Psychiatry · Year 3 · from Psychiatry

Case 2: Panic Disorder with Agoraphobia

Patient Demographics

  • Age: 27 years old
  • Sex: Male
  • Occupation: Software engineer (now working from home)

Chief Complaint

"I had another attack at the grocery store. I thought I was dying. I can't leave my apartment anymore."

History of Present Illness

The patient presents with recurrent episodes of intense fear accompanied by physical symptoms that come on suddenly and peak within minutes. His first episode occurred 6 months ago while driving on the highway. He experienced sudden onset of pounding heart, chest tightness, shortness of breath, sweating, trembling, dizziness, and a sense that he was "going to die." He pulled over and called 911. Emergency workup including ECG and troponins was normal. Since then, he has had approximately 3-4 similar episodes per week. He has become increasingly afraid of having another attack and has begun avoiding situations where attacks have occurred or where escape might be difficult. He now avoids driving (especially highways), grocery stores, movie theaters, airplanes, and crowded restaurants. For the past month, he has rarely left his apartment except for brief walks around his block. He works remotely but is worried about losing his job if required to return to the office. Between attacks, he is constantly worried about when the next one will occur.

Mental Status Examination

Appearance: Young man, casually dressed, appears tired and worried

Behavior: Cooperative, restless, hypervigilant about body sensations

Speech: Normal rate and volume

Mood: "Scared" and "trapped"

Affect: Anxious, fearful, constricted

Thought Process: Linear, goal-directed, focused on fears

Thought Content: Preoccupied with fear of panic attacks and physical sensations, catastrophic thoughts about dying, fear of losing control, no suicidal or homicidal ideation

Perceptions: No hallucinations, heightened awareness of bodily sensations (interoceptive sensitivity)

Cognition: Alert, oriented x4, attention good

Insight: Partial - intellectually knows attacks won't kill him but emotionally convinced he is dying during attacks

Judgment: Impaired by avoidance behaviors

Psychiatric Workup

Screening Tools:

  • Panic Disorder Severity Scale (PDSS): 18 (severe)
  • PHQ-9: 11 (moderate depression, secondary)
  • Mobility Inventory for Agoraphobia: Severe avoidance pattern

Laboratory Studies (prior workup):

  • ECG: Normal sinus rhythm
  • Echocardiogram: Normal
  • TSH: Normal
  • CBC, CMP: Normal
  • Holter monitor: No arrhythmias

Diagnosis

1. Panic Disorder (F41.0)

DSM-5 Criteria:

  • Recurrent unexpected panic attacks (physical symptoms + intense fear)
  • At least one attack followed by 1+ month of:
  • Persistent concern about additional attacks - present
  • Worry about implications/consequences (dying, losing control) - present
  • Significant maladaptive behavioral change related to attacks - present (avoidance)

Panic Attack Symptoms (4+ required):

  • Palpitations - present
  • Sweating - present
  • Trembling - present
  • Shortness of breath - present
  • Chest pain/discomfort - present
  • Dizziness - present
  • Fear of dying - present

(7/13 symptoms confirmed)

2. Agoraphobia (F40.00)

DSM-5 Criteria:

  • Fear/anxiety about 2+ of the following:
  • Public transportation - present (avoids driving)
  • Open spaces - present
  • Enclosed places - present (movie theaters)
  • Crowds - present
  • Being outside the home alone - present
  • Avoidance due to fear of panic-like symptoms - present
  • Situations almost always provoke fear - present
  • Disproportionate to actual danger - present
  • Duration >6 months - present
  • Causes significant distress/impairment - present

Treatment Plan

Pharmacotherapy:

  • Start paroxetine 10 mg daily (FDA-approved for panic disorder)
  • Titrate to 20-40 mg over 4 weeks
  • Note: SSRIs may initially increase anxiety; counsel patient

Bridging anxiolytic:

  • Clonazepam 0.5 mg BID for 2-4 weeks while SSRI takes effect
  • Plan to taper as SSRI becomes effective
  • Avoid long-term benzodiazepine use

Psychotherapy (Essential):

  • CBT with Interoceptive Exposure and In-Vivo Exposure
  • Interoceptive exposure: Deliberately induce feared body sensations (spinning, breathing through straw, running in place) to reduce fear of sensations
  • In-vivo exposure hierarchy:
  1. Walk around block
  2. Brief drive on local streets
  3. Grocery store during off-peak hours
  4. Crowded store
  5. Highway driving
  6. Eventually: airplane travel

Psychoeducation:

  • Explain panic as false alarm (fight-or-flight system misfiring)
  • Physical symptoms are uncomfortable but not dangerous
  • Avoidance maintains and worsens panic/agoraphobia
  • Importance of facing fears gradually

Follow-up:

  • Weekly visits initially during exposure work
  • PDSS monitoring

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