Panic Disorder Case Study: How to Approach Each Prompt
You’ve been handed a case study: a 30-year-old woman rushed to the ER with chest pain, cardiac workup comes back clean, and she leaves with a prescription for Ativan and a provisional diagnosis of Panic Disorder. Now you’re sitting in front of five prompts and not sure where to start.
This guide won’t write your assignment for you. What it will do is map out exactly what each prompt is asking, what academic frameworks apply, and how to structure your thinking so your response is clinically solid.
Patient: 30-year-old female, presented to ED with chest pain, diaphoresis, and shortness of breath.
Workup: Negative for cardiac or physiological cause.
Medication ordered: Lorazepam (Ativan) 0.5 mg PO BID PRN severe anxiety.
Referral diagnosis: Panic Disorder — follow-up with your office.
Read each prompt carefully. Prompts 1–3 are mostly knowledge-based (explain, list, identify). Prompts 4–5 ask you to apply clinical reasoning to this specific patient. Your best responses will do both: show you know the theory, then connect it directly to her presentation.
Prompt 1 — Etiology of Panic Disorder
The word “etiology” means cause or origin. Panic Disorder doesn’t have a single cause. It sits at the intersection of biology, psychology, and environment, so your response should reflect that.
The Biological Thread
Start here. Research consistently points to a neurobiological basis. Heritability studies suggest genetic factors contribute to the disorder, with estimates placing heritability at approximately 40%. There are also structural differences — neuroimaging work has shown smaller temporal lobe volumes in people with panic disorder compared to controls, and altered activity in the amygdala, which plays a central role in the fear response.
The “fear network” model is widely referenced. It proposes that the amygdala, hypothalamus, and brainstem centers form a circuit that is dysregulated in panic disorder — firing off alarm responses even when there’s no real threat. Mentioning this in your response shows you understand the neuroscience behind the symptoms.
Psychological and Cognitive Factors
Biology alone doesn’t explain why some people develop the disorder and others don’t. Cognitive models focus on catastrophic misinterpretation — the tendency to interpret normal bodily sensations (heart racing, shortness of breath) as signs of a life-threatening event. In this patient’s case, she interpreted her symptoms as a heart attack. That’s a textbook example.
Environmental and Situational Triggers
Chronic stress, prior trauma, major life changes, and substance use (especially caffeine and stimulants) can all lower the threshold for panic attacks. Some patients report a clear first panic attack tied to a specific stressful event; others can’t identify any trigger at all.
Biological
Genetic predisposition, neurobiological dysregulation, fear circuit hyperactivity
Psychological
Cognitive distortions, catastrophic thinking, anxiety sensitivity
Environmental
Chronic stress, trauma history, substance use, major life events
Prompt 2 — DSM-5 Clinical Manifestations
This prompt wants you to tie the clinical picture to formal diagnostic criteria. The DSM-5-TR is your primary reference here. Break this into two parts: what happens during a panic attack itself, and what the disorder requires beyond the attacks.
Panic Attack Symptoms (the acute episode)
A panic attack is a discrete period of intense fear that peaks within minutes. To meet the criteria, four or more of the following physical and cognitive symptoms must be present:
| Physical / Somatic | Cognitive / Emotional |
|---|---|
| Palpitations or accelerated heart rate | Fear of losing control or “going crazy” |
| Sweating | Fear of dying |
| Trembling or shaking | Derealization (feelings of unreality) |
| Shortness of breath or smothering sensation | Depersonalization (feeling detached from oneself) |
| Feelings of choking | Paresthesias (numbness or tingling) |
| Chest pain or discomfort | Chills or hot flashes |
| Nausea or abdominal distress | Dizziness, lightheadedness, or faintness |
Panic Disorder — the Full Diagnostic Picture
A single panic attack is not a disorder. The DSM-5 requires all three of the following:
- Recurrent, unexpected panic attacks (at least two)
- At least one attack followed by one month or more of: persistent worry about future attacks OR worry about the consequences of an attack OR significant maladaptive behavioral change (like avoiding exercise because it raises heart rate)
- The disturbance is not attributable to a substance, medication, or another medical condition, and is not better explained by another mental disorder
Your patient presented thinking she was having a heart attack. That’s the fear of dying criterion in action. She had palpitations, chest pain, and shortness of breath — all listed symptoms. When you write this section, reference her specific presentation and show you can match her symptoms to the criteria. That’s what moves you from a generic answer to a clinical one.
