Case study for shortness of breath, chest discomfort

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Puan Z.S. was referred from the Medical Clinic to the psychiatry clinic on 17/06/2010 and presented with the complaint of having on and off shortness of breath associated with chest discomfort for 10 years duration which had worsened in the last 6 months.


Puan Z.S. was apparently well until about 10 years ago. According to her, over the last 10 years she had been experiencing on and off episodes of shortness of breath associated with chest discomfort. These were usually followed by palpitations and tremors of both her hands. She also described herself of being in very intense fear of fainting or dying. However, she had never experienced any associated fainting episodes. She described the onset of these symptoms as sudden and would gradually increase in intensity. Each of the episodes lasted for around 10-15 minutes and it was usually not associated with any precipitating factor or situation. The symptoms would eventually subside spontaneously.

According to Puan Z.S., the episodes were infrequent initially whereby she would only experience the episodes around 2-3 times in a year. However over the last 10 years the episodes had been occurring more frequently. Her condition had generally worsened in the last 6 months as she claimed her episodes had increased in frequency to 2-3 times every month. At times she would have several episodes just within 2 days. In between her episodes, Puan Z.S. would not have these symptoms but she would be very worried of experiencing another similar episode and had the fear of fainting or dying because of her symptoms. She attributed the increase in frequency of attacks this year to be due to the increase in workload at her work place and the associated stress she faces looking after her 4 year old daughter whom she described to be overactive and uncontrollable.

Puan Z.S. has also had some problems being in crowded places. According to her she would actually feel very anxious, dizzy and fearful when she was in crowded places such as shopping malls and night markets. She would try her level best to avoid these places, for instance she would insist on her husband doing marketing on her behalf. If she had to face the situation she would make sure she was accompanied by another person who is usually her husband or friends. This had actually disrupted some of her routine chores.

Puan Z.S. was still able to work but when she experienced the episodic symptoms at work, she had to be on sick leave and had to abandon her work for the day to ease her fear of fainting or dying at her work place. This had affected her work performance. She also claimed that she had been facing some work related stress as her work load had increased especially this year and there were frequent datelines to meet.

Besides these symptoms, Puan Z.S. also had problems sleeping which was occurring on and off. At times she would find it difficult to initiate sleep, however this was not something persistent. She denied having depressive symptoms, suicidal thoughts, manic symptoms or psychotic symptoms.

She initially sought advice at the medical clinic in May 2008. According to patient she was found to have isolated extra heart beat on one occasion and was investigated thoroughly to exclude any underlying heart disease. However, all her investigations, including further Electrocardiography, Holter Electrocardiography and Echocardiography revealed no abnormalities. During her follow up under Obstetrics and Gynaecology clinic for secondary infertility, she was also found to have low thyroid hormone level on one occasion and was referred to medical clinic for further investigations to exclude any underlying thyroid disease. Repeated investigations and clinical findings did not reveal any underlying thyroid disease. Patient was followed up at the medical clinic for 2 years and was given reassurance as all her investigations were normal. She was then finally referred to the psychiatry team for further assessment on 17/06/2010 as her symptoms were worsening and she had not actually shown any improvement in the past.


There is no previous psychiatry history as this was her first contact with the psychiatric team.


Puan Z.S. had a history of having childhood asthma. However she has been symptom free since the age of 7 years old and is currently not on any medication.

She had a history of having endocervical polyp in 2008 and it was surgically removed. She was also previously investigated for secondary infertility under Obstetrics and Gynaecology clinic follow up before she conceived her second child.



(c) (d) (e) (f) (g)

Her father passed away in 1988 at the age of 67 years old. He was suffering from Pulmonary Tuberculosis and also had underlying Asthma.

Her mother is currently 69 years old and is a housewife. She has Diabetes Mellitus and Hypertension.

Her 1st sibling is her eldest brother. He is 50 years old and works as a clerk. He is married with two children.

