A 48-year-old woman with panic attacks

A 48-year-old woman presented to our psychiatric emergency room with panic attacks. Her last attack, with anxiety and restlessness, had occurred 2 h before presentation. On arrival she denied somatic symptoms and asked for alternative treatment options to the anxiolytic drug opipramol, which had been prescribed by her general practitioner. A psychiatrist had confi rmed the diagnosis of panic attacks and recommended an increase in dosage 1 week before presentation.Her panic attacks began 5 weeks previously, after surgery for right ankle fracture. Her right ankle was immobilised in a boot cast, and she was having 40 mg subcutaneous enoxaparin daily as thromboprophylaxis. The panic attacks occurred about twice per week at night, characterised by waking from sleep with intense restlessness, generalised anxiety, perception of threat, dizziness, and sweating. She also reported irritable mood, spontaneous weeping, inability to focus, and a mild but permanent restlessness. Psychological stress factors were recent self-employment and her mother’s terminal illness. Her psychiatric history consisted of one episode of post-partum depression 12 years earlier, with no history of panic attacks or anxiety disorders.None of the panic attacks was accompanied by dyspnoea, chest pain, cough, or haemoptysis. Noting the time association between the onset of attacks and the patient’s ankle fracture, the psychiatrist on call took a detailed history, and noticed that the last attack was preceded by shortness of breath and pallor on standing, with intense restlessness and anxiety. Considering pulmonary embolus as a likely cause of these symptoms, he transferred the patient to the emergency department.On admission she had no dyspnoea or chest pain. Blood pressure was normal, but the initial electrocardiogram (ECG) showed sinus tachycardia (105 bpm), and a prolonged QT interval. D-dimer was raised (4·5 μg/mL FEU) and troponin I was positive. Contrast-enhanced CT scan showed extensive bilateral pulmonary emboli (fi gure), with right ventricular dilatation and interventricular septal bowing, confi rming the diagnosis of pulmonary embolism.