Common Mental Disorders — MCQs
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A 27-year-old woman with panic disorder has been experiencing nocturnal panic attacks approximately twice weekly for the past 2 months, waking her from sleep. She also has daytime panic attacks. She is not currently on any medication. What is the most important differential diagnosis to exclude before attributing these episodes solely to panic disorder?
Which of the following best describes the neurobiological basis for the delayed therapeutic response to SSRIs in depression compared to their immediate effect on synaptic serotonin levels?
A 62-year-old man with newly diagnosed depression and mild cognitive impairment (MMSE 25/30) is being considered for antidepressant treatment. He lives alone and occasionally forgets to take his regular medications for hypertension. Which of the following factors should most influence the choice of antidepressant?
A 44-year-old woman with panic disorder describes that her attacks always occur in crowded places such as shopping centres and public transport. She has started avoiding these situations. She is keen to address this issue. Her panic attacks are well-controlled on sertraline 100mg daily. What is the most appropriate additional intervention?
A 35-year-old woman with moderate depression has been taking citalopram 20mg daily for 5 weeks. She reports some improvement in sleep and appetite but continues to experience low mood and anhedonia. She asks when she should expect to feel better. What is the most appropriate response regarding expected timeframe for therapeutic response?
A 51-year-old man presents with a 3-month history of excessive worry about multiple areas of his life including work, finances, and family health. He reports constant muscle tension, difficulty concentrating, irritability, and poor sleep. He struggles to control the worry. GAD-7 score is 17. He has no previous psychiatric history. What feature would most strongly indicate a need for urgent specialist referral rather than primary care management?
A 33-year-old woman with panic disorder has been taking paroxetine 40mg daily for 6 months with good control of symptoms. She has just discovered she is 8 weeks pregnant. She is concerned about medication risks and asks about continuing treatment. What is the most appropriate management?
What is the primary mechanism by which cognitive behavioural therapy achieves its therapeutic effect in panic disorder?
A 47-year-old man with severe depression has not responded to adequate trials of sertraline, venlafaxine, and mirtazapine over the past 9 months. He has prominent psychomotor retardation, early morning wakening, and has lost 8kg in weight. He expresses passive suicidal ideation but has no active plans. What is the most appropriate next step in management?
A 28-year-old woman presents to the emergency department with sudden onset severe chest pain, breathlessness, trembling, and a feeling of impending doom that started 10 minutes ago. She has had three similar episodes in the past 2 months. Physical examination is unremarkable. ECG shows sinus tachycardia at 118 bpm. Troponin is negative. She is terrified she is having a heart attack. What is the most important immediate management step?
Common Mental Disorders UK Medical PG Practice Questions and MCQs
Question 71: A 27-year-old woman with panic disorder has been experiencing nocturnal panic attacks approximately twice weekly for the past 2 months, waking her from sleep. She also has daytime panic attacks. She is not currently on any medication. What is the most important differential diagnosis to exclude before attributing these episodes solely to panic disorder?
