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. These episodes last 15–30 minutes and occur unpredictably, sometimes 3–4 times per week. She reports that over the past 6 months, she has begun avoiding public transport, crowded markets, and enclosed spaces because she fears having an attack in a situation from which escape might be difficult or embarrassing. She has not had any recent medical illness, and her physical examination and routine blood work are normal. What is the most likely diagnosis?

Explanation

## Diagnosis: Panic Disorder with Agoraphobia ### Clinical Features Present **Key Point:** Panic disorder is characterized by recurrent, unexpected panic attacks followed by persistent worry about future attacks and behavioral changes (avoidance). This patient demonstrates: 1. **Recurrent unexpected panic attacks** — sudden onset of intense fear with autonomic symptoms (palpitations, sweating, trembling) lasting 15–30 minutes 2. **Anticipatory anxiety** — fear of having another attack 3. **Agoraphobic avoidance** — avoidance of public transport, crowds, and enclosed spaces due to fear that escape would be difficult or help unavailable during a panic attack ### Diagnostic Criteria (DSM-5) | Feature | Panic Disorder | Panic Disorder with Agoraphobia | |---------|---|---| | Recurrent unexpected panic attacks | ✓ | ✓ | | Persistent worry about attacks | ✓ | ✓ | | Agoraphobic avoidance | May or may not be present | Present | | Functional impairment | Variable | Significant | **High-Yield:** The presence of **agoraphobic avoidance** (fear of situations where escape is difficult) is the key distinguishing feature that elevates this to panic disorder **with** agoraphobia, rather than panic disorder alone. ### Why This Is Not Other Diagnoses - **Generalized anxiety disorder (GAD):** Characterized by persistent, diffuse worry over multiple life domains lasting ≥6 months, NOT sudden discrete panic attacks - **Specific phobia:** Fear is triggered by a specific object or situation (e.g., heights, animals); this patient's attacks are **unexpected and unpredictable** - **Social anxiety disorder:** Fear is triggered by social situations; this patient's attacks occur in multiple contexts unpredictably **Clinical Pearl:** The **temporal sequence** is crucial: panic attacks come first (unexpected), then agoraphobic avoidance develops secondarily as a coping mechanism. This distinguishes panic disorder with agoraphobia from primary agoraphobia without panic history. [cite:DSM-5 Diagnostic and Statistical Manual of Mental Disorders, 5th Edition]