Recurrent Unexpected Panic Attacks in a 34-Year-Old Warehouse Team Lead: A Psychiatric Evaluation and Differential Diagnosis
Student Name
College of Nursing, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Instructor Name
Month Day, Year
Subjective
Chief complaint: "My heart goes off like an alarm and I think I am dying." The patient is a 34-year-old man employed as a warehouse team lead who presents for an initial psychiatric evaluation after two emergency department visits in the past ten weeks for chest pain and shortness of breath, both negative for acute cardiac disease. He reports eleven discrete episodes over the past eight weeks. Each begins without warning, peaks within about five minutes, and carries pounding heartbeat, chest tightness, sweating, trembling, breathlessness, nausea, and a conviction that he is about to die or lose control. Episodes last twenty to thirty minutes and leave him exhausted for the rest of the shift. Four occurred while he was driving, three at home while resting, and two woke him from sleep.
Between episodes he describes persistent worry about the next one, which he estimates occupies most of every day, and he has changed how he works to prevent it. He has stopped driving on the interstate, takes a longer route to work, avoids the enclosed freight elevator, and has declined two shifts that would have left him alone in the yard at night. Nine weeks ago a forklift collision on his shift seriously injured a coworker whom he stayed with until paramedics arrived. He reports intrusive recollection of that morning two or three times a week and avoidance of the aisle where it happened, but denies nightmares of the event, emotional numbing, and any persistent negative view of himself or of other people.
He has no prior psychiatric treatment, no psychiatric hospitalization, and no history of mania, psychosis, or self-harm. He denies current suicidal or homicidal ideation, intent, or plan, and reports no access to firearms. Substance history includes four to six energy drinks daily since a schedule change five months ago, roughly 600 to 800 milligrams of caffeine, two to three beers on weekend evenings, no tobacco, no cannabis for three years, and no nonprescribed stimulants. Medical history includes a body mass index of 31 and seasonal allergies treated with intermittent pseudoephedrine. His mother was treated for what he describes as a nervous condition. He lives with his partner and their two children, works rotating shifts, and has missed six shifts in the past eight weeks.
Objective: Mental Status Examination, Screening Measures, and Medical Workup
The patient is a well-groomed man appearing his stated age, dressed in work clothing, cooperative, and fully oriented. Psychomotor activity is mildly increased, with frequent shifting in the chair and repeated checking of his own radial pulse during the interview. Speech is normal in rate, volume, and prosody. Mood is reported as on edge, and affect is congruent, mildly anxious, and reactive. Thought process is linear and goal directed. Thought content shows no delusions, no obsessions, and no compulsions, but does show a fixed catastrophic interpretation of benign somatic sensations, in which a rise in heart rate is read as evidence of cardiac arrest. There are no perceptual disturbances. Insight is fair, judgment is intact, and attention, memory, and fund of knowledge are grossly intact on bedside testing.
Screening measures were administered at intake with the patient's consent. The GAD-7 score was 16 of a possible 21, in the severe range for generalized anxiety symptoms (Spitzer et al., 2006). The PHQ-9 score was 9 of a possible 27, in the mild range, with the item on thoughts of being better off dead scored at zero (Kroenke et al., 2001). The PCL-5 score was 24 of a possible 80, below the provisional cutoff commonly used to prompt fuller trauma assessment, with elevations confined to the intrusion and avoidance clusters (Weathers et al., 2013). Medical workup completed before this visit was unremarkable: thyroid stimulating hormone 1.8 mIU/L, complete blood count and metabolic panel within reference limits, urine drug screen negative, and a twelve-lead electrocardiogram showing normal sinus rhythm at 88 beats per minute with two negative troponin levels.
Assessment: Differential Diagnosis and Diagnostic Reasoning
Three diagnoses account for most of this presentation, and the DSM-5-TR criteria separate them on grounds that are testable with the history above (American Psychiatric Association, 2022). Panic disorder requires recurrent unexpected panic attacks together with at least a month of persistent concern about further attacks or a significant maladaptive change in behavior meant to prevent them, and it requires that the attacks not be better explained by a substance, another medical condition, or another mental disorder. This patient meets each element in a documented way: eleven attacks in eight weeks, five of them arising from rest or from sleep and therefore unexpected, eight weeks of anticipatory worry, and route changes, elevator avoidance, and refused shifts as the behavioral change. Nocturnal attacks are the finding that carries the most diagnostic weight, because an attack beginning in sleep cannot have been produced by an external cue.
