Panic disorder and agoraphobia — assessment and stepped management (MEQ)

(i) Assessment priorities. Confirm attack phenomenology (unexpectedness, peak within minutes, symptom cluster), inter-attack worry, and avoidance map (buses, shopping alone). Medical exclusion: review prior ED work-ups; red-flag screen (chest pain with risk factors, hypoxia, syncope with injury, focal neurology, weight loss, late atypical features) — here repeated normal ECG/troponin reduces ACS likelihood but document vitals and when to re-investigate. Substances: caffeine load, nicotine, cannabis, stimulants; non-prescribed alprazolam quantity, frequency, supply, withdrawal risk. Depression and suicide: expand PHQ-9 item into full risk assessment (ideation, intent, plan, means, protective factors). MSE, collateral, function, prior treatments. Differential: panic disorder, agoraphobia, GAD, social anxiety, PTSD, substance-induced anxiety, medical mimics, illness anxiety.[1][5]

(ii) Working diagnoses. Panic disorder (recurrent unexpected attacks + persistent concern and behaviour change) and agoraphobia (fear/avoidance of multiple situations with escape/help concerns) — dual coding. Comorbid depressive symptoms (PHQ-9 14) with passive death wishes — assess whether full MDD criteria met. Caffeine excess and non-prescribed benzodiazepine use as maintaining/complicating factors.[1]

(iii) Psychological plan. First-line CBT with: psychoeducation of false-alarm model; cognitive restructuring of catastrophic misinterpretations; interoceptive exposure; graded in-vivo hierarchy (e.g. short accompanied bus → alone off-peak → peak shopping); systematic dropping of safety behaviours; relapse prevention. Use inhibitory-learning principles (expectancy violation, varied contexts). Typical high-intensity course often ~8–12+ sessions with between-session practice. Collaborative care/primary-care CBT elements if specialist waitlists are long.[2][6]

(iv) Medication. Example: sertraline 25–50 mg orally daily, review early for activation/side-effects and suicide risk given low mood, titrate toward 100–150 mg (up to 200 mg) if tolerated and incomplete response, plan adequate trial at therapeutic dose for several weeks. Monitoring: GI effects, sexual dysfunction, sleep, hyponatraemia if risk factors, interactions. Benzodiazepines: stop non-prescribed alprazolam supply; if a short bridge is needed, prescribe briefly under medical control with a written taper and CBT support for discontinuation — not long-term monotherapy.[3][4][5]

(v) Maintenance. After remission continue effective SSRI typically ≥6–12 months (longer if severe/recurrent/comorbid), maintain exposure skills, reduce caffeine, safety-net for relapse and suicidal thoughts, plan graded functional goals (independent transport/shopping). Coordinate GP follow-up.[3][5]