A 42-year-old woman with moderate depression has been taking citalopram 40mg daily for 3 months with good response. She has a history of recurrent depression with two previous episodes in the past 5 years. She is now in remission and asks about stopping her medication as she feels well. According to NICE guidelines, what is the recommended minimum duration of continued antidepressant treatment after remission for someone with recurrent depression?
Q32
A 39-year-old man with panic disorder presents to the emergency department during an acute panic attack. He describes severe chest tightness, difficulty breathing, tingling in his fingers, and feelings of unreality. His respiratory rate is 28 breaths per minute. He appears distressed and anxious. Observations show: heart rate 110 bpm, blood pressure 145/88 mmHg, oxygen saturations 99% on air. ECG shows sinus tachycardia. Arterial blood gas shows pH 7.48, PaCO2 3.8 kPa, PaO2 13.2 kPa, HCO3 24 mmol/L. What physiological process best explains his paraesthesia and feelings of unreality?
Q33
A 53-year-old woman with treatment-resistant depression has failed adequate trials of sertraline, venlafaxine, and mirtazapine. She has also completed a course of CBT without benefit. Her psychiatrist plans to start augmentation therapy with lithium added to her current antidepressant. What is the target therapeutic plasma lithium level range for augmentation in depression?
Q34
A 35-year-old woman presents with panic disorder and has been experiencing 4-5 panic attacks per week for the past 3 months. She describes intense fear during attacks with palpitations, trembling, and fear of losing control. She has developed avoidance of crowded places. She has never taken psychotropic medication and is anxious about side effects. After discussion, she agrees to try pharmacological treatment. Which SSRI has the most evidence and is specifically licensed for panic disorder in the UK?
Q35
A 49-year-old woman with severe depression and significant suicidal ideation has been started on venlafaxine 75mg daily. She has hypertension, currently well-controlled on ramipril 5mg daily. Before increasing the venlafaxine dose, you review her blood pressure which is 148/94 mmHg on two separate readings. This is elevated compared to her baseline of 125/78 mmHg. What is the most appropriate management of her blood pressure in this context?
Q36
A 56-year-old man presents with a 7-month history of excessive, uncontrollable worry about minor matters including finances, his children's wellbeing, and his health, despite having no objective problems in these areas. He reports restlessness, muscle tension, poor concentration, and sleep disturbance. His symptoms occur most days. He has no history of depression or substance misuse. Physical examination is unremarkable. What is the minimum symptom duration required to meet diagnostic criteria for generalised anxiety disorder?
Q37
A 28-year-old woman with moderate depression has been taking fluoxetine 40mg daily for 5 weeks. She reports some improvement in sleep and appetite but continues to have low mood and anhedonia. She asks when she should expect to feel better. What is the most appropriate advice regarding the expected timeframe for full therapeutic response?
Q38
A 32-year-old man with panic disorder has been taking sertraline 100mg daily for 6 weeks. His panic attacks have reduced from daily to twice weekly, but he reports troublesome side effects including delayed ejaculation and reduced libido, which are affecting his relationship. He is keen to continue treatment but wants to address the sexual dysfunction. What is the most appropriate management of his sexual side effects?
Q39
A 44-year-old woman presents with an 8-week history of low mood, anhedonia, reduced concentration, and feelings of worthlessness. Her PHQ-9 score is 16. She reports passive suicidal ideation but no plans or intent. She has tried self-help strategies without benefit. She mentions that 4 years ago she had a similar episode treated successfully with citalopram 20mg daily, which she took for 8 months before stopping. What is the most appropriate initial management?
Q40
A 37-year-old woman presents with a 4-month history of recurrent panic attacks. She describes sudden episodes of breathlessness, palpitations, and fear of dying that peak within minutes and last approximately 20 minutes. Between attacks, she worries constantly about having another attack while driving, and has stopped using motorways. She has no past psychiatric history. Physical examination and ECG are normal. What is the most appropriate initial management approach?