Her second sibling is her brother who is currently 49 years old and works as a teacher. He is married with 3 children.

Her 3rd sibling is her brother who is 45 years old and is currently working in a factory. He is married with two children.

Puan Z.S. is the patient who is the 4th of five siblings.

She has a younger brother who is 38 years old and is working as a clerk. He is married with 3 children.

There is no family history of any underlying mental illnesses. She has a good relationship with her family members and she is the closest to her younger brother.


Early Childhood History

Puan Z.S. was born via normal spontaneous vaginal delivery. Her mother had an uneventful prenatal and postnatal period with no complications during delivery. Her developmental milestones were normal compared to the other siblings but she could not give further details about it. Her childhood was uneventful. She was generally a healthy child and grew up without any serious illnesses.


She completed her primary and secondary education and described herself of being an average student. In school she was active in sports especially badminton and netball. She did not pursue her tertiary education as her family faced financial difficulties after the death of her father.

Work record

After completing her secondary education she was working in a factory for around 1 year. She stopped working for more than a year as she had to look after her father who was terminally ill. She is currently working as an accounts clerk in Majlis Perbandaran Petaling Jaya for the past 20 years. She is roughly earning about RM2000 per month.

Menstrual history

She attained menarche at the age of 12 years old and has been having regular menses with no other complains of dysmenorrhoea



41 Ex-husband Patient Current Husband



Son Daughter

Puan Z.S. got married to her ex-husband back in 1990. Her ex-husband is currently 41 years old and he was working as a contractor at that time. She left to the United States of America for about a year as her ex-husband had to work there. However they had marital problems because she claimed that they came from very different social classes and they were not compatible. She also revealed that she had problems with her inlaws as she came from a family which was not very well to do and had always been ridiculed for not being rich. According to her they led different lifestyles and she faced difficulties in coping with her ex-husband's expansive lifestyle. These problems led to frequent arguments and ended up in a divorce in 1997. She has a 19 year old son from her first marriage. Her son is currently in college and lives with her mother. According to her, she actually started experiencing the episodic symptoms after the divorce as she claimed that she was very worried about raising her son alone and of her financial status at that time. However she claimed that her mother had helped her in raising her son and was glad that her mother had always been supportive.

She met her second husband in 2000 and they got married in 2002. She claimed that she was very worried about getting married again as she did not want her second marriage to result in a failure as well. Her current husband is a 46 year old man who is also an accounts clerk in Majlis Perbandaran Petaling Jaya. She is happy with her current marriage. She has a 4 year old daughter from her second marriage and the child is looked after by a baby sitter during the day. She claimed that her 4 year old daughter has been overactive, uncontrollable and at times quite impulsive especially in the last 6 months. She faced some difficulties in managing her daughter and expressed stress related to this matter.

Socio-cultural background

She is currently staying in Section 8, Petaling Jaya with her husband and daughter in a rented terrace house.

Substance Use

She does not smoke or consume alcohol. There is no history of illicit substance use.


She has a good relationship with her family members and friends. She described herself as a friendly person. However, after her divorce she had become quieter and preferred to keep things to herself especially her private matters. She enjoys spending her time with her husband and daughter. She is a Muslim and is religiously inclined. She likes to read books during her free time.


General Appearance and Bahaviour

Puan Z.S. was a medium built Malay woman compatible with her age

She was conscious and alert

She was dressed appropriately and neat looking

She was calm and cooperative

Good rapport was established

Good eye contact was maintained

She was forth coming

Speech and Thought

She spoke in Malay

Her speech was coherent and relevant

Normal amount, tone and rate of speech

No looseness of association or flight of ideas

No abnormal thoughts

No suicidal thoughts


She described her mood as 'risau'

Her affect was appropriate to her thoughts and mood with a full range


No perceptual disturbances



She was orientated to time, place and person


Her immediate, recent and remote memories were intact

5 minute recall test was performed and she was able to recall all 5 items given to her

