Clinical Vignette
Patient: "Mrs. P," 41-year-old elementary school teacher, self-referred after her physician prescribed buspirone for "generalized anxiety" and she experienced no improvement after 8 weeks.
Chief Complaint: "I'm anxious all the time, but the worst part is the attacks. I can't go to the grocery store anymore without my husband."
History of Present Illness: Mrs. P describes two distinct anxiety phenomena: (1) Persistent worry: She reports chronic, excessive worry about multiple domains: her children's safety, financial stability, work performance, health (her own and her parents'). She has worried "about everything" for "as long as I can remember" but it has intensified over the past 2 years. She cannot turn off the worry even when she recognizes it is disproportionate. Associated symptoms: muscle tension (chronic neck/shoulder pain), difficulty concentrating at work, irritability with her husband, fatigue despite adequate sleep, and initial insomnia 3-4 nights per week ("my mind won't stop"). (2) Panic attacks: Approximately 8 months ago, she experienced her first panic attack in a grocery store: sudden onset of heart pounding, chest tightness, shortness of breath, dizziness, tingling in her hands, and a conviction she was having a heart attack. ER evaluation was negative (ECG normal, troponin negative). Since then, she has had 12-15 panic attacks, most occurring in crowded or enclosed spaces (stores, movie theaters, her classroom during assemblies). She now avoids grocery stores, malls, crowded restaurants, and movie theaters. She has begun leaving her classroom door open during lessons "in case I need to get out." She describes persistent fear of having another panic attack and monitors her body for early signs ("I check my heart rate constantly").
Timeline: Chronic worry preceded panic attacks by many years. Panic attacks began 8 months ago with progressive avoidance.
Psychiatric History: No prior treatment. No depression. No substance use. No trauma history. Family history: mother has "anxiety" (untreated), sister takes sertraline for panic attacks.
Mental Status Exam: Cooperative, mildly restless. Affect anxious. Speech normal rate. Thought process linear but returns to worry themes. No psychotic symptoms. Denies suicidal ideation.
Step 1: Identifying Two Separable Syndromes
Mrs. P presents with two phenomenologically distinct anxiety syndromes that co-occur. The clinical task is to determine whether one diagnosis accounts for both or whether comorbid diagnoses are required.
| Feature | GAD | Panic Disorder | This Patient |
|---|---|---|---|
| Core feature | Excessive, persistent worry about multiple domains | Recurrent, unexpected panic attacks + persistent concern about attacks | Both present |
| Temporal course | Chronic, ≥6 months | Episodic (attacks) with interictal anxiety | GAD: years. Panic: 8 months |
| Physical symptoms | Muscle tension, fatigue, sleep disturbance | Palpitations, chest pain, SOB, dizziness, paresthesias | Both patterns present |
| Avoidance | Avoidance of worry triggers (cognitive, less behavioral) | Avoidance of situations where panic might occur | Behavioral avoidance of stores, crowds, enclosed spaces |
| Onset pattern | Gradual, insidious | First attack often sudden and memorable | GAD gradual; Panic sudden (grocery store) |
Step 2: GAD Criteria (DSM-5-TR)
Criterion A: Excessive anxiety and worry about multiple events or activities, occurring more days than not for ≥6 months.
Reports chronic worry about children's safety, finances, work, health for years. MET.
Criterion B: Difficulty controlling the worry.
"I can't turn it off even when I know it's disproportionate." MET.
Criterion C: ≥3 of 6 associated symptoms.
(1) Restlessness: mild restlessness on MSE. MET.
(2) Fatigue: "despite adequate sleep." MET.
(3) Difficulty concentrating: at work. MET.
(4) Irritability: with husband. MET.
(5) Muscle tension: chronic neck/shoulder pain. MET.
(6) Sleep disturbance: initial insomnia 3-4 nights/week. MET.
6 of 6 met. Criterion C MET.
GAD Diagnosis: Generalized Anxiety Disorder (F41.1) is supported.
All criteria met. The chronic worry preceded the panic attacks by years and involves multiple diverse domains (children, finances, work, health), which is inconsistent with worry secondary to panic disorder (which would be narrowly focused on future panic attacks).
Step 3: Panic Disorder + Agoraphobia Criteria
Panic Disorder Criterion A: Recurrent unexpected panic attacks (abrupt surges of intense fear reaching a peak within minutes, with ≥4 of 13 symptoms).
12-15 attacks over 8 months. Symptoms: palpitations, chest tightness, SOB, dizziness, paresthesias = 5 symptoms. MET.
Panic Disorder Criterion B: ≥1 attack followed by ≥1 month of persistent concern about additional attacks, or maladaptive behavioral change.
Checks heart rate constantly. Fear of another attack. Avoids stores, crowds. MET.
Agoraphobia Criterion A: ≥2 of 5 agoraphobic situations: (1) public transport, (2) open spaces, (3) enclosed places, (4) standing in line or crowds, (5) being outside home alone.
Avoids: enclosed places (stores, theaters), crowds (assemblies, crowded restaurants). MET (≥2 situations).
Agoraphobia Criterion B: Fears these situations because escape might be difficult or help unavailable in event of panic.
Leaves classroom door open "in case I need to get out." Needs husband in stores. MET.
Diagnostic Conclusion
1. Generalized Anxiety Disorder (F41.1): chronic, multi-domain worry with all 6 associated symptoms.
2. Panic Disorder (F41.0): recurrent panic attacks with persistent concern and behavioral change.
3. Agoraphobia (F40.00): avoidance of ≥2 situation types due to fear of panic.
These are three separate, comorbid diagnoses. The GAD predates the panic disorder by years and involves worry domains unrelated to panic attacks. The panic disorder and agoraphobia developed together 8 months ago. Treating only GAD (as her physician attempted with buspirone) would leave the panic disorder and agoraphobia untreated.
Teaching Points
- GAD and Panic Disorder co-occur frequently. When both are present, the clinician should assign both diagnoses because the treatment targets differ: GAD worry responds to cognitive restructuring and possibly SSRIs/SNRIs, while panic attacks respond to interoceptive exposure and CBT for panic.
- Agoraphobia is a separate diagnosis in DSM-5-TR (it was a specifier of Panic Disorder in DSM-IV). A patient can have agoraphobia without panic disorder, panic disorder without agoraphobia, or both. Each requires independent criterion evaluation.
- Buspirone is FDA-approved for GAD but has no efficacy for panic disorder. SSRIs (sertraline, paroxetine) and SNRIs (venlafaxine) treat both conditions. This medication mismatch explains Mrs. P's treatment failure.
- The temporal sequence is diagnostically informative: when chronic worry precedes panic attacks by years, GAD is likely a primary condition. When worry develops only after panic onset and is focused on future attacks, the worry is better accounted for by Panic Disorder Criterion B.
- Family history supports both diagnoses: her mother has untreated "anxiety" (possibly GAD), and her sister has panic attacks. Anxiety disorders cluster in families, and GAD and Panic Disorder share genetic liability.