Common Mental Disorders UK Medical PG Practice Questions and MCQs
Question 31: A 42-year-old woman with moderate depression has been taking citalopram 40mg daily for 3 months with good response. She has a history of recurrent depression with two previous episodes in the past 5 years. She is now in remission and asks about stopping her medication as she feels well. According to NICE guidelines, what is the recommended minimum duration of continued antidepressant treatment after remission for someone with recurrent depression?
A. 6 months after remission
B. 12 months after remission
C. 24 months after remission (Correct Answer)
D. Continue indefinitely given recurrent episodes
E. Can stop now as she is in remission
Explanation: ***24 months after remission***- For patients with **recurrent depression** (defined as two or more previous episodes plus the current one), **NICE guidelines** recommend continuing antidepressant treatment for at least **2 years** after remission to significantly reduce the risk of relapse.- This patient has a history of two previous episodes, making the current episode her third, thus placing her in the high-risk category for recurrence where extended maintenance is crucial.*6 months after remission*- This duration is typically recommended for individuals experiencing their **first episode of depression** to consolidate recovery and prevent early relapse.- It is considered **insufficient** for patients with a history of recurrent depression due to their significantly higher risk of relapse.*12 months after remission*- While longer than the standard 6 months, this duration is not specifically mandated by **NICE guidelines** for the management of recurrent depressive disorder.- Evidence suggests that a **24-month maintenance period** offers superior protection against relapse in individuals with a history of recurrent episodes compared to 12 months.*Continue indefinitely given recurrent episodes*- **Indefinite continuation** of antidepressants is usually reserved for individuals with a very high frequency of severe relapses, a history of poor response to previous cessation attempts, or when relapse carries significant clinical risk.- While this patient has recurrent depression, indefinite treatment is typically considered after **multiple failed attempts** at discontinuation or for exceptionally severe cases, rather than an initial recommendation for a third episode.*Can stop now as she is in remission*- Stopping antidepressants immediately upon achieving **remission** carries a very high risk of **relapse** due to the underlying neurobiological vulnerabilities in recurrent depression.- Furthermore, abrupt discontinuation can lead to unpleasant **antidepressant discontinuation syndrome**, which can be distressing and mistaken for a relapse.
Question 32: A 39-year-old man with panic disorder presents to the emergency department during an acute panic attack. He describes severe chest tightness, difficulty breathing, tingling in his fingers, and feelings of unreality. His respiratory rate is 28 breaths per minute. He appears distressed and anxious. Observations show: heart rate 110 bpm, blood pressure 145/88 mmHg, oxygen saturations 99% on air. ECG shows sinus tachycardia. Arterial blood gas shows pH 7.48, PaCO2 3.8 kPa, PaO2 13.2 kPa, HCO3 24 mmol/L. What physiological process best explains his paraesthesia and feelings of unreality?
A. Hypoxia due to inadequate ventilation
B. Metabolic alkalosis from excessive CO2 production
C. Respiratory alkalosis from hyperventilation causing decreased cerebral blood flow (Correct Answer)
D. Hypercapnia from respiratory fatigue
E. Lactic acidosis from increased muscle tension
Explanation: ***Respiratory alkalosis from hyperventilation causing decreased cerebral blood flow***
- **Hyperventilation** during a panic attack leads to excessive **CO2 washout**, resulting in **hypocapnia** (PaCO2 3.8 kPa) and **respiratory alkalosis** (pH 7.48).
- **Hypocapnia** causes **cerebral vasoconstriction**, reducing blood flow to the brain, which leads to **feelings of unreality**. The alkalosis also decreases **ionized calcium**, causing **paraesthesia**.
*Hypoxia due to inadequate ventilation*
- The patient is not hypoxic; his **O2 saturations are 99%** and his PaO2 is within the normal range at 13.2 kPa.
