasionally when out with friends (maybe 2–3 times a month). I had a really bad chest tightness during an attack and thought it might be my heart, but it went away.

My Medical Background

• Past medical history: no chronic illnesses, no previous mental health diagnoses
• Medications: combined oral contraceptive pill (ethinylestradiol/levonorgestrel) started 6 months ago
• Allergies: none known
• Social history: lives with 3 other students, full-time undergraduate, drinks alcohol socially (a few drinks on weekends), occasional cannabis, vapes socially; increased caffeine intake during exam revision
• Family history: mother has depression treated with therapy; father has high blood pressure

What I Think & Worry About

• I keep thinking, "Am I going to have another one?" and I'm scared I might be having a heart attack.
• I'm worried this will ruin my exams and I won't cope at university.
• I just want to feel calm and be able to go back to lectures.

If You Ask Me About Other Symptoms...

• Chest pain: "I had a tight chest during an attack — it felt like pressure, but it passed after 10–15 minutes."
• Breathlessness: "I feel short of breath during the attacks, like I can't get a full breath."
• Fainting/syncope: "I've felt lightheaded but never actually fainted."
• Palpitations: "My heart races and I feel it pounding hard in my throat/chest."
• Sleep: "I am sleeping much less — maybe 4–5 hours a night and I wake up anxious."
• Appetite/weight: "I haven't noticed much change in weight, maybe a bit less appetite because I'm stressed."
• Suicidal thoughts: "I haven't thought about killing myself — I'm mostly scared and upset, not wanting to die."
• Recent illness: "I had a bad cold a month ago but I recovered."
• Menstrual: "My periods are a bit irregular sometimes but nothing new recently."

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Clinical Summary

Examination

• General: alert, visibly anxious, slightly diaphoretic
• Vitals: HR 110 bpm (regular), BP 118/72 mmHg, RR 22/min, Temp 36.6°C, O2 sat 98% on air
• Cardiovascular: normal heart sounds, no murmurs, no peripheral edema
• Respiratory: chest clear to auscultation, no wheeze
• Abdomen: soft, non-tender
• Neurological: no focal deficit; hyperventilating during interview at times, slight tremor of hands
• Mental state: anxious affect, coherent and oriented, worried about future attacks, no psychosis, insight present

Investigations

• ECG: sinus tachycardia 110 bpm, normal PR/QRS/ST segments (no ischemic changes)
• Troponin I: <0.01 ng/mL (within reference range) — (no evidence of myocardial injury)
• TSH: 2.1 mU/L (reference 0.4–4.0) — (euthyroid)
• Random blood glucose: 5.2 mmol/L (normal)
• Full blood count: Hb 13.2 g/dL, WCC 6.1 x10^9/L, platelets 250 x10^9/L (within normal limits)
• Urine pregnancy test: negative
• Urine drug screen: cannabinoids detected (consistent with reported occasional use); no amphetamines/cocaine detected

Diagnosis

Primary diagnosis:

• Panic disorder (severe presentation) — supported by recurrent, unexpected episodes of intense fear with prominent autonomic symptoms (palpitations, sweating, trembling, shortness of breath), attacks lasting minutes, daily episodes for the past week with persistent worry about further attacks and behavioral change (avoidance of lectures/library) causing impairment.

Differential diagnoses (with reasoning):

• Generalized anxiety disorder — less likely as the presenting feature is discrete, sudden intense panic attacks rather than pervasive chronic excessive worry across multiple domains.
• Caffeine/stimulant-induced anxiety — contributory factor (high caffeine intake from energy drinks and coffee) and may exacerbate symptoms, but does not fully explain recurrent spontaneous panic attacks and anticipatory anxiety.
• Substance intoxication/withdrawal (cannabis, nicotine) — occasional cannabis use may complicate picture; urine screen positive for cannabinoids but usage pattern (infrequent) makes it less likely the sole cause.
• Cardiac arrhythmia/ischemia — initial concern given palpitations and chest tightness; ECG shows sinus tachycardia and troponin is normal, making an acute cardiac event unlikely.
• Thyrotoxicosis — TSH normal, so unlikely.

Management

• Acute/symptomatic measures:

  • Provide a calm, quiet space; reassure the patient that physical causes have been investigated and immediate life-threatening conditions have been excluded.
  • Teach and coach simple grounding and breathing techniques (slow diaphragmatic breathing, 4-4-4 or box breathing) and progressive muscle relaxation to use during attacks.
  • Consider prescribing a short-acting benzodiazepine (e.g., lorazepam 0.5–1 mg orally as needed) only for severe breakthrough attacks while arranging definitive treatment, with caution about dependence and advising limited short-term use.

• Further treatment and follow-up:

  • Arrange urgent follow-up with student mental health services or primary care within 1 week.
  • Offer psychoeducation about panic attacks and advice to reduce caffeine and avoid recreational drugs while treating symptoms.
  • Recommend first-line definitive treatments: referral for cognitive-behavioural therapy (CBT) focused on panic disorder and consider starting an SSRI (e.g., sertraline) after discussing risks/benefits and ensuring pregnancy test negative and contraception discussed.
  • Safety-net: assess for suicidal ideation regularly; advise to seek emergency care if chest pain changes, fainting, severe breathlessness, or suicidal thoughts develop.
  • Liaise with university disability/academic support to arrange temporary adjustments (deferred exams or flexible deadlines) while treatment is initiated.

Key Learning Points

• Panic disorder often presents with recurrent, sudden discrete episodes of intense fear with autonomic symptoms; look for anticipatory anxiety and behavioral changes (avoidance) when making the diagnosis.

• Always exclude medical causes (cardiac, thyroid, substance intoxication) with targeted history, examination and basic investigations before diagnosing a primary anxiety disorder.

• Initial management includes reassurance, breathing/grounding techniques, short-term symptom control when needed, and prompt referral for CBT and consideration of SSRI for longer-term treatment; address contributing factors such as high caffeine intake and substance use.