Recurrent unexpected panic attacks plus >=1 month of worry about future attacks or maladaptive behavior change.
Also known as: panic attacks, panic disorder, agoraphobia
Overview
Recurrent, unexpected panic attacks — abrupt surges of intense fear or discomfort peaking within minutes — followed by >=1 month of persistent concern about additional attacks, worry about their consequences, or significant maladaptive behavior change.
Epidemiology
Lifetime prevalence ~3-5%. Female-to-male ratio ~2:1. Bimodal onset: late adolescence/early adulthood and mid-30s. ~30-50% develop agoraphobia.
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Question 1PsychiatryMedium
A 28-year-old man has recurrent, unexpected episodes of sudden palpitations, sweating, trembling, shortness of breath, and fear of dying that peak within minutes. For the past 7 months he has worried persistently about having further episodes and now avoids buses, stores, and other crowded public places because escape might be difficult. Which of the following is the most likely diagnosis?
AIllness anxiety disorder
BSocial anxiety disorder
CGeneralized anxiety disorder
DPanic disorder and agoraphobia
ESpecific phobia, situational type
Reveal answer & full explanation
Correct answer: D — Panic disorder and agoraphobia
AIllness anxiety disorder
BSocial anxiety disorder
CGeneralized anxiety disorder
DPanic disorder and agoraphobia✓
ESpecific phobia, situational type
Why Panic disorder and agoraphobia is correct
Recurrent, unexpected attacks of palpitations, sweating, trembling, dyspnea, and fear of dying peaking within minutes are panic attacks; with ≥1 month of persistent concern about further attacks, this defines panic disorder
Avoidance of buses, stores, and crowds because escape might be difficult is agoraphobic avoidance, present here for 7 months (DSM-5-TR agoraphobia typically persists 6 months or more); DSM-5-TR codes panic disorder and agoraphobia as two separate, comorbid diagnoses
Treatment is a selective serotonin reuptake inhibitor (SSRI) — paroxetine, sertraline, and fluoxetine are FDA approved for panic disorder — combined with cognitive behavioral therapy (CBT) using interoceptive (body sensation) and situational (phobic avoidance) exposure
Benzodiazepines are short-term only; they risk dependence and interfere with CBT fear extinction
Why the others are wrong
Specific phobia, situational type — fear is cued by one specific situation (e.g., flying, enclosed spaces) and attacks are expected on exposure; here the initial attacks were unexpected and avoidance spans many settings (confused-with-agoraphobia trap)
Social anxiety disorder — fear centers on social scrutiny or embarrassment; this patient avoids places because escape might be difficult, not because of being judged (buzzword-matching 'avoids public places')
Generalized anxiety disorder — excessive worry across multiple life domains for ≥6 months without discrete unexpected attacks; choosing it anchors on 'worried persistently' while ignoring the episodic attack pattern
Illness anxiety disorder — his fear of dying and persistent worry can look like health anxiety, but illness anxiety disorder is a preoccupation lasting 6 months or more with having or acquiring a serious illness, with absent or only mild somatic symptoms; this patient has discrete, unexpected panic attacks with marked physical symptoms peaking within minutes and avoids places where escape would be difficult (confused-with-health-anxiety trap)
Question 2PsychiatryMedium
A 45-year-old male has had panic attacks for 2 years — sudden episodes of intense fear, palpitations, shortness of breath, dizziness, chest tightness, and fear of dying lasting 10-15 minutes. He now avoids driving, crowded places, and situations where he cannot escape, significantly limiting his work and social life. Which of the following is the most likely diagnosis?
AGeneralized anxiety disorder
BPanic disorder without agoraphobia
CSpecific phobia, situational type
DPanic disorder and agoraphobia
ESocial anxiety disorder (social phobia)
Reveal answer & full explanation
Correct answer: D — Panic disorder and agoraphobia
AGeneralized anxiety disorder
BPanic disorder without agoraphobia
CSpecific phobia, situational type
DPanic disorder and agoraphobia✓
ESocial anxiety disorder (social phobia)
Why Panic disorder and agoraphobia is correct
Panic disorder = recurrent unexpected panic attacks PLUS at least 1 month of persistent concern about future attacks OR maladaptive avoidance behavior — both are present here
Agoraphobia = marked fear or avoidance of two or more situations where escape might be difficult or help unavailable (crowds, driving, bridges, enclosed spaces, public transportation) — matches this patient's avoidance of driving and crowded places
DSM-5 codes panic disorder and agoraphobia as two separate, independently co-codable diagnoses rather than a single combined entity, so both are named when they coexist
The 2-year course with functional impairment of work and social life confirms clinically significant, persistent disease
Why the others are wrong
Social anxiety disorder (social phobia) — fear and avoidance are confined to social or performance situations involving scrutiny by others, not to any setting where escape is difficult (right-concept-wrong-trigger)
Generalized anxiety disorder — excessive worry across multiple life domains for at least 6 months without discrete panic attacks or agoraphobic avoidance (confused-with a chronic-worry picture)
Specific phobia, situational type — fear is limited to one circumscribed stimulus and is not driven by fear of a panic attack; this patient's avoidance is broad and panic-linked (anchoring on the situational overlap)
Panic disorder without agoraphobia — tempting because panic disorder's own criteria include avoidance driven by the attacks and because agoraphobia is often pictured as being housebound, but marked fear and avoidance of two or more situations where escape is difficult, here driving and crowds, meet the separate DSM-5 criteria for agoraphobia, which does not require being housebound, so both diagnoses are made (anchoring on the panic attacks)
Additional high-yield points
First-line treatment: (1) Cognitive behavioral therapy (CBT) with interoceptive exposure (intentionally inducing feared bodily sensations to reduce fear), cognitive restructuring (correcting catastrophic misinterpretation of normal sensations), and gradual in-vivo exposure for agoraphobia; (2) Selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) (sertraline, paroxetine, escitalopram, venlafaxine) — onset 4–8 weeks; treat for minimum 12 months after remission; (3) Combined CBT plus medication is superior for severe or treatment-resistant cases
Benzodiazepines: short-term bridge only — risk of dependence, tolerance, rebound anxiety, and blunting of CBT exposure benefit
D-cycloserine: NMDA partial agonist as adjunct to CBT (investigational)
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Hypersensitive 'fear network' centered on the amygdala with augmented locus coeruleus noradrenergic output; abnormal CO2/lactate sensitivity producing 'false suffocation alarms.' Genetic heritability ~40%.