- A. Obstructive sleep apnoea (Correct Answer)
- B. Nocturnal epilepsy
- C. Nightmares associated with post-traumatic stress disorder
- D. Gastro-oesophageal reflux disease
- E. Night terrors (sleep terrors)
Explanation: ***Obstructive sleep apnoea*** - **Obstructive sleep apnoea (OSA)** can cause sudden awakenings with intense fear, **breathlessness**, and **choking sensations** that perfectly mimic nocturnal panic attacks. - It is a critical medical diagnosis to exclude because it requires specific treatment like **CPAP** to prevent long-term **cardiovascular complications**. *Nocturnal epilepsy* - These episodes usually present with **stereotyped motor movements**, tongue biting, or urinary incontinence, rather than isolated autonomic arousal. - Patients with **nocturnal epilepsy** typically experience **post-ictal confusion** or drowsiness, which is not characteristic of waking from a panic attack with clear recall. *Nightmares associated with post-traumatic stress disorder* - **PTSD nightmares** involve the recall of specific **vivid traumatic content**, whereas nocturnal panic attacks typically lack a specific dream narrative or identifiable trigger within the dream. - Diagnosis requires a history of a **traumatic event** and other cardinal symptoms like **hyperarousal** and avoidance during the day. *Gastro-oesophageal reflux disease* - While **GERD** can cause nocturnal awakening with coughing, a choking sensation, or chest pain, it is usually accompanied by **heartburn**, regurgitation, or a sour taste in the mouth. - It rarely presents with the full constellation of **autonomic symptoms** (palpitations, sweating, tremors, dread) that characterize a panic attack. *Night terrors (sleep terrors)* - **Sleep terrors** typically occur during **slow-wave sleep** (NREM N3), and the individual usually has **no memory** of the event upon waking, often appearing disoriented and unresponsive. - In contrast, a patient experiencing a **nocturnal panic attack** transitions into full wakefulness and maintains clear memory of the distressing symptoms and the intense fear experienced.
Question 72: Which of the following best describes the neurobiological basis for the delayed therapeutic response to SSRIs in depression compared to their immediate effect on synaptic serotonin levels?
- A. Time required for sufficient drug accumulation to reach therapeutic plasma levels
- B. Gradual desensitization of presynaptic serotonin autoreceptors increasing serotonin transmission (Correct Answer)
- C. Progressive increase in serotonin synthesis by tryptophan hydroxylase
- D. Slow penetration of SSRIs across the blood-brain barrier
- E. Time needed for metabolism of SSRIs to their active metabolites
Explanation: ***Gradual desensitization of presynaptic serotonin autoreceptors increasing serotonin transmission***- Initial use of SSRIs causes an increase in serotonin that activates **5-HT1A autoreceptors**, which provide **negative feedback** to inhibit further serotonin release.- Over 2-6 weeks, these autoreceptors **downregulate and desensitize**, allowing for sustained increases in synaptic serotonin and downstream **neuroplastic changes** like increased **BDNF** expression.*Time required for sufficient drug accumulation to reach therapeutic plasma levels*- **Steady-state plasma levels** of SSRIs are typically achieved within a few days, yet the clinical response still lags for several weeks.- Clinical delay is related to **cellular adaptations** in the brain rather than simple **pharmacokinetic accumulation** in the blood.*Progressive increase in serotonin synthesis by tryptophan hydroxylase*- SSRIs primarily act by inhibiting the **serotonin transporter (SERT)**, not by increasing the rate of **serotonin synthesis**.- While synthesis levels may fluctuate, it is the **reuptake inhibition** and subsequent receptor adaptation that drive the therapeutic outcome.*Slow penetration of SSRIs across the blood-brain barrier*- SSRIs are **lipophilic molecules** that readily cross the **blood-brain barrier** shortly after administration.- High concentrations are found in the **central nervous system** long before the patient experiences symptomatic relief from depression.*Time needed for metabolism of SSRIs to their active metabolites*- Most SSRIs are administered as **active compounds** and do not require conversion to an active form to exert their primary biochemical effect.- Even for SSRIs with **active metabolites** (like fluoxetine), the delay in clinical improvement is much longer than the hours or days required for metabolite formation.
Question 73: A 62-year-old man with newly diagnosed depression and mild cognitive impairment (MMSE 25/30) is being considered for antidepressant treatment. He lives alone and occasionally forgets to take his regular medications for hypertension. Which of the following factors should most influence the choice of antidepressant?