A note on agoraphobia: the DSM-5 separates Panic Disorder and Agoraphobia into distinct diagnoses. You can have one without the other. If your patient begins avoiding hospitals, ERs, or situations where she fears she can’t get help during an attack, that’s a signal that agoraphobia may be developing alongside the panic disorder.
Prompt 3 — Neurotransmitter Abnormalities
This is where pharmacology and pathophysiology intersect. Your professor wants to see that you understand why the medications work — which means understanding what’s chemically off in the first place.
Three neurotransmitters are most central to panic disorder:
GABA (Gamma-Aminobutyric Acid)
GABA is the brain’s primary inhibitory neurotransmitter. Its job is to put the brakes on neuronal activity. In panic disorder, there is reduced GABA-ergic tone — meaning the braking system is underperforming. Research using PET imaging has found reduced benzodiazepine receptor binding at GABA-A receptors in patients with panic disorder, which means the brain’s natural “calming” pathway is less effective. This is directly relevant to your case: Ativan (lorazepam) is a benzodiazepine that works precisely by enhancing GABA-A receptor activity, which is why it’s prescribed here.
Serotonin
Dysregulation of the serotonergic system is strongly implicated. Lower serotonin type 1A receptor binding has been found in the amygdala and raphe nuclei of patients with panic disorder. The amygdala is the brain’s fear-processing hub, so inadequate serotonin signaling there contributes to exaggerated fear responses. This is why SSRIs — which increase serotonin availability — are a first-line long-term treatment for panic disorder, even though they’re antidepressants.
Norepinephrine
Norepinephrine drives the fight-or-flight response. In panic disorder, the noradrenergic system is hyperactive. When norepinephrine surges, it produces exactly the symptoms your patient experienced: racing heart, sweating, shortness of breath, a sense of impending doom. The locus coeruleus in the brainstem is the main norepinephrine-producing region and is thought to be overactive in people with panic disorder.
Dopamine, cholecystokinin, and corticotropin-releasing hormone (CRH) have also been implicated. If you want to show depth in your response, a brief mention of the HPA axis — how chronic stress dysregulates cortisol, which in turn affects neurotransmitter balance — ties this back to the biological etiology from Prompt 1.
Prompt 4 — Establishing a Diagnosis
This is the most clinical prompt in the set. You’re now acting as the practitioner this patient has been referred to. What do you do at that first follow-up appointment?
The key word is “approach.” Your professor doesn’t want a rigid checklist — they want to see that you know how to build a clinical picture through history, physical exam findings, and ruling out other causes.
Why You Can’t Skip the History
Panic disorder is a diagnosis of exclusion at its foundation. Before you can confirm it, you need to make sure the symptoms aren’t caused by something else. That ER workup ruled out acute cardiac events, but your history needs to go further.
Key Areas to Cover in the History
| Area | What to Ask / Gather | Why It Matters |
|---|---|---|
| Symptom history | When did attacks start? How many have occurred? Were any “expected” (in a specific place/situation) or all unexpected? | Unexpected attacks are a hallmark of panic disorder vs other anxiety subtypes |
| Medical history | Thyroid disorders, cardiac arrhythmias, pulmonary conditions, hypoglycemia | Many conditions mimic panic attacks physiologically |
| Medication & substance use | Caffeine, stimulants, decongestants, OTC supplements, recreational drugs | These can induce panic-like symptoms and must be excluded per DSM-5 |
| Psychiatric history | Prior mental health diagnoses, treatment, hospitalizations | Panic can co-occur with or be secondary to depression, PTSD, or OCD |
| Family history | Anxiety, panic disorder, depression in first-degree relatives | Supports the biological/genetic component of etiology |
| Psychosocial history | Recent life stressors, relationship status, occupational functioning, trauma history | Identifies environmental triggers and impact on daily life |
| Behavioral changes | Is she avoiding places, activities, or situations since the ER visit? | Avoidance behaviors signal the disorder is progressing and may signal developing agoraphobia |
Mental Status Examination (MSE)
Your physical assessment should include a structured MSE. Key elements to document include general appearance and behavior, affect and mood, thought content and process, insight and judgment, and cognitive functioning. With panic disorder, patients typically present with normal or anxious affect, intact cognition, and good insight — but that last point can vary. A patient who is convinced she had a real heart attack despite the negative workup shows limited insight, which is clinically important.