- Excessive ventilation (RR 28 bpm), rather than inadequate ventilation, is the primary drive during a typical **panic attack**.
*Metabolic alkalosis from excessive CO2 production*
- **Metabolic alkalosis** is characterized by a high **HCO3** level, whereas this patient has a normal bicarbonate of 24 mmol/L.
- Excessive CO2 production would lead to **respiratory acidosis**, not alkalosis, and is not a feature of hyperventilation.
*Hypercapnia from respiratory fatigue*
- **Hypercapnia** refers to elevated PaCO2 levels, but this patient's PaCO2 is low (3.8 kPa) due to rapid breathing.
- Respiratory fatigue usually occurs in chronic or severe end-stage lung disease, which is not consistent with an **acute panic attack** in a young patient.
*Lactic acidosis from increased muscle tension*
- **Lactic acidosis** would result in a **low pH** (acidosis) and a metabolic gap, which contradicts the alkaline pH of 7.48 found here.
- While muscle tension occurs in anxiety, it does not typically generate enough lactic acid to cause systematic **metabolic acidosis** or explain the specific neurological symptoms in this clinical context.
Question 33: A 53-year-old woman with treatment-resistant depression has failed adequate trials of sertraline, venlafaxine, and mirtazapine. She has also completed a course of CBT without benefit. Her psychiatrist plans to start augmentation therapy with lithium added to her current antidepressant. What is the target therapeutic plasma lithium level range for augmentation in depression?
A. 0.2-0.4 mmol/L
B. 0.4-0.6 mmol/L
C. 0.6-1.0 mmol/L (Correct Answer)
D. 1.0-1.2 mmol/L
E. 1.2-1.5 mmol/L
Explanation: ***0.6-1.0 mmol/L***
- This range is the recommended therapeutic target for **lithium augmentation** in **treatment-resistant depression**, aiming to enhance antidepressant effects.
- Achieving levels within this window balances efficacy with a reduced risk of **adverse effects**, making it suitable for long-term use in augmentation.
*0.2-0.4 mmol/L*
- This range is typically considered **sub-therapeutic** for both acute treatment and augmentation, and it is unlikely to provide a significant antidepressant effect.
- Such low levels may not adequately modulate the neurotransmitter systems involved in depression, thus failing to improve symptoms.
*0.4-0.6 mmol/L*
- While sometimes tolerated better by **elderly patients** or those sensitive to side effects, this range is generally below the optimal level for robust augmentation in treatment-resistant depression.
- Most clinical guidelines suggest a slightly higher target to achieve a more definitive **therapeutic response** in augmentation strategies.
*1.0-1.2 mmol/L*
- Levels in this range are typically sought for the **acute treatment of bipolar mania**, not for augmentation in depression, where lower doses are often sufficient.
- Using such high levels for augmentation significantly increases the risk of **lithium toxicity** symptoms, such as tremor, nausea, and cognitive impairment, without additional benefit for depression.
*1.2-1.5 mmol/L*
- These levels are definitively in the **toxic range** for lithium, risking severe adverse effects like ataxia, dysarthria, severe GI upset, and even seizures or cardiac arrhythmias.
- Such concentrations are not indicated for depression augmentation and require immediate medical intervention to prevent serious **lithium poisoning**.
Question 34: A 35-year-old woman presents with panic disorder and has been experiencing 4-5 panic attacks per week for the past 3 months. She describes intense fear during attacks with palpitations, trembling, and fear of losing control. She has developed avoidance of crowded places. She has never taken psychotropic medication and is anxious about side effects. After discussion, she agrees to try pharmacological treatment. Which SSRI has the most evidence and is specifically licensed for panic disorder in the UK?
A. Fluoxetine
B. Citalopram
C. Paroxetine (Correct Answer)
D. Sertraline
E. Escitalopram
Explanation: ***Paroxetine***
- **Paroxetine** was one of the first **SSRIs** to receive specific licensing for **panic disorder** in the UK and is supported by a robust evidence base for this indication.