- A. The speed of onset of therapeutic effect
- B. The medication's anticholinergic profile (Correct Answer)
- C. The once-daily dosing schedule
- D. The cost of the medication
- E. The sedative properties of the medication
Explanation: ***The medication's anticholinergic profile***- In elderly patients with **mild cognitive impairment** (MMSE 25/30), medications with **anticholinergic activity** can significantly worsen memory, increase confusion, and elevate the risk of **delirium or falls**.- Antidepressants like **tricyclic antidepressants (TCAs)** (e.g., amitriptyline) or paroxetine should be avoided as they antagonize **acetylcholine**, which is crucial for cognitive function.*The speed of onset of therapeutic effect*- Most standard antidepressants take approximately **2 to 4 weeks** to show clinical benefit, and this timeline is relatively consistent across different classes like **SSRIs** or **SNRIs**.- While important for patient distress, speed of onset is not the primary clinical concern compared to the potential for causing further **cognitive decline** in a vulnerable patient.*The once-daily dosing schedule*- While simple dosing (once-daily) supports **medication adherence** in a patient who is forgetful, many modern antidepressants already utilize once-daily regimens.- Adherence can be managed with tools like **pill organizers** or caregiver assistance, but the **pharmacodynamic effects** of a drug on the patient's cognition are a more critical concern.*The cost of the medication*- Financial considerations are important for long-term compliance and access, but **patient safety** and the prevention of further **cognitive impairment** take clinical precedence.- Generic versions of safe options like **sertraline** or **escitalopram** are widely available and cost-effective for most patients.*The sedative properties of the medication*- While **sedation** might be useful for patients with comorbid insomnia, it can also increase the risk of **gait instability** and evening confusion (sundowning) in the elderly.- Preventing **anticholinergic-induced cognitive worsening** remains the most critical priority for a patient already showing a declining **MMSE score**, as sedation is a separate, though also important, concern.
Question 74: A 44-year-old woman with panic disorder describes that her attacks always occur in crowded places such as shopping centres and public transport. She has started avoiding these situations. She is keen to address this issue. Her panic attacks are well-controlled on sertraline 100mg daily. What is the most appropriate additional intervention?
- A. Increase sertraline to 150mg to prevent attacks in feared situations
- B. Prescribe propranolol 40mg to take before entering feared situations
- C. Offer graded exposure therapy targeting the avoided situations (Correct Answer)
- D. Add pregabalin 75mg twice daily for anticipatory anxiety
- E. Prescribe alprazolam 0.5mg as required for use in feared situations
Explanation: ***Offer graded exposure therapy targeting the avoided situations*** - The patient's symptoms describe **agoraphobia**, characterized by marked anxiety about, or avoidance of, situations where escape might be difficult or help unavailable during a panic attack, despite controlled panic attacks. - **Graded exposure therapy** is the most effective behavioral intervention for agoraphobia, facilitating **habituation** and **extinction learning** by gradually confronting feared situations. *Increase sertraline to 150mg to prevent attacks in feared situations* - The patient's **panic attacks are already well-controlled** on the current sertraline dose, indicating that increasing medication is unlikely to address the primary issue of **agoraphobic avoidance**. - While SSRIs treat panic disorder, **behavioral interventions** are crucial for overcoming learned avoidance patterns associated with agoraphobia. *Prescribe propranolol 40mg to take before entering feared situations* - **Propranolol** is a beta-blocker that can reduce the **physical symptoms of anxiety** (e.g., palpitations, tremor) but does not address the underlying cognitive fear or **avoidance behaviors** of agoraphobia. - Using it as a **safety behavior** before exposure can inadvertently prevent the patient from learning that anxiety naturally subsides, hindering the effectiveness of exposure therapy. *Add pregabalin 75mg twice daily for anticipatory anxiety* - **Pregabalin** is an anxiolytic, but it is typically a second- or third-line agent and not the most appropriate primary intervention for **agoraphobic avoidance** when panic attacks are controlled. - It does not directly facilitate the **exposure and extinction learning** necessary to overcome specific phobic situations and can add unnecessary polypharmacy. *Prescribe alprazolam 0.5mg as required for use in feared situations* - **Benzodiazepines** like alprazolam carry significant risks of **dependence** and **withdrawal**, and their use can reinforce avoidance behaviors by acting as a **safety pill**. - Their use can interfere with the long-term effectiveness of **exposure-based therapy** by preventing the patient from fully engaging with and habituating to anxious feelings.
