2- Panic Disorder & Agoraphobia

Case 2 - Clinical History: (pp. 16-20)

Answer: B. Recurrent unexpected panic attacks

Explanation:

• Panic disorder requires unexpected panic attacks (out of the blue).

• Attacks don’t have to last a specific time (most last 10–15 minutes).

• While chest pain and palpitations are common, they are not required.

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DSM-5 Update:

• DSM-IV combined “panic disorder with/without agoraphobia.”

• DSM-5 separates panic disorder and agoraphobia into independent diagnoses.

Which of the following features is required for a DSM-5 diagnosis of panic disorder?

A. Panic attacks that only occur in response to feared situations
B. Recurrent unexpected panic attacks
C. Panic attacks lasting more than 30 minutes
D. Panic attacks with chest pain and palpitations

Answer: B. Agoraphobia

Explanation:

• Agoraphobia involves fear/avoidance of situations where escape may be difficult or help unavailable in case of panic symptoms.

• John avoids ≥2 situation types: open spaces, enclosed places, traveling, being away from home.

• Specific phobia is linked to one stimulus, not multiple domains.

• GAD involves excessive worry, not situational avoidance.

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DSM-5 Update:

• In DSM-IV, agoraphobia was a specifier for panic disorder.

• In DSM-5, agoraphobia is a separate diagnosis.

John avoids driving long distances, open spaces, elevators, and being out of town. Which diagnosis best explains these avoidance behaviors?

A. Social anxiety disorder
B. Agoraphobia
C. Specific phobia
D. Generalized anxiety disorder

Answer: C. Alcohol use disorder, in sustained remission

Explanation:

• DSM-5 uses the term alcohol use disorder (mild/moderate/severe).

• John met criteria in the past (severe use).

• He is in sustained remission since abstinent for >12 months.

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DSM-5 Update:

• DSM-IV separated “alcohol abuse” vs. “alcohol dependence.”

• DSM-5 merged them into a single continuum disorder: alcohol use disorder.

John reported daily alcohol consumption of a case of beer for 7 years. He has been abstinent for over 6 years. What is the correct DSM-5 diagnosis?

A. Alcohol intoxication
B. Alcohol use disorder, mild
C. Alcohol use disorder, in sustained remission
D. No diagnosis needed

Answer: A. Concern about having additional attacks or their consequences

Explanation:

• DSM-5 requires persistent concern/worry about additional panic attacks or their consequences (e.g., losing control, fainting, embarrassment).

• John fears passing out, losing motor control, or crashing the car.

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DSM-5 Update:

• DSM-5 kept this requirement (≥1 month of worry/avoidance).

• DSM-IV wording was nearly identical; DSM-5 clarified examples.

During some panic attacks, John fears losing control of his body and falling over. Which DSM-5 panic disorder criterion does this correspond to?

A. Concern about having additional attacks or their consequences
B. Attacks always triggered by external stressors
C. Panic attacks associated only with substance use
D. Panic attacks lasting longer than 30 minutes

Answer: C. His worry was better explained by panic disorder symptoms

Explanation:

• DSM-5 allows comorbid GAD and panic disorder if criteria are met.

• In John’s case, worry was mainly centered on panic attacks, so it was judged “subclinical” for GAD.

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DSM-5 Update:

• DSM-5 emphasizes ruling out that anxiety/worry is not better explained by another disorder.

• DSM-IV used a similar exclusion rule but DSM-5 wording is clearer.

John’s therapist considered generalized anxiety disorder (GAD) but did not assign the diagnosis. Why?

A. John had no anxiety symptoms
B. His worry was only about his job
C. His worry was better explained by panic disorder symptoms
D. GAD and panic disorder cannot be diagnosed together

Answer: B. His maternal family history of panic disorder and alcohol abuse

Explanation:

• Predisposing factors = long-term vulnerabilities that increase risk (e.g., genetics, temperament, family history).

• John’s extensive maternal family history of panic disorder and alcoholism predisposed him.

Predisposing Factor

Which of the following is the best example of a predisposing factor for John’s panic disorder?

A. Moving to upstate New York for a new job
B. His maternal family history of panic disorder and alcohol abuse
C. Avoiding driving after his recent attack
D. His wife driving him home after the attack

Answer: C. His first panic attack at 4:30 a.m. after drinking with friends

Explanation:

• Precipitating factors = triggers that initiate the onset of the disorder.

• John’s first panic attack occurred after drinking and poor sleep, which set off his disorder.

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Update:

• DSM-5 criteria focus on symptoms and duration, but clinicians use formulation models (4Ps) to understand onset and maintenance.

Precipitating Factor

Which event most clearly represents a precipitating factor in John’s case?

A. Having three children
B. Daily anxiety about panic attacks
C. His first panic attack at 4:30 a.m. after drinking with friends
D. Reading self-help books

Answer: C. His avoidance of elevators, open spaces, and driving

Explanation:

• Perpetuating factors maintain the disorder (avoidance, safety behaviors, anxious interpretations).

• John avoids many places, reinforcing anxiety and preventing exposure.

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Update:

• DSM-5 notes avoidance behaviors in agoraphobia; clinical formulation expands on how these maintain symptoms.

Perpetuating Factor

Which of the following best illustrates a perpetuating factor for John’s panic disorder?

A. His belief that doctors missed a heart problem
B. His use of Lamaze breathing to calm down
C. His avoidance of elevators, open spaces, and driving
D. His initial prescription for Valium

Answer: A. His high level of education and professional success

Explanation:

• Protective factors reduce the risk or help in recovery.

