A 38-year-old woman presents with recurrent unexpected episodes of intense fear accompanied by palpitations, chest tightness, shortness of breath, dizziness, and a sense of impending doom, each lasting about 10 minutes. A thorough cardiac and neurological work-up is normal. She now avoids public transport fearing an episode away from help. What is the first-line pharmacological treatment for her primary diagnosis?

• A Alprazolam for acute symptom control as primary maintenance treatment
• B Propranolol to block peripheral autonomic manifestations
• C Buspirone for long-term anxiolytic effect
• D Selective serotonin reuptake inhibitor (e.g., sertraline or fluoxetine) ✓

Explanation

Panic disorder with agoraphobia is best treated long-term with SSRIs or SNRIs as first-line pharmacotherapy, combined with cognitive behavioural therapy (CBT) including interoceptive exposure. Benzodiazepines provide rapid relief but foster dependence, withdrawal, and do not address the underlying disorder; they are not recommended as primary maintenance treatment. Propranolol reduces somatic symptoms but lacks efficacy for cognitive aspects of panic. Buspirone is effective for generalised anxiety disorder but not for panic disorder.

Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.

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Written and medically reviewed by the StethoPrep medical team.