Question 75: A 35-year-old woman with moderate depression has been taking citalopram 20mg daily for 5 weeks. She reports some improvement in sleep and appetite but continues to experience low mood and anhedonia. She asks when she should expect to feel better. What is the most appropriate response regarding expected timeframe for therapeutic response?
- A. Maximum therapeutic benefit usually occurs within 2 weeks of starting treatment
- B. Continue current dose for at least another 1-2 weeks as full response may take 6-8 weeks (Correct Answer)
- C. Lack of response by 5 weeks indicates treatment failure and medication should be changed
- D. Improvement in physical symptoms suggests likely response but mood symptoms may take 12 weeks
- E. Increase dose to 40mg now as 20mg is likely insufficient
Explanation: ***Continue current dose for at least another 1-2 weeks as full response may take 6-8 weeks*** - Antidepressants like **SSRIs** (Citalopram) typically require an adequate trial of **4 to 8 weeks** at a therapeutic dose to evaluate full efficacy.- Improvement in **biological symptoms** (sleep and appetite) at 5 weeks is a positive prognostic sign that mood and **anhedonia** may soon follow.*Maximum therapeutic benefit usually occurs within 2 weeks of starting treatment*- While side effects appear quickly, the **therapeutic lag** means clinical mood improvement rarely peaks within the first 2 weeks.- Only **neurovegetative symptoms** might show early shifts, but core psychological symptoms take significantly longer due to needed **downregulation of receptors**.*Lack of response by 5 weeks indicates treatment failure and medication should be changed*- A change in medication is considered **premature** before reaching the 6-to-8-week mark, especially if the patient is showing partial improvement.- Clinical guidelines recommend a minimum of **6 weeks** at a therapeutic dose before declaring a **non-response** and switching classes.*Improvement in physical symptoms suggests likely response but mood symptoms may take 12 weeks*- Although recovery is gradual, characterizing the standard window for initial therapeutic assessment as **12 weeks** is longer than the standard 6–8 week guideline for initial response.- Waiting 12 weeks without a dose adjustment or review would delay the optimization of treatment for a patient with **persistent depression**.*Increase dose to 40mg now as 20mg is likely insufficient*- **Citalopram 20mg** is a standard therapeutic dose; increasing it before the 8-week assessment increases the risk of **dose-dependent side effects** (e.g., QTc prolongation).- Dose escalation is generally reserved for when there is **no response** or only a partial response after the full 6-to-8-week trial period has elapsed.
Question 76: A 51-year-old man presents with a 3-month history of excessive worry about multiple areas of his life including work, finances, and family health. He reports constant muscle tension, difficulty concentrating, irritability, and poor sleep. He struggles to control the worry. GAD-7 score is 17. He has no previous psychiatric history. What feature would most strongly indicate a need for urgent specialist referral rather than primary care management?
