Panic disorder with agoraphobia
Recurrent panic attacks for 18 months; avoidance has shrunk her radius to a 3-block neighborhood.
Presenting concern
PDSS at intake: 17 (severe). 4–6 panic attacks/week, mostly anticipatory. Avoids subway, highways, theaters, anywhere she 'can't easily leave.' Carries water, mints, and a benzodiazepine 'in case.' Quit her gym, working hybrid only.
History
First panic attack in a meeting room after a poorly slept week. Misread as cardiac event — ER workup negative. Spiral of catastrophic interpretation since. No trauma, no substance use, no prior psych history.
- PRN benzo use risks reinforcing safety-behavior loop
- 18-month duration — avoidance consolidated
- Partner inadvertently accommodating (drives her everywhere)
- Anticipatory anxiety > attack distress (sign of advanced fear of fear)
- Bright, psychologically minded
- Cardiac workup complete (medical reassurance done)
- Engaged partner willing to be coached
- Stable job, stable income
Conceptualization across modalities
Catastrophic misinterpretation of normal interoceptive cues (heart rate, dizziness, breathlessness) → panic → safety behaviors and avoidance → loss of disconfirmation → spreading agoraphobic radius. PRN benzo is itself a safety behavior, narrowing window of natural extinction.
- Interoceptive exposure (spinning, breath-holding, straw breathing) to break fear of sensation
- Cognitive work on catastrophic predictions
- Situational exposure hierarchy with safety-behavior drops
- Collaborative benzo taper with prescriber
Experiential avoidance of panic sensations is the disorder, not panic itself. Willingness to feel anxiety in service of values reverses the agoraphobic narrowing.
- Defusion from 'I'm dying / going crazy' thoughts
- Values-led exposure ('what would I do today if anxiety wasn't a vote?')
- Acceptance practices with interoceptive sensations
- Drop the struggle metaphors
Treatment plan
Engagement (1–3)
Panic cycle psychoed, formulation, breathing retraining as bridge skill.
Interoceptive (4–7)
In-session interoceptive exposures, daily homework, cognitive work on sensations.
Situational (8–13)
Graded in-vivo exposure with safety-behavior drops; partner-coached.
Consolidation (14–16)
Generalize, taper benzo, relapse-prevention plan.
Differential diagnosis
- Cardiac or thyroid cause (ruled out via workup)
- Specific phobia, situational subtype
- PTSD with panic features (no index trauma here)
- Substance-induced panic (caffeine, stimulant use)
Session arc
Panic cycle diagram, normalize sensations, formulate her loop.
In-session spin, hyperventilate, straw breathe — escalating distress tolerance to sensations.
Hierarchy from elevator → bus → subway → theater; safety-behavior drops at each rung.
Solo exposures, benzo taper, relapse plan.
Cultures with somatic idioms of distress may present primarily with physical symptoms — chest pain, dizziness, shortness of breath — and resist a psychiatric framing. Validate the body experience; build the brain–body model collaboratively rather than declaring 'it's just anxiety.'
Reassuring the client about safety can become a covert safety behavior delivered by the therapist. Practice tolerating their uncertainty in session; that's the whole intervention.
Between-session work
- Daily interoceptive exposure (3 minutes, logged with SUDS pre/post)
- 2x/week situational exposure from current hierarchy rung
- Drop one safety behavior per week (water bottle, mints, phone-check)
- No PRN benzo use during exposure — coordinate with prescriber
Common pitfalls
- Doing situational exposure before interoceptive — fear of sensation is the engine
- Letting the partner stay in 'driver/protector' role through treatment
- Skipping the benzo taper conversation — guarantees relapse
- Calling a session 'successful' when she didn't panic; successful = she stayed willing if she did
- "Am I colluding with any of her safety behaviors?"
- "What's my plan if a panic attack happens in session?"
- "How do I coordinate the benzo taper with the prescriber without triangulating?"
PDSS to 5 by session 14. Subway re-entered week 10. Benzo discontinued by week 16. Booked an overseas flight before discharge — chose to fly despite anxiety, not because anxiety was gone.