Information and Vocabulary

Her intelligence and general knowledge were appropriate to her background educational level


She was able to give the correct meaning for two Malay proverbs

She was able to give the similarities of objects which were tested on her

Attention and Concentration

Her attention and concentration was good

She was able to complete the serial 7 test with no mistakes and was able to complete it within 2 minutes

She was able to spell the word 'DUNIA' backwards


Her judgement was good


Her insight was good

She realises that her experiences were abnormal

She realises that her experiences were perceived as abnormal by others

She accepts the fact that she has a psychological problem

She realises that she needs to be treated


Puan Z.S. was conscious and alert. She was orientated to time, place and person. She was calm and cooperative.

Blood pressure : 120/80 mmHg

Pulse rate : 90 beats per minute with good volume and regular rhythm

Temperature : Afebrile

General : Good hydration and fair nutrition. No pallor, jaundice or

tremor. No palpable goitre.

Cardiovascular : Heart sound was of dual rhythm with no murmurs.

Respiratory : Trachea was central with equal air entry in both lungs and no

added sounds.

Abdomen : Soft, non-tender, no organomegaly. Bowel sounds present.

Central Nervous

System : pupils were equal and reactive to light. No neck stiffness or

gross cranial nerve abnormalities detected. Tone was normal

and power was 5/5 in all limbs. Reflexes were present and

equal bilaterally with down going plantar reflexes.


Full blood count

Hb 11.7 g/dL

Red cell count 4.7 x 10^12 /L

Haematocrit 38 %

MCV 80 fl

MCH 24 pg

MCHC 30 g/dL

RDW 13.8 %

Platelet count 253 x 10^3 /uL

WBC 4.5 x 10^3 /uL

Renal function test

Sodium 142 mmol/L

Potassium 4.6 mmol/L

Chloride 102 mmol/L

Urea 3.0 mmol/L

Creatinine 59 umol/L

Liver function test

Total protein 76 g/L

Albumin 44 g/L

Total bilirubin 5.5 umol/L



Alkaline phosphatase 65 IU/L

Gamma GT 15 IU/L

Random blood sugar

Glucose 4.9 mmol/L

Thyroid function test

TSH 2.94 mIU/L


No abnormalities detected

Holter Electrocardiography

No abnormalities detected


Normal left ventricular wall thickness

No regional wall motion abnormalities

Normal cardiac chambers sizes

Normal valves morphology

Normal left ventricular systolic function

Left ventricular ejection fraction: 65%


Presenting problems

Puan Z.S is a 42 year old Malay lady with no known underlying medical or psychiatric illness, was referred from the medical clinic for psychiatric assessment as she presented with on and off shortness of breath associated with chest discomfort for 10 years. She was investigated thoroughly and found not to have any underlying medical causes for her symptoms. She has been having panic attacks which is characterised by episodic shortness of breath, chest discomfort, palpitation, tremors of both her hands and fear of dying or fainting for the past 10 years which has gradually worsened over the years especially in the last 6 months. She would also experience anxiousness in crowded situations and would avoid these circumstances.

These symptoms have disrupted her routine chores and affected her work performance.

Predisposing factors

Female gender

Precipitating factors

Previous history of divorce

Her doubts of a successful second marriage

Work related stress

Difficulties in coping with managing an overactive daughter

Perpetuating factors

Untreated condition for 10 years

Continuous work related stress

Has not sought medical advice regarding her daughter's condition which is left untreated and this will cause ongoing difficulties in coping with her daughter

Protective prognostic factor

Female gender

Good insight

Good compliances to medication

Good family support

Good premorbid functioning

No co-morbid physical illness

Poor prognostic factors

Long duration of untreated illness

Ongoing stressors related to work and daughter


According to DSM IV TR ( Diagnostic and Statistical Manual of Mental Disorders IV Text Revision), the multiaxial diagnosis would be as follows:

Axis I 300.21 Panic Disorder with Agoraphobia

Axis II Deferred

Axis III Nil

Axis IV Psychosocial problems related to work stress and

difficulties in coping with her daughter's behaviour

Axis IV GAF 61-70 Some difficulty in social or occupational functioning

(17/06/10) but generally functioning pretty well, has some

meaningful interpersonal relationships

Points for diagnosis

Prominent panic attacks whereby she describes having episodes of shortness of breath, chest discomfort, palpitation, tremors of both her hands and intense fear of fainting or dying which lasted for 10-15 minutes.

