Case of the month answers – what was causing this patient’s panic episodes?

In the latest in our series, Dr Peter Bagshaw described an unusual case of a female patient who initially presented with panic episodes. Answer revealed below!

Note details of this case have been changed to protect individuals’ identities

A 52-year-old year old female patient presented with a recent history of panic episodes. In particular, these came over her when driving, and she would have to pull over to recover. There was a history of mild OCD but no other significant medical history.

On direct questioning she admitted insomnia but no other symptoms, although, oddly, she volunteered that she had developed a craving for pears; the GP found she was going through a very difficult time with a divorce and moving house. On examination he noted mild tachycardia but nil else.

The patient was prescribed citalopram and referred for CBT; she returned six weeks later saying she felt a little worse, and was now struggling to work. The tachycardia was more troublesome, so she was signed off work and an ECG was arranged. This confirmed sinus tachycardia, for which she was prescribed low-dose bisoprolol.

A month later, she returned feeling much worse.

What would you do next, and what might it show?

Answer

A blood test was arranged which showed normal thyroid function but a haemoglobin of 5.3.

The anaemia was found to be caused by menorrhagia, in turn caused by fibroids.

Admission and transfusion resolved all her symptoms, including her pear craving, and subsequent surgery for her fibroids prevented recurrence.

In this case, the tachycardia was due to the anaemia but misattributed to anxiety (likely because of the reported life stressors and insomnia). Similarly, the panic episodes while driving, assumed to be related to anxiety, were likely down to the cognitive effects of anaemia meaning the patient was unable to process information properly.

Patients will often not report menorrhagia or other symptoms, particularly if the change occurs over a long period of time. Mental health presentations of physical illness are not uncommon, and doctors may go straight down the mental health route without considering physical causes, particularly if other factors seem to point in that direction.

Several guides such as this one give differential diagnoses and recommend a minimum of screening for anaemia and hyperthyroidism in even low-risk patients before settling on a diagnosis of anxiety.

Dr Peter Bagshaw is a GP and mental health lead at Somerset ICB

For more diagnostic puzzles, see previous articles in our Case of the month series: