A 32-year-old woman from Delhi presents to the emergency department with a 6-month history of recurrent, unexpected episodes of intense fear lasting 15–20 minutes. During these episodes, she experiences palpitations, diaphoresis, trembling, chest discomfort, and a fear of dying or losing control. Between episodes, she worries constantly about having another attack and has begun avoiding crowded places, public transport, and shopping malls. She denies any recent stressors, substance use, or medical illness. Vital signs are normal; physical examination and ECG are unremarkable. What is the most likely diagnosis?

Explanation

## Diagnosis: Panic Disorder with Agoraphobia **Key Point:** Panic Disorder is characterized by recurrent, unexpected panic attacks followed by persistent worry about future attacks and behavioral changes (avoidance). When avoidance of situations feared to trigger panic becomes prominent, the diagnosis becomes Panic Disorder with Agoraphobia. ### Clinical Features Present in This Case | Feature | Criterion | Present? | |---------|-----------|----------| | Recurrent unexpected panic attacks | ≥2 attacks | Yes (6 months) | | Panic symptoms (≥4 of 13) | Palpitations, diaphoresis, trembling, chest discomfort, fear of dying/losing control | Yes (5 symptoms) | | Duration of panic attack | 15–20 minutes | Yes | | Anticipatory anxiety | Constant worry about future attacks | Yes | | Agoraphobic avoidance | Avoids crowds, public transport, malls | Yes | | Medical causes ruled out | Normal ECG, vitals, exam | Yes | **High-Yield:** The **two-part diagnostic requirement** for Panic Disorder with Agoraphobia: 1. Recurrent unexpected panic attacks (the core feature) 2. Agoraphobic avoidance (fear and avoidance of places/situations from which escape is difficult or embarrassing) ### Why Agoraphobia Develops Agoraphobia is not a primary fear of open spaces but rather a **fear of having a panic attack in situations from which escape would be difficult or help unavailable**. This patient's avoidance of crowds, public transport, and malls reflects this mechanism. **Clinical Pearl:** Panic attacks in Panic Disorder are **spontaneous and unexpected**, unlike phobias where anxiety is triggered by a specific feared object/situation. The absence of a clear trigger in this case supports Panic Disorder over a phobic disorder. **Mnemonic: PANIC** — Persistent worry, Attacks unexpected, Negative medical workup, Intense symptoms (≥4), Catastrophic thoughts (fear of dying/losing control). ### Differential Considerations - **Generalized Anxiety Disorder:** Presents with chronic, diffuse worry and muscle tension, NOT episodic panic attacks with sudden onset. - **Social Phobia:** Fear is triggered by social/performance situations; panic is expected and situation-specific, not spontaneous. - **Acute Stress Disorder:** Requires a clear stressor and symptoms within 3 days to 1 month of trauma; this patient denies recent stressors and has a 6-month history. [cite:DSM-5 Diagnostic Criteria for Panic Disorder and Agoraphobia]