• John is educated, employed, and has family support, all of which can be resilience factors.

Protective Factor

Which is the best example of a protective factor in John’s case?

A. His high level of education and professional success
B. His family history of alcoholism
C. His avoidance of social situations
D. His use of Xanax for symptom relief

Answer: B. Remaining near walls when walking

Explanation:

• Safety behaviors = coping strategies that reduce perceived risk but maintain anxiety (e.g., carrying meds, holding onto walls, pulling over while driving).

• Therapy and abstaining from alcohol are adaptive strategies, not safety behaviors.

Safety Behaviors

Which of the following behaviors would be considered a safety behavior in John’s case?

A. Attending therapy regularly
B. Remaining near walls when walking
C. Avoiding alcohol completely
D. Reading self-help books

Answer: B. Panic disorder, agoraphobia, and alcohol use disorder (in sustained remission)

Explanation:

• His diagnoses are:

  • Panic disorder (300.01)

  • Agoraphobia (300.22)

  • Alcohol use disorder, in sustained remission (305.00/F10.20)

• GAD symptoms were subclinical, so not assigned.

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Update:

• DSM-5 allows separate diagnosis of panic disorder and agoraphobia (unlike DSM-IV).

Comorbidity

Which of the following best describes John’s comorbidities?

A. Panic disorder and social anxiety disorder
B. Panic disorder, agoraphobia, and alcohol use disorder (in sustained remission)
C. Agoraphobia and generalized anxiety disorder
D. Panic disorder and somatic symptom disorder

Answer: A. Cognitive-behavioral therapy (CBT) with interoceptive exposure

Explanation:

• CBT, especially with interoceptive exposure (exposure to feared bodily sensations), has the strongest evidence.

• Long-term benzodiazepine use is not recommended due to dependence risk.

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Update:

• DSM-5 doesn’t prescribe treatments, but APA guidelines and RCTs show CBT is first-line; meds (SSRIs) are often adjunctive.

Treatment Planning

Based on John’s case, which treatment approach has the strongest evidence base for panic disorder with agoraphobia?

A. Cognitive-behavioral therapy (CBT) with interoceptive exposure
B. Psychoanalysis focused on childhood trauma
C. Long-term benzodiazepine use only
D. Support groups without structured therapy

Answer: B. Maternal history of panic disorder and agoraphobia

Explanation:

• Predisposing = long-term vulnerabilities (e.g., genetics, early environment).

• John’s mother and extended maternal relatives had panic disorder and alcohol problems, which increased his vulnerability.

Predisposing Factor – Family History

Which of the following best describes John’s predisposing factor for developing panic disorder?

A. Reading self-help books about anxiety
B. Maternal history of panic disorder and agoraphobia
C. His use of Lamaze breathing during an attack
D. Moving to a new job in upstate New York

Answer: C. Carrying anti-anxiety medication for reassurance

Explanation:

• Safety signals = objects/people carried to feel safe (like a talisman).

• John carries medication as reassurance, even if he doesn’t use it.

• Safety behaviors = actions taken during panic (e.g., pulling over, holding onto walls).

Which of the following is an example of a safety signal in John’s case?

A. Remaining near walls when walking
B. Driving to the side of the road
C. Carrying anti-anxiety medication for reassurance
D. Using Lamaze breathing techniques

Answer: B. Roche; anxiety, muscle spasms, seizures

Explanation:

• Valium = brand name for diazepam, first marketed by Roche.

• It is a benzodiazepine used for anxiety, seizures, muscle spasms, and alcohol withdrawal.

• Valium (diazepam) is also a benzodiazepine.

• Valium is the brand name (or trade name) owned by the company that is used commonly by the people.

• Diazepam is the official, standard, generic, medical, and scientific name that is used by health care professionals

Medication – Valium

Valium (generic name: diazepam) is manufactured by which company and is primarily used to treat:

A. Pfizer; schizophrenia
B. Roche; anxiety, muscle spasms, seizures
C. Eli Lilly; depression
D. Janssen; bipolar disorder

Answer: A. Pfizer; panic disorder and generalized anxiety disorder

Explanation:

• Xanax = brand name for alprazolam, manufactured by Pfizer.

• FDA-approved for panic disorder and generalized anxiety disorder.

• Commonly prescribed but has high dependence potential.

• Xanax (alprazolam) is a benzodiazepine.

• Xanax is the brand name (or trade name) owned by the company that is used commonly by the people.

• Alprazolam is the official, standard, generic, medical, and scientific name that is used by health care professionals

Medication – Xanax

Xanax (generic name: alprazolam) is manufactured by which company and is FDA-approved for:

A. Pfizer; panic disorder and generalized anxiety disorder
B. Roche; schizophrenia
C. Janssen; PTSD and depression
D. Eli Lilly; social anxiety disorder

Answer: C. Risk of dependence and tolerance

Explanation:

• Benzodiazepines act on GABA receptors and reduce acute anxiety.

• Effective in the short term, but long-term use risks tolerance, dependence, and withdrawal.

• Thus, they are not considered first-line maintenance treatment.

Medication – Clinical Consideration

Which of the following is a main clinical limitation of long-term benzodiazepine use (e.g., Xanax, Valium) for panic disorder?

A. They are ineffective for panic attacks
B. They increase panic disorder symptoms permanently
C. Risk of dependence and tolerance
D. They have no effect on GABA neurotransmission

• 300.01 Panic disorder

• 300.22 Agoraphobia

• 305.00 Alcohol use disorder, in sustained remission

DSM-5 Diagnosis

Therefore, based on the preceding information, John’s DSM-5 diagnoses were as follows: