Depression — MCQs

10 questions

A 43-year-old woman presents with episodes of severe anxiety, palpitations, and sweating. These occur unpredictably and last 10-15 minutes. Between episodes she feels well. What is the most likely diagnosis?

A 28-year-old woman presents with episodes of palpitations, sweating, and tremor lasting 15 minutes. These occur 2-3 times weekly. Physical examination is normal between episodes. What is the most likely diagnosis?

A 30-year-old woman presents with episodes of feeling detached from herself and her surroundings, as if watching herself from outside her body. These episodes last 10-15 minutes and cause significant distress. What is the most likely diagnosis?

A 40-year-old woman presents with recurrent episodes of palpitations, sweating, and tremor lasting 10-15 minutes. These occur 2-3 times per week with no obvious trigger. Physical examination and ECG during an episode are normal. What is the most likely diagnosis?

A 34-year-old woman presents with recurrent episodes of palpitations, anxiety, and tremor lasting 10-15 minutes. These occur 2-3 times per week with no obvious trigger. Physical examination and ECG during an episode are normal. What is the most likely diagnosis?

A 27-year-old woman presents with amenorrhea, weight loss, and excessive exercise. She has fine lanugo hair and her BMI is 16 kg/m². She denies having an eating disorder. What is the most likely diagnosis?

A 60-year-old woman with treatment-resistant depression has been referred for electroconvulsive therapy (ECT) after failing adequate trials of four different antidepressants including augmentation strategies. She has severe depression with psychomotor retardation, significant weight loss, and pervasive guilt. Her family is concerned about potential cognitive side effects of ECT. They ask about factors that might be modified to minimise cognitive adverse effects while maintaining treatment efficacy. Which modification would most effectively reduce cognitive side effects while preserving antidepressant efficacy?

A 38-year-old solicitor presents with a 10-week history of low mood, anhedonia, fatigue, and reduced concentration. She describes feeling guilty about her work performance despite no objective evidence of problems. She has prominent anxiety symptoms including worry, restlessness, and muscle tension present most days. Her PHQ-9 is 17 and GAD-7 is 14. She has no past psychiatric history. What is the most appropriate initial pharmacological treatment choice?

A 35-year-old woman with panic disorder has been stable on escitalopram 20mg daily for 18 months, remaining panic-free for 12 months. She wishes to discontinue medication as she is planning pregnancy. She previously had severe panic disorder with 8-10 attacks weekly and significant agoraphobic avoidance requiring 6 months off work. She received CBT alongside medication. Which approach to discontinuation carries the optimal balance of minimising withdrawal symptoms while reducing recurrence risk?

Q10

A 52-year-old businessman presents with symptoms of both panic disorder and alcohol dependence. He reports drinking 60-80 units per week for the past 3 years. He experiences 3-4 panic attacks weekly, mostly in the morning, with palpitations, sweating, and tremor. He recognises he uses alcohol to manage his anxiety symptoms. He has no history of seizures or delirium tremens. He is motivated to address both problems. What is the most appropriate initial management strategy?

Depression UK Medical PG Practice Questions and MCQs

Question 1: A 43-year-old woman presents with episodes of severe anxiety, palpitations, and sweating. These occur unpredictably and last 10-15 minutes. Between episodes she feels well. What is the most likely diagnosis?

A. Generalized anxiety disorder
B. Panic disorder (Correct Answer)
C. Social anxiety disorder
D. Hyperthyroidism
E. Pheochromocytoma

Explanation: ***Panic disorder***- The patient is presenting with classic symptoms of a **panic attack**: discrete, unexpected episodes of intense fear accompanied by physical symptoms (palpitations, sweating) that peak rapidly (usually within 10 minutes) and then resolve.- A **Panic disorder** diagnosis requires recurrent unexpected panic attacks, followed by worry about future attacks or significant behavioral changes related to the attacks.*Generalized anxiety disorder*- GAD involves **chronic, pervasive, excessive worry** about numerous events or activities, often lasting for at least six months.- The symptoms are persistent instability rather than the acute, time-limited, discrete episodes described in this clinical vignette.*Social anxiety disorder*- This disorder involves intense fear or anxiety specifically related to **social or performance situations** where the individual may be exposed to scrutiny by others.- The patient's episodes are described as **unpredictable** and not tied to specific social contexts, making this diagnosis unlikely.*Hyperthyroidism*- While **hyperthyroidism** can cause anxiety-like symptoms (nervousness, palpitations, sweating) due to elevated metabolism, these symptoms are typically **persistent** rather than occurring as short, discrete attacks.- Diagnosis is confirmed by laboratory evidence (e.g., low **TSH**).*Pheochromocytoma*- This neuroendocrine tumor causes episodes of anxiety, palpitations, and sweating due to **catecholamine surges**.- Paroxysms are often associated with life-threatening **hypertensive crises** and severe headaches, which are not mentioned, and panic disorder is statistically much more common for this presentation.