Validated Screening Tools
Consider using the Panic Disorder Severity Scale (PDSS) or the GAD-7 as part of your systematic assessment. These give you a structured, reproducible baseline to track across visits. You should also consider ordering thyroid function tests if not already done — hyperthyroidism is a common organic cause of panic-like symptoms.
Don’t just list history items. Walk through why each piece of information helps you either confirm or rule out panic disorder. Show the clinical reasoning, not just the checklist. This is what separates a good answer from a great one.
Prompt 5 — Non-Pharmacological, Pharmacological, and Nursing Interventions
This is often the longest section of a psych nursing case study, and for good reason — it directly tests your ability to apply the nursing process. You need to address all three components: non-pharmacological, pharmacological, and nursing-specific interventions. Each serves a different function in this patient’s care.
Non-Pharmacological Interventions
Cognitive Behavioral Therapy (CBT) is the gold standard for panic disorder. This is the intervention with the strongest evidence base. CBT for panic disorder typically includes two core components: cognitive restructuring (helping the patient identify and challenge catastrophic thinking about physical symptoms) and interoceptive exposure (deliberately inducing mild physical sensations in a controlled setting to help the patient learn they are not dangerous). When you write this section, name the therapy and explain the mechanism — don’t just say “refer to therapy.”
Psychoeducation should happen before anything else. Your patient just had a terrifying ER visit. She needs to understand what panic disorder is, what causes the physical symptoms, and — critically — that her body is not in danger during an attack. This reduces the fear-of-fear cycle that perpetuates the disorder.
Breathing retraining and relaxation techniques. Hyperventilation is both a symptom of panic attacks and something that worsens them. Teaching diaphragmatic breathing (slow, belly-focused breathing) and progressive muscle relaxation gives the patient tools she can use immediately when an attack begins.
Lifestyle modifications deserve mention. Encourage the reduction or elimination of caffeine, which directly stimulates the sympathetic nervous system. Regular aerobic exercise has shown anxiolytic effects. A consistent sleep schedule helps regulate the autonomic nervous system. These aren’t dramatic interventions, but they lower the baseline arousal level — which means attacks may become less frequent or less intense.
Mindfulness-based interventions such as MBSR (Mindfulness-Based Stress Reduction) have an evidence base for anxiety disorders and can complement CBT particularly well for patients who are resistant to exposure-based approaches.
Pharmacological Interventions
Your answer should reflect that there is a first-line, evidence-based approach — and that the Ativan already prescribed is not it for long-term management. This nuance is what your professor is looking for.
| Medication Class | Examples | Role in This Patient | Key Nursing Considerations |
|---|---|---|---|
| SSRIs (first-line) | Sertraline (Zoloft), escitalopram, fluoxetine | Long-term management; reduce panic attack frequency and anticipatory anxiety; need 4–6 weeks for full effect | Educate patient that antidepressant ≠ depression; warn about initial mild anxiety increase in first 1–2 weeks; do not stop abruptly |
| SNRIs (first-line) | Venlafaxine (Effexor XR) | Alternative to SSRIs; similar mechanism and timeline | Monitor blood pressure; similar counseling as SSRIs |
| Benzodiazepines (short-term / PRN) | Lorazepam (Ativan) — already prescribed | Rapid symptom relief for acute severe anxiety; NOT a long-term solution | High dependence risk; educate on PRN use only; do not combine with alcohol; monitor for sedation, fall risk; do not discontinue abruptly |
| TCAs (second-line) | Imipramine, clomipramine | Effective but tolerated less well; used when SSRIs/SNRIs fail | Monitor cardiac effects; toxic in overdose — assess suicide risk before prescribing |
For your patient specifically: she has been started on lorazepam PRN. When you write the pharmacological section, acknowledge this — but your plan should include a recommendation for transitioning to an SSRI or SNRI for long-term management once she’s established in care. The Ativan provides bridge relief while a first-line medication has time to reach therapeutic effect.