Clinical presentation
Symptoms
Panic attack: >=4 of 13 symptoms peaking within minutes — palpitations, sweating, trembling, dyspnea, choking sensation, chest pain, nausea, dizziness, chills/heat, paresthesias, derealization/depersonalization, fear of losing control, fear of dying
Attacks last 10-30 minutes; afterwards, patients feel exhausted
Anticipatory anxiety between attacks and avoidance of perceived triggers
Agoraphobia: fear/avoidance of >=2 of: public transportation, open spaces, enclosed spaces, lines/crowds, being outside the home alone; the fear or avoidance is persistent, typically >=6 months
Signs / physical exam
During attack: tachycardia, tachypnea, diaphoresis, mild HTN, tremor, hyperventilation
Between attacks: typically normal exam
Differential diagnosis
Cardiac (ACS, arrhythmia, SVT) — Exertional trigger, abnormal ECG/troponin, persistent symptoms — must exclude in first presentations
DSM-5-TR: Recurrent unexpected panic attacks AND >=1 month of one or both: (a) persistent concern about additional attacks or their consequences, (b) significant maladaptive change in behavior related to attacks. Not attributable to substance/medical condition and not better explained by another disorder. Agoraphobia is a separate, often co-occurring diagnosis.
Labs
Targeted to exclude medical mimics: ECG, troponin (if cardiac risk), TSH, BMP, glucose, urine drug screen, urine metanephrines (paroxysmal HTN)
Imaging
Not routinely required; CT/CTA only if PE, dissection, or other organic cause suspected
Diagnostic algorithm
flowchart TD
A["Recurrent UNEXPECTED abrupt fear surges<br/>peaking within minutes"] --> B["Exclude medical mimics<br/>ECG / TSH / glucose / UDS"]
B --> C{">=4 panic symptoms?"}
C -->|Yes| D["Panic attack"]
D --> E{">=1 month worry<br/>or behavior change?"}
E -->|Yes| F["Panic Disorder"]
E -->|No| G["Isolated panic attacks"]
F --> H["CBT with exposure +/- SSRI/SNRI"]
F --> I["Short-term benzo bridge<br/>if severe"]
Panic disorder diagnostic and treatment algorithm.
Treatment
First-line
Cognitive behavioral therapy — interoceptive exposure targets fear of bodily sensations; graded in vivo exposure to avoided situations is added for agoraphobia — strongest evidence base
SSRI — sertraline, escitalopram, paroxetine, fluoxetine (start at low dose to avoid initial activation)
SNRI — venlafaxine XR
Patient education: panic attacks are time-limited, not dangerous; reduce safety behaviors
Second-line / adjunct
Benzodiazepine (clonazepam, lorazepam, alprazolam) — short-term bridge for severe early symptoms; avoid as long-term monotherapy due to dependence and rebound anxiety; absolutely avoid in SUD
Tricyclic antidepressants (imipramine, clomipramine) — effective but anticholinergic and overdose-toxic
Suicide risk increased relative to non-anxious controls
Repeated ED visits and unnecessary cardiac workups
PANCE pearls
Panic attacks peaking >10 minutes or with focal neurologic signs are atypical — broaden the differential.
Alprazolam has the highest dependence and rebound risk; if benzodiazepines are used, clonazepam (longer half-life) is preferred.
Cognitive model: catastrophic misinterpretation of benign bodily sensations drives the panic cycle — interoceptive exposure breaks the association.
Continue SSRI for >=12 months after remission to reduce relapse.
Buspirone and beta-blockers (propranolol) do not prevent panic attacks — buspirone is used for GAD, and beta-blockers only blunt peripheral adrenergic symptoms (their main anxiety use is performance anxiety).
References
APA 2009 — American Psychiatric Association Practice Guideline for the Treatment of Patients with Panic Disorder, 2nd ed. (2009)
NICE CG113 — NICE Clinical Guideline 113: Generalised anxiety disorder and panic disorder in adults
DSM-5-TR — American Psychiatric Association. DSM-5-TR (2022)
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