Question 2: A 28-year-old woman presents with episodes of palpitations, sweating, and tremor lasting 15 minutes. These occur 2-3 times weekly. Physical examination is normal between episodes. What is the most likely diagnosis?

A. Hyperthyroidism
B. Panic disorder (Correct Answer)
C. Pheochromocytoma
D. Cardiac arrhythmia
E. Hypoglycemia

Explanation: ***Panic disorder*** - The clinical picture describes classic **panic attacks**, which are abrupt, time-limited episodes of intense fear or discomfort peaking within minutes and involving symptoms like **palpitations**, sweating, and tremor.- Panic disorder is the most likely diagnosis when such recurrent, unexpected attacks occur and the physical examination is **unremarkable** between episodes.*Hyperthyroidism* - Symptoms of hyperthyroidism, such as palpitations and tremor, are typically **persistent** and chronic, not brief, self-limiting episodes lasting only 15 minutes.- A physical examination would likely reveal persistent findings like **tachycardia** or *goiter*, which are noted to be normal in this patient between episodes.*Pheochromocytoma* - Although this condition causes episodic symptoms (paroxysms) mimicking anxiety, they are often associated with severe, paroxysmal **hypertension** and are usually less frequent than 2-3 times per week.- Given the high prevalence of anxiety disorders, **panic disorder** is epidemiologically the most likely diagnosis compared to this rare tumor, before requiring biochemical confirmation.*Cardiac arrhythmia* - While some arrhythmias cause palpitations, episodes that spontaneously resolve in precisely 15 minutes and recur frequently without evidence of **structural heart disease** are less typical of primary arrhythmia.- Significant recurrent arrhythmias often present with more alarming red-flag symptoms such as **syncope** or chest pain, which are not mentioned here.*Hypoglycemia* - Symptoms typically occur in association with **fasting** or excessive insulin/medication and are usually characterized by both adrenergic symptoms (sweating) and neuroglycopenic symptoms (e.g., confusion).- The episodic nature, unrelated to food intake or diabetic status (implied), and consistency of the 15-minute duration favor an **autonomic surge** related to anxiety over a metabolic cause.

Question 3: A 30-year-old woman presents with episodes of feeling detached from herself and her surroundings, as if watching herself from outside her body. These episodes last 10-15 minutes and cause significant distress. What is the most likely diagnosis?

A. Panic disorder
B. Dissociative disorder (Correct Answer)
C. Schizophrenia
D. Depression
E. Anxiety disorder

Explanation: ***Dissociative disorder***- The presenting symptoms of feeling detached from oneself (**depersonalization**) and surroundings (**derealization**) are pathognomonic features of **Depersonalization/Derealization Disorder**, a type of dissociative disorder.- These episodic experiences, lasting 10-15 minutes and causing distress, clearly align with the diagnostic criteria for this condition.*Panic disorder*- Characterized by recurrent, unexpected **panic attacks** that include severe physical symptoms like **palpitations**, shortness of breath, and chest pain, peaking within minutes.- Although depersonalization/derealization can occur during a panic attack, the core complaint here is pure detachment, not an overwhelming surge of **physical anxiety** or intense fear.*Schizophrenia*- Schizophrenia is primarily characterized by **psychotic symptoms** such as **hallucinations** (e.g., auditory) and **delusions**, which are absent in this presentation.- The disorder requires a minimum duration of symptoms and active phase criteria (e.g., disorganized speech or behavior) distinct from isolated episodic detachment.*Depression*- Core features of depression involve persistent **depressed mood** and **anhedonia** (loss of pleasure or interest), along with changes in sleep, appetite, and energy.- While sometimes associated with severe mental illness, episodic dissociation is not the defining criterion for Major Depressive Disorder.*Anxiety disorder*- This term is broad, but common diagnoses like Generalized Anxiety Disorder (GAD) involve persistent, excessive, and uncontrollable **worry** about various life events.- The clinical picture involves profound subjective detachment rather than chronic high levels of pervasive **anxiety** or restlessness.