- A. Severity of anxiety symptoms with GAD-7 score of 17
- B. Duration of symptoms exceeding 6 months
- C. Presence of active suicidal planning with intent (Correct Answer)
- D. Comorbid symptoms of depression
- E. Failure to respond to an initial trial of SSRI treatment
Explanation: ***Presence of active suicidal planning with intent*** - The presence of **active suicidal planning** with intent is a **psychiatric emergency** that overrides routine primary care management, necessitating an **urgent specialist referral** for safety and risk assessment. - While passive ideation might be managed in primary care, **clear intent and planning** indicate a high risk of self-harm requiring immediate secondary care intervention. *Severity of anxiety symptoms with GAD-7 score of 17* - A **GAD-7 score of 17** indicates severe anxiety, but this level of severity can often be initiated and managed within a **primary care setting** using standard protocols like CBT or SSRIs. - High symptom severity alone is not an automatic trigger for **urgent** referral unless it is associated with significant diagnostic uncertainty or immediate risk. *Duration of symptoms exceeding 6 months* - A duration of **6 months** or more is a standard diagnostic criterion for **Generalized Anxiety Disorder (GAD)** under DSM-5 and ICD-11 guidelines. - This timeframe establishes the **chronicity** of the condition but does not inherently signify a need for **urgent specialist escalation**; rather, it confirms the diagnosis often managed in primary care. *Comorbid symptoms of depression* - It is clinically common for GAD to coexist with **depressive symptoms**, and these cases are typically managed in primary care by addressing both conditions simultaneously. - Unless the **comorbid depression** presents with severe functional impairment, psychotic features, or active suicidal ideation with intent, it does not mandate an immediate specialist referral. *Failure to respond to an initial trial of SSRI treatment* - Failure of a **first-line treatment** (like an SSRI) is a common clinical scenario that usually prompts a switch to a different medication or **psychological therapy** within primary care. - Specialist referral for **treatment resistance** usually occurs after the failure of multiple sequential interventions, rather than as an urgent requirement after a single trial.
Question 77: A 33-year-old woman with panic disorder has been taking paroxetine 40mg daily for 6 months with good control of symptoms. She has just discovered she is 8 weeks pregnant. She is concerned about medication risks and asks about continuing treatment. What is the most appropriate management?
- A. Stop paroxetine immediately and start CBT
- B. Switch to sertraline as it has better safety data in pregnancy
- C. Continue paroxetine and arrange detailed fetal cardiac scanning (Correct Answer)
- D. Reduce paroxetine dose to 20mg daily to minimize fetal exposure
- E. Stop all medication and monitor symptoms closely
Explanation: ***Continue paroxetine and arrange detailed fetal cardiac scanning*** - While paroxetine has a known association with an increased risk of **congenital cardiac malformations**, particularly if exposed during the first trimester, at 8 weeks gestation, the critical period of **organogenesis** is largely complete. - The risk of **maternal relapse** or **discontinuation syndrome** from abruptly stopping an effective antidepressant can be more harmful than continued exposure, necessitating a **detailed fetal cardiac scan** to monitor for potential structural abnormalities. *Stop paroxetine immediately and start CBT* - Immediate cessation of paroxetine can precipitate severe **discontinuation syndrome** and a high risk of **panic disorder relapse**, which can negatively impact both maternal and fetal well-being. - Stopping at 8 weeks does not reverse the **teratogenic risk** already incurred during the critical period of organogenesis, while creating new risks for the mother. *Switch to sertraline as it has better safety data in pregnancy* - Switching medications at this stage exposes the fetus to a **second drug** while the mother risks experiencing **withdrawal symptoms** from paroxetine, without mitigating the cardiac risk already established. - While **sertraline** is often preferred for new prescriptions in pregnancy, discontinuing an effective treatment and initiating another in a stable patient is generally not recommended unless the current treatment is failing. *Reduce paroxetine dose to 20mg daily to minimize fetal exposure* - Reducing the dose may render the treatment **subtherapeutic**, leading to a **relapse of panic symptoms** for the mother without necessarily eliminating the risk of malformation. - Physiological changes in pregnancy often require **maintaining or even increasing** SSRI doses due to altered pharmacokinetics, so dose reduction offers no proven safety benefit regarding malformation risk at this stage. *Stop all medication and monitor symptoms closely* - Discontinuing effective treatment for **panic disorder** carries a very high risk of **relapse**, which can lead to significant maternal distress, functional impairment, and adverse **neonatal outcomes**. - Monitoring without active treatment is generally insufficient for a patient with a severe enough panic disorder to require 40mg daily of paroxetine for control.
Question 78: What is the primary mechanism by which cognitive behavioural therapy achieves its therapeutic effect in panic disorder?
