A first-year MBBS student came to OPD with intermittent episodes of a feeling of impending doom accompanied by intense perspiration. Usually, the attacks occur prior to her exams. What is the most likely diagnosis?

Correct Answer: C. Panic disorder

Panic disorder is characterized by recurrent, unexpected panic attacks — sudden episodes of intense fear or discomfort lasting 5–20 minutes, accompanied by physical symptoms (palpitations, sweating, trembling, dyspnea, chest pain, dizziness). The key discriminator here is the acute onset of "impending doom" with intense perspiration in discrete episodes, not a chronic background anxiety. Although this student's attacks occur before exams (a situational trigger), the sudden, intense nature and autonomic storm (perspiration) are hallmarks of panic attacks, not generalized worry. Per DSM-5 criteria (adopted in Indian psychiatric practice), panic disorder requires recurrent unexpected attacks followed by persistent worry about future attacks or behavioral changes. The episodic, acute presentation with vegetative symptoms is pathognomonic. Indian guidelines and Harrison's Psychiatry emphasize that panic attacks are time-limited surges of terror, not prolonged anxiety. The student's description of discrete episodes with physical autonomic features (sweating, sense of doom) fits panic disorder perfectly, even though the trigger is identifiable (exams).

Why the other options are wrong

A. Social anxiety disorder — Social anxiety disorder involves persistent fear of social situations where the person fears scrutiny or embarrassment. While exams are social in context, the key feature here is acute episodic panic with autonomic symptoms (sweating, impending doom), not anticipatory anxiety about being judged. Social anxiety is more about worry before/during social exposure, not sudden terror attacks with vegetative symptoms. B. Generalized anxiety disorder — GAD presents with persistent, excessive worry lasting ≥6 months across multiple life domains (academics, health, finances, relationships). The hallmark is chronic background anxiety, not discrete episodes. This student has episodic attacks with sudden onset and intense autonomic symptoms, not the sustained, diffuse worry pattern of GAD. GAD lacks the acute panic surge quality. D. Conversion disorder — Conversion disorder involves unconscious psychological conflict manifesting as neurological symptoms (paralysis, blindness, seizures) without organic pathology. This student's symptoms are genuine autonomic panic responses (sweating, fear), not pseudo-neurological deficits. Conversion disorder does not present with panic attacks or autonomic storms; it mimics neurological disease.

High-Yield Facts

Mnemonics

PANIC = Panic Attacks Need Intense Catastrophic thinking Panic attacks are sudden, intense episodes (not chronic worry) with catastrophic thoughts (impending doom, fear of dying/losing control) and autonomic symptoms (sweating, palpitations). Use this to distinguish from GAD's diffuse, persistent anxiety. 5-20 Rule Panic attacks peak within 5–20 minutes and resolve within that window. If anxiety is chronic and diffuse over hours/days, think GAD. If it's a sudden terror surge, think panic.

NBE Trap

NBE pairs exam-related triggers with anxiety disorders to lure students into choosing "social anxiety" or "GAD" based on context alone. The trap: situational triggers do NOT exclude panic disorder. The discriminator is the acute, intense autonomic surge (impending doom + sweating), not the trigger itself.

Clinical Pearl

In Indian medical schools and competitive exams, panic disorder is the most common anxiety disorder presenting in high-stress students. A key bedside pearl: *ask about the duration and onset of symptoms. Panic attacks are sudden and brief (5–20 min); GAD is chronic and pervasive*. This distinction separates panic from other anxiety disorders in the exam hall.

_Reference: Harrison's Principles of Internal Medicine, Ch. 466 (Anxiety Disorders); DSM-5 Diagnostic Criteria for Panic Disorder; Kaplan & Sadock's Synopsis of Psychiatry (Indian adaptation)_