A 32-year-old woman presents to the psychiatry clinic with a 6-month history of recurrent, unexpected panic attacks characterized by palpitations, dyspnea, chest discomfort, and fear of dying. She has developed anticipatory anxiety and avoids public places and crowded settings. Physical examination and cardiac workup (ECG, troponin, echocardiography) are normal. She denies substance use or medical comorbidities. What is the most appropriate next step in management?

Explanation

## Management of Panic Disorder with Agoraphobia ### Diagnostic Confirmation This patient meets DSM-5 criteria for panic disorder with agoraphobia: - Recurrent unexpected panic attacks - Persistent worry about future attacks - Avoidance behavior (agoraphobia) - Medical causes excluded (cardiac workup normal) **Key Point:** Once organic causes are ruled out, pharmacotherapy is the first-line intervention for panic disorder, especially when agoraphobia is present. ### First-Line Pharmacotherapy | Agent Class | Examples | Evidence | Onset | Dependence Risk | |---|---|---|---|---| | **SSRIs** | Sertraline, paroxetine, escitalopram | Gold standard; FDA-approved | 2–4 weeks | None | | **SNRIs** | Venlafaxine XR | Highly effective | 2–4 weeks | None | | Tricyclic antidepressants | Imipramine, clomipramine | Effective but older | 2–4 weeks | None | | Benzodiazepines | Alprazolam, clonazepam | Rapid onset but NOT first-line | Hours | **High** | **High-Yield:** SSRIs are the first-line pharmacological treatment for panic disorder because they: 1. Reduce panic attack frequency and severity 2. Address anticipatory anxiety and agoraphobia 3. Have no abuse potential 4. Are well-tolerated long-term ### Why Sertraline 50 mg Daily? - Typical starting dose for panic disorder - Requires 2–4 weeks to show effect; patient should be counseled about this - Dose may be titrated to 100–200 mg daily based on response **Clinical Pearl:** Patients often experience initial anxiety increase in the first 1–2 weeks; reassurance and brief psychoeducation reduce dropout rates. ### Combined Approach - **Pharmacotherapy + psychotherapy (CBT)** is superior to either alone - CBT can begin concurrently with SSRI initiation - Exposure-based techniques address agoraphobic avoidance [cite:Harrison 21e Ch 465]