Episodes were not associated with any precipitating factor or situation.

In between episodes there is a persistent concern of experiencing another attack and worry about the implications of the attack.

The presence of anxiety symptoms when being in crowded places and the situations are preferably avoided.

Symptoms have led to deterioration in work performance and had affected her attendance at work.

Other underlying medical causes which can give rise to a similar presentation of symptoms have been thoroughly investigated and ruled out.


Social phobia

Social phobia is usually characterised by clinically significant anxiety provoked by exposure to certain types of social or performance situations, which often leads to avoidant behaviour. The focus of anxiety is fear of scrutiny, humiliation and embarrassment by other people. This patient experienced panic attacks which were not associated with any particular factor or situation. However, she did experience anxiety symptoms in crowded places and later developed avoidant behaviour. Her main worry was of having another panic attack in future and the consequences of it rather than of scrutiny or humiliation by other people.

Generalized anxiety disorder

This patient had anxiety symptoms and was worried with associated sleep problems at times. However these symptoms were not persistent but rather episodic. Her worries were more related to experiencing a future panic attack and not on a number of events or for no apparent reason. The symptoms of panic attack were more prominent in this patient when she presented to the psychiatric clinic for further assessment.



The goals of treatment were:

Full remission of patient's symptoms

Rehabilitation to return to her full function

Prevention of relapse

Choice of treatment setting

Treatment for most of patients who present with panic disorder would be done on an outpatient basis and they rarely require to be hospitalized. Patients who may require inpatient treatment are probably individuals with co-morbid depression who may have a risk for suicide. Besides that, patients who are presenting with underlying substance dependence may need hospitalization as this pool of patients may require detoxification. Puan Z.S. presented to the walk in psychiatric clinic and her overall condition was generally quite stable with no associated suicidal behaviour or a history of substance dependence. Therefore she was treated on an outpatient basis as she did not require hospitalization.

Pharmacological treatment

Patient was started on a selective serotonin reuptake inhibitor, Tab Escitalopram 10 mg OM

She was also started on anxiolytics, Tab Lorazepam 1 mg ON/PRN, which was advised to be taken at night and on a necessary basis

An Anxiolytic was prescribed to provide a symptomatic relief for her symptoms in an acute panic attack. Besides that, it was also used to prevent the potential side effect of escitalopram, especially agitation and worsening of symptoms initially.

Psychological treatment

Patient was taught relaxation techniques.

She was also given demonstrations on how to control her breathing through breathing techniques.

Patient was given psychoeducation regarding the disorder and the associated symptoms which she can anticipate.

She was also explained about the medication and its associated side effects, especially agitation and worsening of symptoms initially.

Patient was given psychoeducation regarding the importance of compliance to medication and to subsequent follow up sessions with the treating psychiatrist.

Patient also tried her own 'exposure therapy' for her agoraphobia. She confronted the situation accompanied by her spouse.

Social treatment

Several sessions were done with her spouse to explain about the nature of the illness and the need for good support.

This would actually increase patient's motivation and self confidence.

They were both also given an option to seek professional advice regarding their daughter's 'overactive' behaviour.

Subsequent follow up sessions


She was seen again after two weeks and her symptoms were reviewed.

Patient was able to tolerate the medication well.

She was compliant to medication and her symptoms had improved slightly.

Her frequency of panic attacks reduced to three episodes in the last two weeks from the previous visit.

However she still had ongoing stressors which were work related and she displayed symptoms of agoraphobia.