Nursing Interventions
This part of the prompt is specifically asking what you as the nurse do. It’s not enough to list what the psychiatrist or prescriber does. Your interventions need to reflect the nursing role directly.
- Establish therapeutic rapport early. A patient who felt dismissed or confused by the ER experience needs to feel heard. Acknowledge the fear she experienced — don’t minimize it by emphasizing that the cardiac workup was negative without also validating how real and terrifying the attack felt.
- Provide clear psychoeducation about panic disorder: what it is, what causes the physical symptoms, how treatment works, and realistic timelines for improvement.
- Teach PRN medication use accurately: explain that Ativan should be used for severe acute anxiety only, not preventively. Discuss the risk of dependence and the importance of using it as prescribed.
- Teach and demonstrate breathing techniques at the appointment rather than just handing her a pamphlet. Have her practice diaphragmatic breathing with you before she leaves.
- Screen for safety. Panic disorder has a notable comorbidity with depression. Conduct a brief depression screen (PHQ-9) and assess for suicidal ideation at intake and each visit.
- Assess for avoidance behaviors. Ask specifically whether she has been avoiding the gym, driving, or going to places where she fears she could have another attack and not get help. Early identification of avoidance prevents the development of agoraphobia.
- Facilitate referral to CBT. Don’t just mention it — ensure the referral happens. Follow up to confirm the patient made contact with the therapist.
- Coordinate care. Communicate with the prescribing provider about the appropriateness of initiating a long-term anxiolytic medication. Document your assessment findings, education provided, and the patient’s response.
- Involve the patient in the care plan. Panic disorder treatment is highly dependent on patient engagement. Shared decision-making improves adherence. Let her choose between therapy modalities where options exist.
Your patient is 30, female, presented in a crisis, and is now sitting in your office probably confused and frightened. Every intervention you describe should address a real and specific need she has. Generic answers lose marks. The more you connect your interventions to her presentation, history, and the medication she’s already on, the stronger your response will be.
What Else Might Come Up
Depending on your program’s expectations, you may also need to address some additional related areas. Here’s a brief map of what those look like:
Ativan-Specific Nursing Education
Since lorazepam is specifically named in the case, your professor may expect detailed patient teaching around it. Cover onset of action (typically 30–60 minutes orally), common side effects (sedation, dizziness, cognitive slowing), the risk of falls, and the fact that it should not be combined with alcohol or other CNS depressants. Most importantly: this medication should not be stopped abruptly after regular use — taper is required to avoid withdrawal seizures.
Comorbidities to Consider
Panic disorder commonly co-occurs with major depressive disorder, generalized anxiety disorder, and substance use disorders. A thorough intake will screen for these. If your case or rubric asks you to address comorbidities, use these as your starting point.
Cultural and Gender Considerations
Anxiety disorders are more prevalent in women, and women are more likely to present with somatic symptoms (chest pain, nausea) as the lead complaint. Cultural factors can also affect how patients describe psychological distress — some patients will only report physical symptoms and resist a mental health framing. Your nursing approach should be culturally sensitive and avoid labeling or dismissing physical symptoms as “just anxiety.”
For an academic post on how to approach a different type of mental health nursing case study, see our guide on structuring mental health nursing assignments. If you need help understanding how to use pharmacological and non-pharmacological categories in nursing care plans more broadly, our nursing care plan walkthrough breaks down the format.