- It is known for its high efficacy in reducing the frequency of **panic attacks**, though it is associated with a higher risk of **discontinuation syndrome** due to its short half-life.
*Fluoxetine*
- While effective for **depression** and **OCD**, **Fluoxetine** is not specifically licensed for the treatment of **panic disorder** in the UK.
- Its long half-life may be beneficial for some, but it can initially be more **activating**, potentially worsening acute anxiety symptoms.
*Citalopram*
- **Citalopram** is widely used for **depression**, but it lacks a specific license for **panic disorder** in the UK.
- Caution is required with higher doses due to the risk of **QT interval prolongation**, which necessitates monitoring in certain populations.
*Sertraline*
- **Sertraline** is licensed for panic disorder and often used as first-line due to its **tolerability**, but the question highlights paroxetine's historical precedence in licensing and evidence.
- It is generally preferred in patients with **cardiac comorbidities** but was not the primary focus of early specific licensing for this condition.
*Escitalopram*
- **Escitalopram** is a licensed and effective treatment for **panic disorder** with a favorable side effect profile.
- Although highly effective, it typically carries higher costs and was licensed later than **Paroxetine** for this specific indication.
Question 35: A 49-year-old woman with severe depression and significant suicidal ideation has been started on venlafaxine 75mg daily. She has hypertension, currently well-controlled on ramipril 5mg daily. Before increasing the venlafaxine dose, you review her blood pressure which is 148/94 mmHg on two separate readings. This is elevated compared to her baseline of 125/78 mmHg. What is the most appropriate management of her blood pressure in this context?
A. Stop venlafaxine immediately and switch to mirtazapine
B. Continue venlafaxine at current dose, optimize antihypertensive therapy, and monitor blood pressure closely (Correct Answer)
C. Reduce venlafaxine dose to 37.5mg daily
D. Continue current management as this blood pressure elevation is not clinically significant
E. Switch to fluoxetine which has no effect on blood pressure
Explanation: ***Continue venlafaxine at current dose, optimize antihypertensive therapy, and monitor blood pressure closely***- **Venlafaxine** is an **SNRI** that can cause dose-dependent **hypertension** due to its noradrenergic effects, but given the patient's **severe depression** and **suicidal ideation**, maintaining psychiatric stability is a priority.- Since her blood pressure (148/94 mmHg) is elevated but not in a hypertensive crisis, the safest approach is to **optimize her antihypertensive medication** (e.g., increasing ramipril) to allow for continued antidepressant therapy.*Stop venlafaxine immediately and switch to mirtazapine*- Immediate cessation of an antidepressant in a patient with **suicidal ideation** poses a high risk of acute clinical deterioration and potential **withdrawal symptoms**.- Medication changes should be managed cautiously and are generally reserved for when blood pressure remains **uncontrolled** despite optimization of antihypertensives.*Reduce venlafaxine dose to 37.5mg daily*- A dose reduction would likely lead to **subtherapeutic** levels, which is inappropriate for a patient experiencing **severe depression**.- Reducing the dose does not address the underlying need for blood pressure management if the patient eventually requires dose escalation for **symptom control**.*Continue current management as this blood pressure elevation is not clinically significant*- An increase from 125/78 to 148/94 mmHg is a **clinically significant** rise that increases cardiovascular risk if left unaddressed.- Guidelines mandate **monitoring blood pressure** both before and during venlafaxine treatment, especially before any planned **dose increases**.*Switch to fluoxetine which has no effect on blood pressure*- While **SSRIs** like fluoxetine generally do not affect blood pressure, switching treatments unnecessarily disrupts the therapeutic timeline for a high-risk patient.- There is no guarantee of immediate efficacy with a new agent, making **optimization of current therapy** a more stable clinical choice in the acute phase.
