Psychiatry · Year 2 · from Psychiatry
Case 1: Panic Disorder with Agoraphobia
Patient Presentation
Demographics: 32-year-old female
Chief Complaint: "I'm having heart attacks, but the doctors say there's nothing wrong with my heart."
History of Present Illness: A 32-year-old marketing executive presents to the psychiatry clinic after being referred by cardiology following her third emergency department visit in 2 months for "chest pain and heart racing." Each episode was characterized by sudden onset of palpitations, chest tightness, shortness of breath, dizziness, sweating, and an overwhelming sense of impending doom. The first attack occurred 3 months ago while grocery shopping; she became convinced she was having a heart attack and called 911. Extensive cardiac workup including ECG, troponins, echocardiogram, and stress test were all normal. Since the first attack, she has become increasingly fearful of having another one. She now avoids grocery stores, shopping malls, and driving on highways. She will only go to restaurants if seated near the exit. She has called in sick to work multiple times to avoid the commute. She worries constantly about when the next attack will occur and what it means for her health. She denies caffeine, stimulant, or illicit drug use.
Physical Examination:
- Vital signs: BP 118/76, HR 88, RR 16
- General: Anxious-appearing female, fidgeting
- Cardiac: Regular rate and rhythm, no murmurs
- Pulmonary: Clear to auscultation
Mental Status Examination:
- Appearance: Well-groomed, age-appropriate
- Behavior: Restless, frequently checking pulse
- Mood: "Anxious, scared"
- Affect: Anxious, congruent
- Thought content: Preoccupied with health concerns, catastrophic thoughts about panic attacks
- Insight: Partial - acknowledges cardiac workup was normal but still fears heart disease
Workup:
- Panic Disorder Severity Scale: 18 (severe)
- Mobility Inventory for Agoraphobia: Significant avoidance across multiple domains
- TSH: 2.1 mIU/L (normal)
- CBC, CMP: Within normal limits
- Urine drug screen: Negative
- Review of cardiac workup confirms no pathology
Diagnosis: Panic Disorder with Agoraphobia
Treatment:
- Psychoeducation about panic attacks as false alarm response - not dangerous
- Started sertraline 25 mg daily (low initial dose due to SSRI activation risk in panic disorder), titrated to 100 mg over 4 weeks
- Lorazepam 0.5 mg prescribed for rescue use, maximum 2-3 times per week
- Referral for cognitive behavioral therapy with focus on:
- Cognitive restructuring of catastrophic misinterpretations
- Interoceptive exposure to feared physical sensations
- In vivo exposure to avoided situations using hierarchy
- Practiced interoceptive exposures in session (hyperventilation, spinning)
- Developed exposure hierarchy starting with short drives, progressing to mall visits
- At 8-week follow-up: panic attacks reduced from 4-5/week to 1-2/week
- Agoraphobic avoidance improving with systematic exposure
- Lorazepam use minimal; plan to discontinue once CBT complete
Clinical Pearl: Panic attacks reach peak intensity within minutes and include at least 4 of 13 symptoms. Panic disorder requires recurrent unexpected panic attacks plus persistent concern or behavioral change. The initial worsening of anxiety that can occur with SSRI initiation necessitates starting at low doses and slow titration in panic disorder. Interoceptive exposure - deliberately inducing feared bodily sensations - is a key component of CBT for panic disorder and directly targets the fear of panic symptoms themselves.