- A. Gradual exposure to feared situations leading to habituation and reduced avoidance
- B. Identifying and modifying catastrophic misinterpretations of bodily sensations (Correct Answer)
- C. Restructuring early maladaptive schemas from childhood experiences
- D. Teaching relaxation techniques to reduce physiological arousal during attacks
- E. Enhancing insight into unconscious conflicts underlying anxiety symptoms
Explanation: ***Identifying and modifying catastrophic misinterpretations of bodily sensations***- The **cognitive model of panic disorder** posits that panic attacks are primarily driven by **catastrophic misinterpretations** of benign bodily sensations (e.g., chest pain as a heart attack, dizziness as fainting).- CBT specifically targets these **cognitive distortions** by teaching patients to identify, challenge, and modify their fearful thoughts, leading to a more realistic appraisal of internal cues.*Gradual exposure to feared situations leading to habituation and reduced avoidance*- While **exposure therapy** (including interoceptive and in vivo exposure) is an important component of CBT for panic disorder, it primarily addresses **conditioned fear responses** and **avoidance behaviors**, not the core cognitive misinterpretations.- This technique focuses on **habituation** to feared external or internal stimuli, whereas the primary mechanism involves restructuring thought patterns about bodily sensations.*Restructuring early maladaptive schemas from childhood experiences*- This approach is characteristic of **Schema-Focused Therapy**, which aims to identify and modify deeply ingrained, pervasive negative patterns (schemas) originating in childhood.- Standard CBT for panic disorder is more **present-focused**, concentrating on current cognitive distortions and behavioral patterns rather than extensively exploring early developmental experiences.*Teaching relaxation techniques to reduce physiological arousal during attacks*- **Relaxation techniques** (e.g., diaphragmatic breathing, progressive muscle relaxation) are often used as adjunctive tools to manage anxiety and physiological arousal.- However, over-reliance on relaxation can sometimes become a **safety behavior**, inadvertently reinforcing the belief that bodily sensations are dangerous and need to be controlled, rather than challenging the cognitive misinterpretation itself.*Enhancing insight into unconscious conflicts underlying anxiety symptoms*- This is the primary goal of **psychodynamic psychotherapy**, which seeks to uncover hidden emotional conflicts, past traumas, and defense mechanisms that contribute to anxiety symptoms.- CBT is a **structured, short-term, and present-oriented** therapy that focuses on conscious thought patterns and observable behaviors, distinctly different from the principles of psychodynamic approaches.
Question 79: A 47-year-old man with severe depression has not responded to adequate trials of sertraline, venlafaxine, and mirtazapine over the past 9 months. He has prominent psychomotor retardation, early morning wakening, and has lost 8kg in weight. He expresses passive suicidal ideation but has no active plans. What is the most appropriate next step in management?