Question 36: A 56-year-old man presents with a 7-month history of excessive, uncontrollable worry about minor matters including finances, his children's wellbeing, and his health, despite having no objective problems in these areas. He reports restlessness, muscle tension, poor concentration, and sleep disturbance. His symptoms occur most days. He has no history of depression or substance misuse. Physical examination is unremarkable. What is the minimum symptom duration required to meet diagnostic criteria for generalised anxiety disorder?
A. 2 weeks
B. 1 month
C. 3 months
D. 6 months (Correct Answer)
E. 12 months
Explanation: ***6 months***
- According to both **ICD-10 and DSM-5** diagnostic criteria, **Generalised Anxiety Disorder (GAD)** requires excessive anxiety and worry to be present for at least **6 months**.
- This criteria helps differentiate GAD from **short-term stress reactions** or **adjustment disorders**, ensuring the condition is chronic and persistent.
*2 weeks*
- A **2-week duration** is the minimum requirement for diagnosing a **Major Depressive Episode**, but it is insufficient for a GAD diagnosis.
- Symptoms lasting only two weeks may represent an **acute stress reaction** rather than a long-standing anxiety disorder.
*1 month*
- **1 month** is the required duration for diagnosing **Panic Disorder** (following an attack) or **Post-Traumatic Stress Disorder (PTSD)**.
- For GAD, a one-month history is too brief to meet the clinical threshold for a generalized, pervasive worry pattern.
*3 months*
- **3 months** is often the timeframe used for **Adjustment Disorder**, where symptoms develop in response to a specific stressor.
- While technically a chronic state if it persists, it does not meet the standardized **6-month threshold** required for a definitive GAD diagnosis.
*12 months*
- A **12-month duration** is not required for GAD; waiting this long would delay diagnosis and necessary clinical intervention.
- This period is more commonly associated with certain pediatric diagnoses like **Conduct Disorder** or to define **remission** periods.
Question 37: A 28-year-old woman with moderate depression has been taking fluoxetine 40mg daily for 5 weeks. She reports some improvement in sleep and appetite but continues to have low mood and anhedonia. She asks when she should expect to feel better. What is the most appropriate advice regarding the expected timeframe for full therapeutic response?
A. Maximum benefit typically occurs at 2-4 weeks and she should be at full response now
B. Continue current treatment as full response may take up to 12 weeks (Correct Answer)
C. The lack of significant mood improvement at 5 weeks indicates treatment failure
D. Partial response at 5 weeks is unusual and suggests fluoxetine is not effective
E. Improvement in neurovegetative symptoms like sleep suggests full response is imminent within days
Explanation: ***Continue current treatment as full response may take up to 12 weeks***- While initial signs of efficacy can appear within 2-4 weeks, the **full therapeutic response** for an SSRI like fluoxetine often requires **6-12 weeks** of consistent use.- This patient shows a **partial response** with improved neurovegetative symptoms (sleep/appetite), which is a positive prognostic indicator for eventual **remission of mood** symptoms.*Maximum benefit typically occurs at 2-4 weeks and she should be at full response now*- The **2-4 week window** is usually the time to observe the **onset of action**, not the peak or maximum clinical benefit.- **Neurovegetative symptoms** often improve early, but core emotional symptoms like **anhedonia** take significantly longer to resolve.*The lack of significant mood improvement at 5 weeks indicates treatment failure*- **Treatment failure** is typically defined after a trial of at least **6-8 weeks** at a therapeutic dose; 5 weeks is insufficient time for a definitive assessment.- Fluoxetine has a very **long half-life**, which can sometimes lead to a slightly slower steady-state achievement and clinical response compared to other SSRIs.*Partial response at 5 weeks is unusual and suggests fluoxetine is not effective*- A **partial response** at 5 weeks is actually a common and expected clinical trajectory, suggesting the medication is biologically active.- It provides a basis to **maintain the current dose** rather than declaring it ineffective or switching medications prematurely.*Improvement in neurovegetative symptoms like sleep suggests full response is imminent within days*- Improvement in sleep and appetite indicates the medication is working, but **mood and anhedonia** do not typically follow within a matter of days.- It is essential to manage **patient expectations** to ensure they do not discontinue treatment when mood symptoms do not shift immediately after physical ones.