She did not require anymore anxiolytics and this medication was discontinued.


Patient was still having panic attacks but overall the frequency and intensity of the attacks were reduced.

She was compliant to medication and her awareness about the disorder had increased.


She was still compliant to medication.

Her symptoms were improving and she felt more confident.

Her work load related to her profession had reduced as new staffs were enrolled to share the work load.

She and her husband had consulted a doctor regarding their daughter's behavioural problem and the issue was being addressed.

She was able to go to the night market and 'bazaar Ramadhan' with her husband and claimed that her anxiety symptoms were controllable.

This motivated her and reinforced adherence to medication.


Overall patient had improved.

Her medication was continued as she did not require an increase in dose.

She responded well with Tab Escitalopram 10 mg OM and that was continued.

Reassurance was given and patient was advised to continue all the behaviour therapy given to her.


Patient was very well and appeared confident.

She did not experience any panic attacks in the last six weeks from the previous visit.

She was able to function well at her work place, was able to look after her daughter and attended to her household chores.

She was also able to go to crowded places initially with her husband and subsequently she had tried doing it herself.


Panic disorder has been shown to be a potentially disabling disorder, unless this condition is controlled as well as successfully treated. This condition has been stated to be frequently mistaken for other life threatening events. This is because of the symptoms which are associated with panic disorder. It has been implied that effective treatment of this condition has been shown to actually reduce the cost pertaining to medical care by about 94 %. (1)

According to a study done, death rates in patients with panic disorder, were found to have actually exceeded the rates in the general population. In this mentioned study, 20% of the total deaths in 113 psychiatric in-patients with panic disorder which were followed 35 years later were found to be suicides. However it was not clear whether panic disorder was implicated to be the main cause of suicide. This is because these patients had also co-morbid anxiety disorder. Besides that, this study also detected that men presented with panic disorder had twice the risk of developing cardiovascular mortality when compared with men who are in the general population. (1)

Puan Z.S. presented with panic attacks which had been present for almost 10 years and was worsening in its severity. She was initially investigated in the medical clinic and was found to have isolated extra heart beats. However further cardiac investigations revealed no abnormalities and she was still followed up under the care of a physician in the medical clinic.

The lifetime prevalence associated with Panic Disorder (PD) is of 1% to 3%, and it usually presents with a history of sudden attacks of intense fear which is accompanied by somatic, in particular cardiac symptoms comprising palpitations, chest pain, as well as tachycardia. 89% of patients with PD have been found to complain of palpitations, in which up to 25% of patients were initially referred to cardiac clinics for atypical chest pain or even palpitations which were later being diagnosed with PD. (2)

Inversely, palpitations caused by paroxysmal supraventricular tachycardia (PSVT) has also been found to be associated with anxiety symptoms in approximately 20% of patients and these patients may be misdiagnosed as PD. (3-5)

Radiofrequency ablation is shown to offer curative therapy for the patients with PSVT and can significantly reduce anxiety symptoms. Folowing a successful catheter ablation, a small group of patients were still found to be suffering from panic symptoms, and this pointed to a possible actual comorbidity in at about 4% of cases. (6)

This clearly shows that proper and extensive medical investigations are necessary to rule out a possible underlying cardiac problem when patients present with symptoms of a panic attack. Although Puan Z.S was investigated thouroughly in the medical clinic and a possible cardiac abnormality was ruled out, there was a significant delay in referring her to the psychiatric unit for assessment. The delay in diagnosis of Panic Disorder caused her to suffer from worsening symptoms and this affected her functioning significantly.

