A 32-year-old woman from Delhi presents to the psychiatry outpatient department with a 2-year history of sudden, unexpected episodes of intense fear accompanied by palpitations, sweating, trembling, and a sense of impending doom. Each episode lasts 10–20 minutes and resolves spontaneously. Between episodes, she remains well. Over the past 6 months, she has begun avoiding crowded places, public transport, and shopping malls out of fear of having another attack in a situation from which escape might be difficult. She has not had any recent medical illness, and physical examination and routine investigations are unremarkable. Which of the following is the most likely diagnosis?

Explanation

## Clinical Diagnosis: Panic Disorder with Agoraphobia ### Key Clinical Features **Key Point:** Panic disorder is characterized by recurrent, unexpected panic attacks followed by persistent worry about future attacks and behavioral changes (avoidance). This patient presents with: 1. **Recurrent unexpected panic attacks** — sudden onset of intense fear with autonomic symptoms (palpitations, sweating, trembling) lasting 10–20 minutes 2. **Anticipatory anxiety** — fear of future attacks 3. **Agoraphobic avoidance** — avoidance of crowded places, public transport, and malls (situations from which escape is difficult) ### Diagnostic Criteria (DSM-5) | Feature | Panic Disorder | With Agoraphobia | |---------|---|---| | Recurrent unexpected panic attacks | ✓ Required | ✓ Required | | Anticipatory anxiety | ✓ | ✓ | | Avoidance behavior | Variable | ✓ Prominent | | Feared situations | None specific | Crowds, transport, open spaces, enclosed spaces | **High-Yield:** The presence of agoraphobic avoidance (avoiding situations from which escape might be difficult) is the distinguishing feature that elevates this to "panic disorder *with* agoraphobia." ### Differential Pathophysiology **Clinical Pearl:** Panic attacks in panic disorder are *unexpected* (not triggered by a specific stimulus), whereas phobic attacks are *cued* (triggered by the phobic object/situation). This patient's initial attacks were unexpected; the avoidance developed *secondarily*. ### Why This Is Not Other Diagnoses - **Generalized anxiety disorder:** Characterized by persistent, diffuse worry over ≥6 months, not discrete panic attacks. - **Social anxiety disorder:** Fear is specific to social/performance situations; this patient fears having an attack in any crowded place. - **Specific phobia:** Fear is tied to a single object or situation (e.g., heights, flying); this patient has multiple feared situations. [cite:DSM-5 Diagnostic and Statistical Manual of Mental Disorders]