Question 38: A 32-year-old man with panic disorder has been taking sertraline 100mg daily for 6 weeks. His panic attacks have reduced from daily to twice weekly, but he reports troublesome side effects including delayed ejaculation and reduced libido, which are affecting his relationship. He is keen to continue treatment but wants to address the sexual dysfunction. What is the most appropriate management of his sexual side effects?
A. Add sildenafil to be taken before sexual activity
B. Reduce sertraline dose to 50mg daily
C. Switch to mirtazapine (Correct Answer)
D. Add bupropion to augment current therapy
E. Continue current dose and reassure that side effects will resolve within 2-3 weeks
Explanation: ***Switch to mirtazapine***
- **Mirtazapine** is an effective antidepressant and anxiolytic with a significantly lower propensity for **sexual side effects** compared to SSRIs like sertraline.
- Its mechanism involves **alpha-2 adrenergic antagonism** and potent **5-HT2 and 5-HT3 receptor blockade**, which avoids the common serotonergic pathways responsible for sexual dysfunction.
*Add sildenafil to be taken before sexual activity*
- **Sildenafil** primarily treats **erectile dysfunction (ED)** by improving blood flow, but it does not address **delayed ejaculation** or **reduced libido**, which are the patient's main complaints.
- This approach is incomplete and may lead to increased **pill burden** without resolving the core issues of sexual dysfunction in this context.
*Reduce sertraline dose to 50mg daily*
- While reducing the dose might lessen sexual side effects, the patient is not in full remission from **panic attacks** (still experiencing them twice weekly), so a dose reduction risks a relapse or worsening of his primary disorder.
- Maintaining an **effective therapeutic dose** for the panic disorder should take precedence unless other options are exhausted.
*Add bupropion to augment current therapy*
- **Bupropion** is an antidepressant that can sometimes alleviate SSRI-induced sexual dysfunction, particularly **reduced libido**, but it is generally **contraindicated** in patients with **panic disorder** due to its activating and **pro-adrenergic** effects, which can worsen anxiety or precipitate panic attacks.
- It is not routinely recommended for augmentation in **panic disorder** due to this risk and may not be licensed for this indication in all regions.
*Continue current dose and reassure that side effects will resolve within 2-3 weeks*
- **SSRI-induced sexual dysfunction** is often persistent and **dose-dependent**, typically not resolving spontaneously with continued treatment or over a short period like 2-3 weeks.
- Ignoring these significant and distressing side effects can lead to poor **patient adherence** and discontinuation of effective treatment for panic disorder.
Question 39: A 44-year-old woman presents with an 8-week history of low mood, anhedonia, reduced concentration, and feelings of worthlessness. Her PHQ-9 score is 16. She reports passive suicidal ideation but no plans or intent. She has tried self-help strategies without benefit. She mentions that 4 years ago she had a similar episode treated successfully with citalopram 20mg daily, which she took for 8 months before stopping. What is the most appropriate initial management?