Sub-clinical and full-blown types of panic disorder are now implicated to have an association with substantial costs which has been found to relate directly to excessive health care expenses, patients' out-of-pocket costs as well as production losses. Based on conservative estimates, a case of a full-blown PD may generate a cost of about € 10,000 per patient per year. On the other hand even a sub-clinical case generates € 6,000, which actually surpasses the costs of a depressive disorder. (7-10) This clearly shows that offering preventive interventions for patients with PD are very likely to be cost-effective. (11,12)

A substantial number of patients among the population actually suffer from subthreshold PD. (13-15) Subthreshold PD can be simply defined as the presence of several symptoms of PD, which does not meet the DSM-IV diagnostic criteria. In a study which was reported by Norton, Dorward and Cox (16), it was found that 35.9% of 256 normal subjects actually reported experiencing one or more episode of panic attack in the last year, with 22.7% only experiencing either one or more panic attacks within the last three weeks. These subjects who had reported panic attacks may actually be at risk of developing a full-blown PD. (17,18)

Based on the history taken from Puan Z.S., she actually reported having panic attacks which started more than 10 years ago. According to her, the initial attacks were only occurring in a frequency of 2-3 times in a year. This may have been an indication of subthreshold PD which put her at risk of developing a full blown Panic Disorder. Unfortunately she was treated for her condition years after the onset of her symptoms and she only received repeated reassurance for her condition over several years. This worsened her condition and her prognosis was also poorer.

Although there are many effective treatments for PD (19), all these patients do not necessarily always receive what is called empirically supported treatments. It is said that even if the stated treatments were offered, the actual proportion of burden which is averted would still unfortunately be low. (20) In addition to this, it usually takes several years before treatment is sought, and when especially not properly treated the associated prognosis is poor and it is found that the disorder may take a chronic course. (21) Therefore prevention and initiating early intervention in PD are of great importance and interest. Panic prevention and early intervention programmes which are aimed at patients with subthreshold or even mild PD may substantially reduce current panic disorder symptomatology.

Based on a study by Swinson, Soulios, Cox, and Kuch, 33 adults who had presented to the emergency department complaining of panic attacks were randomly assigned to different groups receiving reassurance (n = 16) or exposure instruction (n = 17). Subjects who had actually received the exposure instruction significantly improved over a period of six-months for symptoms of depression, avoidance, as well as panic frequency. On the other hand, subjects receiving reassurance only did not improve for any of the stated variables. (22)

This clearly shows that, Puan Z.S would have benefitted substantially if she received proper intervention even when she had subthreshold PD rather than just repeated reassurance.

There are two main categories of treatment that have been shown to be effective in the treatment of panic disorder. The first category is pharmacotherapy including benzodiazepines and antidepressants, and the other category is psychotherapy which includes behaviour therapy and cognitive behaviour therapy. Recent guidelines have said that selective serotonin reuptake inhibitors (SSRIs) can be used as the first-line pharmacological treatment and states that its efficacy was actually comparable to psychotherapy alone. (23) However, one of the most recently published systematic review has indicated that the combination of antidepressant and psychotherapy, was found to be superior to either monotherapy in the short term, or to antidepressant alone. However it was shown to be as good as psychotherapy alone when given in the long term management. (24)

Various interacting neuroanatomical regions have been shown to be involved in the pathogenesis of Panic Disorder. Dysfunction of the serotonin (5-HT) system appears to show a crucial role in the development and worsening of panic attacks. (25) Research involving the mechanisms which underlie fear and avoidance has shown that the serotonergic and noradrenergic systems are involved in specific locations. (26) Serotonin has an inhibitory effect especially within three brain systems: firstly the noradrenergic activity invloving locus ceruleus, secondly the defense and escape behaviors which are mediated by periaqueductal gray region, and thirdly the production of corticotrophin releasing factor (CRF) by hypothalamus. SSRIs has been shown to be able to produce an anti-panic activity through the stated mechanisms over a period of time by reducing the "downstream manifestations of panic". (27)

Puan Z.S. was given escitalopram and lorazepam was also prescribed to provide a symptomatic relief for her symptoms in an acute panic attack. Besides that, it was also used to prevent the potential side effect of escitalopram, especially agitation and worsening of symptoms initially. She responded well to these medications and the lorazepam which was initiated was actually stopped early in the course of her treatment as she was showing significant improvement with pharmacotherapy.