Posttraumatic stress disorder is the differential that has to be worked rather than dismissed, given a qualifying event nine weeks ago and intrusive recollection since. It is not supported here. The criteria require symptoms across four clusters, intrusion, avoidance, negative alterations in cognition and mood, and marked alterations in arousal and reactivity, and this patient's findings sit in two of the four, with a PCL-5 score below the usual screening threshold. Generalized anxiety disorder was also considered and fails on both timeline and focus, since it requires at least six months of excessive worry across several domains, while this worry is eight weeks old and is about the attacks themselves. Agoraphobia is the closest competing diagnosis and stays open, because he already avoids two of the listed situation types.
Substance and medical causes are the last gate and the one most often skipped. Caffeine intoxication and caffeine-induced anxiety disorder are live considerations at 600 to 800 milligrams a day, and intermittent pseudoephedrine can produce the same somatic pattern, so both were tested against the timeline. Neither explains attacks that began three months after the schedule change or attacks that wake him at night, and the workup argues against thyrotoxicosis, arrhythmia, and acute coronary syndrome. The working diagnosis is panic disorder, with caffeine recorded as a contributing factor rather than the cause and the trauma exposure recorded and monitored. Past-year prevalence of panic disorder among United States adults is estimated near 2.7 percent from national survey data collected in 2001-2003, and is roughly twice as high in women as in men (National Institute of Mental Health, 2023).
Plan, Safety, and Follow-Up
Treatment begins with the interpretation rather than with the sensation. Cognitive behavioral therapy for panic disorder with interoceptive exposure is the first-line psychotherapy, offered here as twelve weekly sessions with the referral placed at this visit. Pharmacologic treatment is a selective serotonin reuptake inhibitor started low and titrated over four to six weeks, with the patient told in advance that anxiety may rise during the first two weeks so that an expected effect is not read as failure. Benzodiazepines are not prescribed. Standing use would maintain the catastrophic interpretation the therapy is designed to change, and as-needed use functions as a safety behavior. Caffeine is reduced by about 100 milligrams a week rather than stopped at once, since abrupt withdrawal produces headache and irritability this patient would reasonably read as relapse.
Safety assessment is documented at every visit rather than at intake alone. He denies ideation, intent, plan, and means today, has no prior attempt, and lives with adults who can be included in a plan, and the practice guideline for the psychiatric evaluation of adults treats that assessment as a standing requirement rather than a single-occasion task (American Psychiatric Association, 2016). He agrees to contact the clinic or emergency services if that changes. Follow-up is in two weeks, with the GAD-7 and PHQ-9 repeated each visit and the PCL-5 repeated at week eight so trauma symptoms are tracked rather than assumed resolved. The finding that would change the diagnosis is named in advance: if avoidance broadens to a third and fourth situation type, agoraphobia is added as a second diagnosis.
References
American Psychiatric Association. (2016). The American Psychiatric Association practice guidelines for the psychiatric evaluation of adults (3rd ed.). American Psychiatric Association Publishing.
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
National Institute of Mental Health. (2023). Any anxiety disorder. U.S. Department of Health and Human Services. https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder
Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092-1097. https://doi.org/10.1001/archinte.166.10.1092
Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013). The PTSD checklist for DSM-5 (PCL-5) [Measurement instrument]. National Center for PTSD.
How this NRNP 6635 Week 4 example is structured
In many sections the NRNP 6635 Week 4 assignment asks for a written evaluation of a case rather than an essay about a disorder, and your classroom's instructions decide the exact form and template. This example follows the order diagnostic reasoning actually runs in Walden University's Psychopathology and Diagnostic Reasoning course, a graduate psychiatric mental health nurse practitioner course. The subjective section gathers everything before anything is interpreted, including the substance and medical history that later decides two of the differentials. The objective section separates what was observed, administered and resulted from what was reported. The assessment section then works the differential out loud, arguing against the competing diagnoses before naming the working one. The plan closes with safety, follow-up intervals, and the finding that would change the diagnosis.
NRNP 6635 Week 4 questions, answered
Do I have to use a real patient for an NRNP 6635 case write-up?
No, and using one creates a privacy problem you do not need. Sections differ on whether a supplied case, a media case, or a constructed composite is expected, and your classroom's instructions decide. The evaluation above uses a composite built so that the history, the screening scores, and the workup all point at a differential a reader can follow, which is hard to do with a half-remembered real encounter.
How much of the DSM-5-TR criteria should I quote in a psychiatric evaluation?
Very little. Summarize the criteria in your own words, cite the manual once in the reference list, and spend the space showing which of this patient's findings meet or fail each element. Long quoted criteria lists read as padding and leave no room for the reasoning that is actually being assessed. Paraphrase carries the argument; quotation only proves you found the page.
How many differential diagnoses should the assessment section carry?
Three to five worked properly beats eight listed. Include at least one that is close enough to be genuinely competing, one from a different category such as a substance or medical cause, and state what evidence would move you. A differential the writer never argues against does no work, and a list without reasoning reads as a table of contents rather than an assessment.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Walden University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.