Panic disorder and agoraphobia — structured clinical viva

This is severe panic disorder with agoraphobia and chronic benzodiazepine use, with pseudo-resistance to an inadequate SSRI trial (50 mg for only 10 days — neither dose nor duration sufficient, and early activation may have been mislabelled as failure). ECT is not indicated for uncomplicated panic/agoraphobia and should be gently corrected if the partner equates it with "stronger treatment for anxiety."^[1][4]

Formulation. Vulnerability (anxiety sensitivity), precipitants (first unexpected attacks), maintaining factors (avoidance, safety behaviours, diazepam as safety signal, no exposure therapy), and functional collapse (housebound). Assess depression/suicide risk, substances, and medical differentials as always.^[4]

Plan. Collaborative psychoeducation; high-quality CBT with interoceptive and graded situational exposure (home-based/outreach if needed initially); restart SSRI carefully — e.g. sertraline 25 mg then 50 mg with slow titration toward a therapeutic range with early review for activation; do not escalate to "stronger tranquilisers" as definitive care.^[1][3][4]

Benzodiazepine. Agree a slow supervised taper, convert to a longer-acting agent if appropriate under local practice, and pair with CBT techniques shown to aid benzodiazepine discontinuation in panic.^[2]

Communication. Empathise with the partner's desperation; explain evidence hierarchy (CBT + SSRI/SNRI); set functional goals (leaving house, short trips); book early review; safety-net depression/suicide.^[4]