Question 4: A 40-year-old woman presents with recurrent episodes of palpitations, sweating, and tremor lasting 10-15 minutes. These occur 2-3 times per week with no obvious trigger. Physical examination and ECG during an episode are normal. What is the most likely diagnosis?

A. Hyperthyroidism
B. Panic disorder (Correct Answer)
C. Cardiac arrhythmia
D. Pheochromocytoma
E. Caffeine excess

Explanation: ***Panic disorder***- The sudden, recurrent, brief attacks (10–15 minutes) of intense fear with physical symptoms like **palpitations**, **sweating**, and **tremor**, in the absence of an underlying medical condition (normal ECG), are characteristic of a **panic attack**.- The unpredictable nature ("no obvious trigger") and recurrence (2–3 times per week) fulfill the diagnostic criteria for **Panic Disorder**.*Hyperthyroidism*- While hyperthyroidism causes symptoms like **palpitations**, **sweating**, and **tremor**, these are typically persistent and chronic, not episodic and brief (10-15 minutes) as described.- A physical examination would likely reveal additional signs such as **goiter**, **exophthalmos**, or sustained **tachycardia**, which are absent here.*Cardiac arrhythmia*- Arrhythmias, even paroxysmal ones (e.g., PSVT), almost always cause demonstrable **ECG changes** (e.g., tachycardia, rhythm irregularity) during an episode, which are explicitly stated as normal in this patient.- The prominence of diffuse **sweating** and **tremor** alongside palpitations, in the context of a normal ECG, points away from a primary cardiac etiology.*Pheochromocytoma*- Paroxysms due to pheochromocytoma (episodic catecholamine release) typically involve severe, episodic **hypertension** and intense **headaches** along with palpitations, findings not mentioned in this clinically normal presentation.- While attacks can mimic panic, the underlying pathology often results in profound physiological changes (e.g., significant BP surge) that would likely be detected or at least suspected during physical examination.*Caffeine excess*- Symptoms from caffeine excess are often continuous or predictable based on **recent high consumption**, rather than occurring spontaneously 2–3 times per week with "no obvious trigger."- Significant caffeine intoxication would usually present with more sustained **tremor**, **restlessness**, or high resting heart rate, symptoms inconsistent with a completely normal physical exam.

Question 5: A 34-year-old woman presents with recurrent episodes of palpitations, anxiety, and tremor lasting 10-15 minutes. These occur 2-3 times per week with no obvious trigger. Physical examination and ECG during an episode are normal. What is the most likely diagnosis?

A. Hyperthyroidism
B. Panic disorder (Correct Answer)
C. Cardiac arrhythmia
D. Pheochromocytoma
E. Caffeine excess

Explanation: ***Panic disorder***- This is supported by the recurrent, unprovoked episodes of intense **anxiety**, **palpitations**, and **tremor**, consistent with **panic attacks**.- Panic attacks are typically brief, peaking within 10 minutes and resolving within 30 minutes, and are associated with a **normal physical examination** and **ECG** during the episode.*Hyperthyroidism*- Symptoms like palpitations and tremor in **hyperthyroidism** are usually constant and persistent, not brief and episodic (10-15 minutes).- Hyperthyroidism is associated with other signs like **weight loss**, heat intolerance, and requires abnormal **thyroid function tests (TFTs)** for diagnosis.*Cardiac arrhythmia*- Although the patient reports palpitations, a true **cardiac arrhythmia** would typically manifest with identifiable changes on the **ECG performed during the episode**.- The **normal ECG** during the episode makes a significant arrhythmia less likely, and sustained arrhythmias suggest an underlying electrical instability or **structural heart disease**.*Pheochromocytoma*- This condition causes episodic symptoms (paroxysms) but classically includes severe, pounding **headache**, diaphoresis, and marked, though transient, **hypertension**, which are critical differentiating factors not noted here.- Diagnosis relies on demonstrating elevated plasma or urinary **metanephrines**, which would be pursued if more typical features were present.*Caffeine excess*- Symptoms due to **caffeine excess** would have a clear, identifiable trigger (recent high caffeine consumption), which contradicts the finding of "no obvious trigger" in this patient history.- Caffeine-induced anxiety and palpitations would typically resolve reliably upon reducing or eliminating **caffeine** from the diet.

Question 6: A 27-year-old woman presents with amenorrhea, weight loss, and excessive exercise. She has fine lanugo hair and her BMI is 16 kg/m². She denies having an eating disorder. What is the most likely diagnosis?