Escitalopram increases intrasynaptic levels of serotonin. This is by blocking the reuptake of the neurotransmitter into the neuron. Among the SSRIs currently in the market escitalopram has been indicated to have the highest affinity for serotonin transporter (SERT). The enantiomer of escitalopram (R-citalopram) is responsible in counteracting the serotonin-enhancing action of escitalopram. Due to this, escitalopram is a more potent and efficacious antidepressant than citalopram, which is a combination of escitalopram and R-citalopram. In order to reason out this phenomenon, researchers from the involved pharmaceutical companies proposed that escitalopram has the ability in enhancing its own binding through an extra interaction with another allosteric site involving the transporter. (28)

Benzodiazepines have been found to be the most commonly prescribed pharmacological treatment for patients presenting with panic disorder (29). There are some documented advantages to the treatment with benzodiazepines. This medication leads to effects on panic attacks at an earlier stage (30) with milder adverse effects when compared to antidepressants (31).

Benzodiazepines have been implied to enhance the effect of neurotransmitter gamma-aminobutyric acid (GABA), which eventually results in several actions. Sedative, hypnotic (sleep-inducing), anxiolytic (anti-anxiety), anticonvulsant, muscle relaxant and amnesic action are among the results seen with benzodiazepines. (32) All these properties make the benzodiazepines useful in the management of anxiety, insomnia, agitation, as well as seizures, muscle spasms, and alcohol withdrawal. (33)

As a result of benzodiazepines effectiveness, tolerability and the rapid onset of anxiolytic action, this medication is frequently used in the treatment of anxiety which is associated with panic disorder. The American Psychiatric Association (APA) guidelines has stated that, in general, benzodiazepines are very well tolerated, and the use of this medication for the initial treatment for panic disorder has been shown to be strongly supported by many controlled trials. (34)

Therapeutic approaches to treatment especially in terms of psychotherapy have also been proven to be effective in PD. Cognitive Behaviour Therapy (CBT) are the most studied therapy of these therapeutic approaches. It is said to be useful especially for the pool of patients who do not consent or wish to take medication and it is said that therapeutic response is as significant as with pharmacotherapy as well as potentially longer lasting. (35) CBT comprises several important areas namely psychoeducation, cognitive restructuring, as well as exposure to stimuli which is associated with triggering panic attacks (e.g. ,feared situations or physical sensations) to help in the reduction of symptoms associated with PD. CBT requires a significant commitment of energy and time by the patient. Another important aspect is the fact that it avoids medication side effects as well as drug interactions. (36,37,38)

One of the important recommendations in further improving the treatment of Puan Z.S. is the concomitant use of CBT which could be offered to her in addition to pharmacotherapy. As it has been noted, patient's compliance to treatment and follow up has been promising and this would further enhance her improvement of symptoms.

Another important aspect to study in this patient is the circumstances which led to the development her symptoms. Patient experienced the symptoms following her divorce with her ex-husband. According to her she actually felt very worried with the fact that she had to raise her son all by herself and was worried about her capability in terms of finances. However she claimed that with the support of her mother she managed to carry out her responsibilities as a mother and gave the best for her son.

Psychological factors, stressful life events, as well as environment are believed to play a role in the onset of panic disorder. It has been found that people who face a situation of coping with excessive responsibilities at a certain period of time may develop a tendency to experience panic attacks. Significant personal loss, including an emotional attachment to a romantic partner, life transitions, and significant life change can act as triggers to the onset of panic attacks. (39)

In conclusion, the management of a patient with Panic Disorder should start at a very early stage of subthreshold PD. Physicians and psychiatrist should consider this diagnosis after ruling out other medical problems and proceed to do the necessary intervention without causing a delay in the management of a patient with Panic Disorder. This would overall lead to a better prognosis, it would be cost-effective and patients would be satisfied.