How do you diagnose and treat a middle-aged adult patient with nocturnal panic attacks, mild anxiety, and symptoms suggestive of agoraphobia, and do you rule out agoraphobia in panic disorder?

Agoraphobia and Panic Disorder: Diagnostic Approach

No, you do not rule out agoraphobia when panic disorder is present—these are independent diagnoses that frequently co-occur but can exist separately, and both should be diagnosed when criteria are met. 1

Understanding the Diagnostic Relationship

The historical view that agoraphobia was merely a complication of panic disorder has been fundamentally revised. Over 50% of agoraphobia cases never meet criteria for panic disorder or even liberally-defined panic-like symptoms, establishing agoraphobia as an independent disorder in its own right. 1, 2

Key Diagnostic Principles

• Agoraphobia can occur with or without panic disorder—these are separate diagnostic entities that should both be coded when present 1, 2
• The fear in agoraphobia centers on "incapacitation or humiliation due to unpredictable, sudden symptoms" rather than necessarily fearing a full panic attack 1
• When panic disorder and agoraphobia coexist, both diagnoses should be made 3, 4

Diagnostic Criteria for Your Patient

Confirming Agoraphobia

Agoraphobia requires fear of at least two situations where escape might be difficult or help unavailable—if only one situation is feared, diagnose situational-type specific phobia instead (72.8% of single-situation cases are actually specific phobia). 1, 2

For your middle-aged patient with nocturnal panic attacks and agoraphobia symptoms:

• Assess the number of feared situations systematically (public transportation, open spaces, enclosed spaces, crowds/lines, being outside home alone) 1
• Verify that fear is out of proportion to actual danger and causes significant distress or functional impairment 1
• Confirm duration of at least 6 months 1

Confirming Panic Disorder

• Nocturnal panic attacks are diagnostic of panic disorder when they meet criteria for recurrent unexpected panic attacks with abrupt surge of intense fear 5
• Assess for anticipatory anxiety about future attacks, which differentiates panic disorder from isolated panic attacks 6

Critical Medical Exclusions

Before finalizing psychiatric diagnoses, systematically exclude medical mimics: 5, 7

• Hyperthyroidism (check TSH, free T4)—can cause palpitations, tremor, sweating 5
• Hypoglycemia/diabetes (check glucose, HbA1c) 5
• Cardiac arrhythmias (obtain ECG, especially given nocturnal timing) 5

Clinical Implications When Both Diagnoses Present

Patients with panic disorder plus agoraphobia (PDA) have significantly worse outcomes than panic disorder alone: 4, 8

• More severe panic symptoms and psychiatric comorbidity 4
• Younger age of onset 4
• Longer benzodiazepine use duration 4
• Higher rates of antipsychotic augmentation needed 4
• Elevated suicide risk 8
• More frequent comorbid social phobia and hypomanic episodes 8

Treatment Approach for Comorbid PDA

First-Line Pharmacotherapy

Initiate an SSRI as first-line treatment for both panic disorder and agoraphobia—SSRIs are effective for panic attacks, anticipatory anxiety, and avoidance behavior. 5, 3

• SSRIs with lower withdrawal liability should be prioritized for long-term prophylaxis 3
• Avoid benzodiazepines as first-line or long-term treatment due to dependence risk and higher mortality, though short-term bridging (first few days) while SSRIs take effect is acceptable 5, 3

Essential Psychotherapy Component

Initiate cognitive-behavioral therapy (CBT) concurrently with medication—CBT is the best-studied non-pharmacological approach and provides durable skills that may prevent relapse after medication discontinuation. 5, 3

Common Diagnostic Pitfalls to Avoid

• Don't assume agoraphobia is secondary to panic disorder—assess and diagnose independently 1, 2
• Don't diagnose agoraphobia with only one feared situation—this is likely specific phobia requiring reclassification 1, 2
• Don't overlook comorbid depression (occurs in 70% of agoraphobia with panic attacks) which requires concurrent treatment 6
• Don't miss trauma history—sexual harassment, assault, and trauma are common underlying triggers, particularly in women 5

Assessment of Suicide Risk

Immediately assess for suicidal ideation or self-harm behaviors in all patients with panic disorder, especially when comorbid with agoraphobia or depression—this combination significantly increases suicide risk. 5, 8