A. Hyperthyroidism
B. Anorexia nervosa (Correct Answer)
C. Depression
D. Celiac disease
E. Addison's disease

Explanation: ***Anorexia nervosa***- The combination of **severe underweight** (BMI 16 kg/m²), **amenorrhea**, deliberate **excessive exercise**, and the presence of **lanugo hair** (a sign of severe caloric deficit/starvation) is classic for Anorexia Nervosa.- Denial of an eating disorder, despite clear clinical indications, is a common psychological feature of this psychiatric condition.*Hyperthyroidism*- While hyperthyroidism causes weight loss and sometimes amenorrhea, it is characterized by symptoms of **hypermetabolism** like **tachycardia**, tremor, anxiety, and intolerance to heat.- It would not typically involve the specific psychological drive for **excessive exercise** seen in this presentation, nor is **lanugo hair** a typical finding.*Depression*- Depression can cause significant weight loss, but this is usually due to **anorexia** (loss of appetite), not the intense **deliberate restriction** and **driven excessive exercise** seen in this patient.- The presence of severe physical signs of starvation, such as **lanugo hair** at this BMI, points toward a primary eating disorder rather than depression alone.*Celiac disease*- Celiac disease causes weight loss due to malabsorption, typically accompanied by **gastrointestinal symptoms** such as chronic diarrhea, abdominal pain, or **steatorrhea**.- This diagnosis lacks the specific behavioral components of **body image distortion** and pathological restriction/excessive exercise central to Anorexia Nervosa.*Addison's disease*- Addison's disease (primary adrenal insufficiency) can cause unexplained weight loss and amenorrhea, but the hallmark is **hyperpigmentation** (especially in skin folds and mucous membranes) and specific electrolyte abnormalities (**hyponatremia** and **hyperkalemia**).- This patient lacks these adrenal features, and the clinical picture is dominated by the behavioral components of starvation.

Question 7: A 60-year-old woman with treatment-resistant depression has been referred for electroconvulsive therapy (ECT) after failing adequate trials of four different antidepressants including augmentation strategies. She has severe depression with psychomotor retardation, significant weight loss, and pervasive guilt. Her family is concerned about potential cognitive side effects of ECT. They ask about factors that might be modified to minimise cognitive adverse effects while maintaining treatment efficacy. Which modification would most effectively reduce cognitive side effects while preserving antidepressant efficacy?

A. Using unilateral electrode placement on the non-dominant hemisphere rather than bilateral placement (Correct Answer)
B. Reducing the electrical dose to just above seizure threshold regardless of electrode placement
C. Extending the interval between treatments from twice weekly to once weekly throughout the course
D. Using ultra-brief pulse width stimulation with bilateral electrode placement
E. Limiting the total number of ECT sessions to a maximum of 6 treatments

Explanation: ***Using unilateral electrode placement on the non-dominant hemisphere rather than bilateral placement*** - **Right-unilateral (RUL) ECT** is consistently associated with significantly fewer **cognitive adverse effects**, particularly regarding verbal memory and orientation, compared to **bilateral ECT**. - While bilateral placement is generally faster-acting, RUL ECT maintains comparable **antidepressant efficacy** provided the electrical dose is sufficiently higher (typically 6 times) than the **seizure threshold**. *Reducing the electrical dose to just above seizure threshold regardless of electrode placement* - While lower doses minimize cognitive side effects, using a dose just above the **seizure threshold** in unilateral ECT is often **ineffective** for treating depression. - To ensure efficacy in RUL placement, the dose must be significantly above threshold; therefore, reducing it too low risks a non-therapeutic response. *Extending the interval between treatments from twice weekly to once weekly throughout the course* - Reducing treatment frequency to **once weekly** may slow the rate of cognitive decline but significantly delays the **speed of remission** and clinical improvement. - **Twice-weekly sessions** are the standard of care to balance clinical response time with the risk of cumulative cognitive impairment. *Using ultra-brief pulse width stimulation with bilateral electrode placement* - **Ultra-brief pulse (0.3ms)** stimulation reduces cognitive side effects compared to standard brief pulse, but the benefits are most established when combined with **unilateral placement**. - Combining ultra-brief pulses with **bilateral placement** still poses a higher risk of cognitive deficits compared to the unilateral alternative. *Limiting the total number of ECT sessions to a maximum of 6 treatments* - Arbitrarily limiting sessions may result in **incomplete remission** or early relapse, as many patients require 8 to 12 sessions for a full therapeutic response. - Treatment course length should be determined by **clinical response** and recovery from symptoms like psychomotor retardation, rather than a fixed number of treatments.

