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Presenting complaint

Bill was a 28-year-old unemployed man living with his girlfriend. He presented complaining of fatigue and "light spots" in front of his eyes. He reported having seen an optometrist who could find no cause and suggested he attend his general practitioner.

Past history

Bill had attended a number of doctors, and was vague regarding details. He reported having been referred to a neurologist three years ago to investigate numbness in his feet, but no cause was found. He also reported attending casualty once for a suspected heart attack, but tests were clear.

Further questioning

Bill reported his fatigue had fluctuated over two years, and his "light spots" were also variable, describing them as "spots in my sight where it seems brighter".

Further questioning revealed Bill was worried he might have multiple sclerosis, which he had read about, but also feared he was "going crazy", like an uncle who had been admitted to a "mental institution" many years ago.

Bill also reported episodes of palpitations of sudden onset, with sweating, racing pulse, nausea and a feeling that he was going to collapse. These lasted between 10 minutes and two hours. He experienced about two attacks every three weeks, for over six months. Bill had been reluctant to mention them, fearing it was further evidence he was going crazy.

Mental state examination

Bill presented as neat and tidy. He was keen to give as many details as possible. His speech was slightly fast and his affect anxious. He did not appear depressed. Thought content revealed a mild preoccupation with the belief he had a serious medical condition or was going crazy. There were no psychotic features and cognitive function was intact.

Physical examination and investigations

Physical examination was unremarkable. Investigations (full blood examination, electrolytes, urea and creatinine, liver function tests, thyroid function tests, a random blood sugar test, B₁₂ and folate levels and a urine drug screen) gave normal results. A discharge summary from his casualty attendance revealed a work-up for acute myocardial infarction had been unremarkable.

Diagnostic assessment

Bill was diagnosed as suffering panic disorder, without agoraphobia, any associated depression or underlying medical conditions. He was given information about the condition, including a suitable self-help book on anxiety reduction, and treated with a combination of pharmacotherapy (a selective serotonin reuptake inhibitor) and supportive psychotherapy with cognitive-behavioural techniques to deal with panic attacks.

Bill's condition improved dramatically over the next six weeks and maintained a slower improvement over six months, with only one episode of relapse associated with a temporary break up in a relationship.

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