A 32-year-old woman from Delhi presents to the psychiatry outpatient clinic 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. She reports that these attacks occur unpredictably, sometimes even during sleep. Over the past 6 months, she has begun avoiding crowded places, public transport, and shopping malls out of fear that an attack might occur and she won't be able to escape. She has not experienced any significant medical illness or substance use. On mental status examination, she is anxious but oriented. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: Panic Disorder with Agoraphobia ### Key Diagnostic Features **Key Point:** Panic disorder is characterized by recurrent, unexpected panic attacks followed by persistent worry about future attacks and/or significant behavioral changes (avoidance). This patient meets criteria for panic disorder with agoraphobia because: 1. **Panic attacks:** Sudden onset of intense fear with autonomic symptoms (palpitations, sweating, trembling) lasting 10–20 minutes 2. **Unexpected onset:** Attacks occur unpredictably, including during sleep — this rules out situationally-bound anxiety 3. **Agoraphobic avoidance:** Avoidance of public places, transport, and crowds due to fear of panic attacks and inability to escape 4. **Duration:** 2-year history with recent behavioral changes (past 6 months) ### Differential Diagnosis Table | Feature | Panic Disorder + Agoraphobia | Generalized Anxiety Disorder | Social Phobia | Specific Phobia | | --- | --- | --- | --- | --- | | **Attack onset** | Sudden, unexpected | Gradual, persistent worry | Triggered by social situations | Triggered by specific object/situation | | **Duration of episodes** | 10–30 min (acute) | Chronic (6+ months) | Variable, situational | Brief, upon exposure | | **Avoidance pattern** | Multiple situations (agoraphobia) | Minimal avoidance | Social/interpersonal situations | Specific object/activity | | **Nocturnal attacks** | Yes, common | No | No | No | | **Autonomic symptoms** | Intense, acute | Mild, chronic | Present but situational | Present but situational | **High-Yield:** Nocturnal panic attacks (waking in fear) are pathognomonic for panic disorder and virtually never occur in GAD, social phobia, or specific phobia. ### Clinical Pearl **Clinical Pearl:** Agoraphobia in panic disorder develops *secondarily* — the patient avoids situations where escape might be difficult or help unavailable if a panic attack occurs. This is distinct from primary agoraphobia (rare) or specific phobia, where the fear is of the situation itself, not of having a panic attack within it. ### DSM-5 Criteria Snapshot - ≥4 panic attacks (unexpected) in 4 weeks, OR ≥1 attack + ≥1 month of persistent worry about future attacks - Avoidance of situations where escape is difficult or help is unavailable - Symptoms cause clinically significant distress or functional impairment - Not attributable to substance use or medical condition **Mnemonic: PANIC** — **P**anic attacks (sudden, unexpected), **A**utonomic symptoms (palpitations, sweating), **N**octurnal onset (common), **I**ntense fear (impending doom), **C**onditioned avoidance (agoraphobia develops)