Question 8: A 38-year-old solicitor presents with a 10-week history of low mood, anhedonia, fatigue, and reduced concentration. She describes feeling guilty about her work performance despite no objective evidence of problems. She has prominent anxiety symptoms including worry, restlessness, and muscle tension present most days. Her PHQ-9 is 17 and GAD-7 is 14. She has no past psychiatric history. What is the most appropriate initial pharmacological treatment choice?

A. Commence sertraline as it effectively treats both depressive and anxiety symptoms (Correct Answer)
B. Commence mirtazapine for its combined antidepressant and anxiolytic effects with rapid onset
C. Commence pregabalin for the generalised anxiety disorder with review to add an antidepressant if depression persists
D. Commence a low-dose benzodiazepine for anxiety symptoms with an SSRI added after anxiety is controlled
E. Commence venlafaxine as an SNRI is more effective than SSRIs for mixed anxiety-depression

Explanation: ***Commence sertraline as it effectively treats both depressive and anxiety symptoms***- In a mixed presentation, **NICE guidelines** recommend treating the **depression** first, and **SSRIs** like sertraline are the first-line choice for both **Moderately Severe Depression** (PHQ-9: 17) and **GAD**.- Sertraline is preferred due to its **extensive evidence base**, cost-effectiveness, and better **safety profile** compared to secondary options.*Commence mirtazapine for its combined antidepressant and anxiolytic effects with rapid onset*- While effective for sleep and anxiety, **mirtazapine** is generally considered a second-line option due to side effects like **sedation** and **weight gain**.- It is often reserved for patients who cannot tolerate SSRIs or have specific needs for **appetite stimulation**.*Commence pregabalin for the generalised anxiety disorder with review to add an antidepressant if depression persists*- **Pregabalin** is licensed for Generalised Anxiety Disorder but is not an effective treatment for **depressive symptoms** or clinical depression.- It is classified as second or third-line for anxiety and carries a risk of **dependence and misuse**.*Commence a low-dose benzodiazepine for anxiety symptoms with an SSRI added after anxiety is controlled*- **Benzodiazepines** should be avoided as initial treatment due to the high risk of **dependence**, tolerance, and lack of efficacy for **depressive symptoms**.- Managing anxiety first with these agents can mask symptoms and delay the effective treatment of the **underlying clinical depression**.*Commence venlafaxine as an SNRI is more effective than SSRIs for mixed anxiety-depression*- Evidence does not support **SNRIs** being more effective than **SSRIs** for the initial treatment of mixed anxiety and depression.- **Venlafaxine** is usually a second-line choice because of a more difficult **side effect profile** and significant **withdrawal/discontinuation syndrome**.

Question 9: A 35-year-old woman with panic disorder has been stable on escitalopram 20mg daily for 18 months, remaining panic-free for 12 months. She wishes to discontinue medication as she is planning pregnancy. She previously had severe panic disorder with 8-10 attacks weekly and significant agoraphobic avoidance requiring 6 months off work. She received CBT alongside medication. Which approach to discontinuation carries the optimal balance of minimising withdrawal symptoms while reducing recurrence risk?

A. Discontinue escitalopram abruptly as SSRIs can be safely stopped without tapering due to long half-lives
B. Reduce by 50% every week for 2 weeks then stop, as escitalopram has relatively low discontinuation syndrome risk
C. Gradually taper over at least 4 weeks while reinstating CBT techniques and monitoring for early signs of recurrence (Correct Answer)
D. Switch to fluoxetine for 2 weeks before discontinuation due to its longer half-life reducing withdrawal symptoms
E. Reduce dose by 25% every 2 weeks while commencing a tricyclic antidepressant which is safer in pregnancy

