Panic disorder & agoraphobia

Panic cases test two linked skills: telling panic disorder from a panic attack that is just a feature of something else, and recognizing agoraphobia as its own diagnosis that can stand alone or co-occur.

Panic attack. An abrupt surge of intense fear or discomfort that peaks within minutes, with four or more of thirteen physical and cognitive symptoms (pounding heart, sweating, trembling, shortness of breath, choking sensation, chest pain, nausea, dizziness, chills or heat sensations, numbness or tingling, derealization or depersonalization, fear of losing control or "going crazy," fear of dying). Attacks can occur in any disorder; when they do not define panic disorder, they are recorded as a "with panic attacks" specifier on the other diagnosis.

Panic disorder at exam depth. Recurrent unexpected panic attacks, with at least one followed by one month or more of persistent worry about more attacks or their consequences (heart attack, losing control) and/or a significant maladaptive change in behavior to avoid them (avoiding exercise or unfamiliar places). Not due to a substance or medical condition, and not better explained by another disorder (for example, attacks only in feared social situations or only to a specific phobic object).

Agoraphobia at exam depth. Marked fear or anxiety about two or more of five situations: public transportation, open spaces, enclosed spaces, standing in line or being in a crowd, and being outside the home alone. The client fears these because escape might be difficult or help unavailable if panic-like or embarrassing symptoms occur; the situations are avoided, require a companion, or are endured with intense fear. The fear is out of proportion, lasts six months or more, and causes impairment. Agoraphobia is diagnosed regardless of whether panic disorder is present; when both are met, both are diagnosed.

Hinge differentials.

• Specific phobia, situational type: fear limited to one situation type.
• Social anxiety disorder: fear of negative evaluation, not of being trapped without help.
• GAD: chronic diffuse worry rather than discrete attacks.
• PTSD: attacks and avoidance triggered by trauma reminders.
• Medical conditions: cardiac arrhythmia, hyperthyroidism, asthma, pheochromocytoma, hypoglycemia.
• Substances: stimulants, caffeine, cannabis, and withdrawal from alcohol or sedatives.

On the NCMHCE. Many clients first seek emergency care for an attack; the counselor still recommends a medical evaluation (cardiac, thyroid) when it has not been done, and screens caffeine, stimulant and alcohol use. Track attack frequency separately from general anxiety scores, since one can improve while the other does not. First-line treatment is CBT for panic: psychoeducation about the fight-or-flight response, cognitive restructuring of catastrophic misinterpretations, interoceptive exposure to feared bodily sensations, and in vivo exposure for agoraphobic avoidance. Reduce safety behaviors gradually. Refer for medication evaluation when needed (SSRIs are a common class; benzodiazepines carry dependence concerns). Screen for depression and suicide risk.

Clinical Pearl: Panic disorder needs unexpected attacks plus a month of worry or behavior change; agoraphobia needs two of five situations for six months and is diagnosed on its own. Interoceptive exposure is the signature intervention.