- A. Add lithium augmentation to current antidepressant
- B. Refer for consideration of electroconvulsive therapy
- C. Switch to a monoamine oxidase inhibitor
- D. Commence combination therapy with venlafaxine and mirtazapine
- E. Refer to secondary care for consideration of alternative treatments (Correct Answer)
Explanation: ***Refer to secondary care for consideration of alternative treatments*** - This patient meets the criteria for **treatment-resistant depression**, having failed three adequate antidepressant trials (SSRI, SNRI, and NaSSA) and presenting with **severe symptoms** like psychomotor retardation, significant weight loss, and early morning wakening. - **NICE guidelines** recommend referral to **secondary care mental health services** when primary care management has been unsuccessful, especially with biological features and **passive suicidal ideation**, to explore more advanced treatment options. *Add lithium augmentation to current antidepressant* - **Lithium augmentation** is a recognized strategy for treatment-resistant depression but is typically initiated and closely monitored by **specialist mental health services** due to its narrow therapeutic index. - It requires rigorous monitoring of **serum levels**, renal function, and thyroid function, which makes it unsuitable for initiation as a first next step in primary care for this complex case. *Refer for consideration of electroconvulsive therapy* - **Electroconvulsive therapy (ECT)** is highly effective for severe depression with **psychotic features** or **severe psychomotor retardation**, and is a specialist-level intervention. - While ECT might be considered, the immediate appropriate step is a **referral to specialists** who can perform a comprehensive assessment, including evaluating the suitability for ECT. *Switch to a monoamine oxidase inhibitor* - **MAOIs** are older antidepressants, usually considered second-line or third-line options due to significant **dietary restrictions** (tyramine-rich foods) and potential for severe drug interactions. - These medications require **specialist supervision** and are rarely initiated in primary care due to the risk of **hypertensive crisis** and complex management. *Commence combination therapy with venlafaxine and mirtazapine* - This combination, sometimes referred to as "**California Rocket Fuel**," targets multiple neurotransmitters and can be effective for severe depression but carries an increased risk of **serotonin syndrome** and other side effects. - Such complex augmentation strategies typically necessitate **secondary care assessment** and careful monitoring to evaluate patient suitability, manage potential side effects, and optimize the treatment response.
Question 80: A 28-year-old woman presents to the emergency department with sudden onset severe chest pain, breathlessness, trembling, and a feeling of impending doom that started 10 minutes ago. She has had three similar episodes in the past 2 months. Physical examination is unremarkable. ECG shows sinus tachycardia at 118 bpm. Troponin is negative. She is terrified she is having a heart attack. What is the most important immediate management step?
- A. Administer oral diazepam 5mg for acute symptom relief
- B. Arrange urgent cardiology assessment and echocardiogram
- C. Provide reassurance and education about panic attacks (Correct Answer)
- D. Start propranolol 40mg three times daily for symptom control
- E. Commence escitalopram 10mg once daily
Explanation: ***Provide reassurance and education about panic attacks*** - The patient's presentation with sudden onset **severe chest pain**, **breathlessness**, **trembling**, and a **feeling of impending doom**, along with recurrent episodes and negative cardiac workup (unremarkable physical exam, **negative troponin**, sinus tachycardia), is classic for a **panic attack**. - The most important immediate step is **reassurance** and **education** to help the patient understand that her symptoms are anxiety-related and not life-threatening, thereby breaking the cycle of **catastrophic misinterpretation** of bodily sensations. *Administer oral diazepam 5mg for acute symptom relief* - While **benzodiazepines** can provide rapid symptom relief, they are generally reserved for severe cases or as a bridge to other treatments due to risks of **sedation**, **dependence**, and potential for masking symptoms. - Prioritizing non-pharmacological interventions like reassurance and psychoeducation in the acute setting empowers the patient and encourages coping skills without immediate medication reliance. *Arrange urgent cardiology assessment and echocardiogram* - Given the **negative troponin** and **sinus tachycardia** on ECG, and the absence of other concerning physical findings, an acute cardiac event has been effectively ruled out. - Further urgent cardiac investigations would likely reinforce the patient's **health anxiety** and delay appropriate management for the underlying panic disorder. *Start propranolol 40mg three times daily for symptom control* - **Beta-blockers** like propranolol can help mitigate some peripheral physical symptoms of anxiety such as **palpitations** and **tremor**, but they do not address the core psychological and cognitive components of a panic attack or disorder. - They are not considered a **first-line acute treatment** for panic attacks and are less effective than psychological interventions or SSRIs for overall panic disorder management. *Commence escitalopram 10mg once daily* - **SSRIs** like escitalopram are the **first-line pharmacological treatment** for long-term management of **panic disorder**, but they typically take several weeks to achieve therapeutic effects. - Initiating an SSRI is a long-term strategy, not the most important immediate step in the emergency department for an acute panic attack, where immediate symptom de-escalation and psychoeducation are paramount.
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