Explanation: ***Gradually taper over at least 4 weeks while reinstating CBT techniques and monitoring for early signs of recurrence*** - A **gradual taper** over at least 4 weeks is recommended by **NICE guidelines** to minimize the risk of **discontinuation syndrome** and allow monitoring of symptom recurrence. - Incorporating **CBT techniques** provides the patient with non-pharmacological coping specialized for panic disorder, which is crucial given her history of severe **agoraphobic avoidance**. *Discontinue escitalopram abruptly as SSRIs can be safely stopped without tapering due to long half-lives* - **Abrupt discontinuation** of SSRIs is not recommended as it significantly increases the risk of **withdrawal symptoms** such as dizziness, electric shock sensations, and rebound anxiety. - While **fluoxetine** has a long half-life, **escitalopram** has a moderate half-life and requires a tapered approach to ensure safety and stability. *Reduce by 50% every week for 2 weeks then stop, as escitalopram has relatively low discontinuation syndrome risk* - A 50% reduction per week is considered a **rapid taper** and may still trigger significant **discontinuation symptoms** in a patient who has been on treatment for 18 months. - Stability for 12 months is positive, but her history of **8-10 attacks weekly** suggests a high underlying vulnerability that warrants a more cautious, slower reduction. *Switch to fluoxetine for 2 weeks before discontinuation due to its longer half-life reducing withdrawal symptoms* - While switching to **fluoxetine** is a recognized strategy for drugs with very short half-lives (like paroxetine), it is generally an **unnecessary extra step** for escitalopram. - This approach adds the complexity of transitioning between medications and does not inherently address the need for **psychological support** during the final cessation phase. *Reduce dose by 25% every 2 weeks while commencing a tricyclic antidepressant which is safer in pregnancy* - Introduction of a **tricyclic antidepressant (TCA)** is inappropriate when the patient's explicit goal is to be **medication-free** for pregnancy planning. - TCAs are not necessarily "safer" than SSRIs in pregnancy and carry their own risks, including higher **toxicity in overdose** and significant side-effect profiles.

Question 10: A 52-year-old businessman presents with symptoms of both panic disorder and alcohol dependence. He reports drinking 60-80 units per week for the past 3 years. He experiences 3-4 panic attacks weekly, mostly in the morning, with palpitations, sweating, and tremor. He recognises he uses alcohol to manage his anxiety symptoms. He has no history of seizures or delirium tremens. He is motivated to address both problems. What is the most appropriate initial management strategy?

A. Commence an SSRI immediately for panic disorder while simultaneously initiating alcohol reduction strategies
B. Manage alcohol withdrawal first using a benzodiazepine-assisted reduction regimen before addressing panic disorder (Correct Answer)
C. Start propranolol for panic symptoms and naltrexone for alcohol dependence simultaneously
D. Refer to specialist dual diagnosis services before initiating any specific treatment
E. Commence CBT for panic disorder while the patient continues to drink at current levels to establish therapeutic alliance

Explanation: ***Manage alcohol withdrawal first using a benzodiazepine-assisted reduction regimen before addressing panic disorder*** - The patient's heavy alcohol consumption (60-80 units/week for 3 years) and morning symptoms like **palpitations, sweating, and tremor** strongly indicate **alcohol withdrawal**, which requires immediate and safe management, typically with **benzodiazepines**, to prevent serious complications. - Many anxiety and panic symptoms are often **exacerbated by or secondary to alcohol use and withdrawal**; therefore, stabilizing the patient through detoxification allows for a more accurate assessment and effective treatment of the underlying panic disorder. *Commence an SSRI immediately for panic disorder while simultaneously initiating alcohol reduction strategies* - Starting an **SSRI** while the patient is actively drinking heavily is not advisable as alcohol can significantly **interfere with the medication's efficacy** and increase the risk of side effects. - This approach makes it challenging to differentiate between **medication-induced side effects**, ongoing **alcohol withdrawal symptoms**, and the primary **panic disorder**. *Start propranolol for panic symptoms and naltrexone for alcohol dependence simultaneously* - **Propranolol** is a beta-blocker that primarily addresses the **physical symptoms of anxiety** (e.g., palpitations, tremor) but does not treat the core panic disorder or manage the underlying risks of **alcohol withdrawal**. - **Naltrexone** is effective for **reducing cravings and preventing relapse** in alcohol dependence but is not indicated for the acute management of **alcohol withdrawal** itself. *Refer to specialist dual diagnosis services before initiating any specific treatment* - While a **dual diagnosis service** is crucial for integrated care, delaying all treatment for a referral can put the patient at risk of **severe alcohol withdrawal complications** that require prompt intervention. - Initial **detoxification and stabilization** are often initiated in acute care settings or by the primary team before a comprehensive dual diagnosis assessment can be completed. *Commence CBT for panic disorder while the patient continues to drink at current levels to establish therapeutic alliance* - **Cognitive Behavioral Therapy (CBT)** for panic disorder is significantly less effective during active heavy alcohol use because alcohol impairs **cognitive function, memory, and insight**, hindering the patient's ability to engage with and benefit from therapy. - Continuing to drink at high levels undermines the therapeutic goals of CBT, which aim to help patients develop **healthy coping mechanisms** for anxiety without relying on substances.

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