A. Refer for computerised CBT and review in 6 weeks
B. Start citalopram 20mg daily with follow-up in 2 weeks (Correct Answer)
C. Start citalopram 10mg daily with follow-up in 2 weeks
D. Arrange urgent psychiatric assessment due to suicidal ideation
E. Offer group CBT and reassess pharmacological options if no improvement
Explanation: ***Start citalopram 20mg daily with follow-up in 2 weeks***- For a patient with **moderate depression** (PHQ-9 score 16) and a history of successful treatment, **antidepressants** are indicated, especially when self-help has failed.- Restarting the **previously effective dose** of citalopram (20mg) is appropriate, and a **two-week follow-up** is mandatory to monitor side effects and **suicidal ideation** in patients under 30 or those with risk factors.*Refer for computerised CBT and review in 6 weeks*- While **computerised CBT** is a low-intensity intervention, it is typically insufficient as a standalone treatment for **moderate depression** when the patient has already failed self-help.- A **six-week review** is too late for a patient starting a new treatment phase or presenting with **passive suicidal ideation**.*Start citalopram 10mg daily with follow-up in 2 weeks*- Although a lower dose might reduce initial side effects, there is no history of **intolerance**, and 20mg was the **proven therapeutic dose** for this specific patient.- Starting at sub-therapeutic levels may **delay clinical improvement** in a patient experiencing significant distress and functional impairment.*Arrange urgent psychiatric assessment due to suicidal ideation*- **Passive suicidal ideation** without specific plans, intent, or access to means does not meet the criteria for **urgent secondary care referral**.- Management can safely occur in **primary care** unless risk escalates or the patient becomes unresponsive to standard treatments.*Offer group CBT and reassess pharmacological options if no improvement*- NICE guidelines suggest that for **moderate depression**, medication should be offered either alone or in combination with high-intensity psychological interventions, rather than delaying it.- Given her **past positive response** to medication, delaying pharmacological treatment would likely prolong her current **depressive episode** unnecessarily.
Question 40: A 37-year-old woman presents with a 4-month history of recurrent panic attacks. She describes sudden episodes of breathlessness, palpitations, and fear of dying that peak within minutes and last approximately 20 minutes. Between attacks, she worries constantly about having another attack while driving, and has stopped using motorways. She has no past psychiatric history. Physical examination and ECG are normal. What is the most appropriate initial management approach?
A. Prescribe propranolol 40mg to be taken as required before potentially triggering situations
B. Initiate escitalopram 10mg daily and provide psychoeducation about panic disorder (Correct Answer)
C. Refer for formal psychodynamic psychotherapy
D. Prescribe alprazolam 0.5mg to be taken during panic attacks
E. Arrange 24-hour Holter monitoring before considering psychiatric treatment
Explanation: ***Initiate escitalopram 10mg daily and provide psychoeducation about panic disorder***
- First-line treatment for **panic disorder** includes either **Cognitive Behavioral Therapy (CBT)** or an **SSRI** like escitalopram, which manages both the attacks and the **anticipatory anxiety**.
- Psychoeducation is vital to help the patient understand that the physical symptoms of panic are not life-threatening, reducing the **catastrophic misinterpretation** of sensations.
*Prescribe propranolol 40mg to be taken as required before potentially triggering situations*
- While **beta-blockers** can mask peripheral autonomic symptoms like palpitations, they do not treat the underlying **anxiety or psychological components** of panic disorder.
- Propranolol is more commonly used for **performance-based social anxiety** rather than preventing spontaneous panic attacks.
*Refer for formal psychodynamic psychotherapy*
- **Psychodynamic psychotherapy** is not considered a first-line psychological intervention for panic disorder; **CBT** is the evidence-based gold standard.
- Treatment should focus on addressing the current **avoidance behaviors** (agoraphobia) and panic cycles rather than long-term personality or past-relationship exploration.
*Prescribe alprazolam 0.5mg to be taken during panic attacks*
- **Benzodiazepines** like alprazolam are not recommended first-line due to the high risk of **dependence**, tolerance, and potential for causing **rebound anxiety**.
- Using medication "as needed" during an attack can lead to **safety behaviors** that prevent the patient from learning that the panic attack will naturally subside.
*Arrange 24-hour Holter monitoring before considering psychiatric treatment*
- Further cardiac testing is unnecessary as the patient has a **normal ECG** and physical examination, and the symptoms are classic for panic attacks.
- Excessive medical investigations can be counterproductive by reinforcing the patient's **illness anxiety** and delaying necessary psychiatric treatment.
