The Student Who Cannot Take the Metro
Arjun, 24, a final-year engineering student, has had five episodes in the past three weeks in which his heart races, he sweats, his hands tremble, and he is convinced he is about to die. Each episode peaks within 10 minutes and leaves him exhausted. Two occurred on the metro, one in a crowded lift, and two while sitting alone in his room. Since the first episode he has worried constantly about having another, has stopped taking the metro, and has begun asking his roommate to sit with him while he studies. He avoids the canteen at peak hours. He denies low mood, sleeps 7 hours, eats normally, and has no history of substance use or medical illness; a physician's basic tests are normal. He has missed 6 of 20 lab sessions. His parents say he is 'just stressed' and should 'be a man'.
1. What is the leading psychological hypothesis, and what alternatives must be ruled out before any label is applied?
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The leading hypothesis is panic disorder, possibly with agoraphobic avoidance, but this is a hypothesis for a qualified clinician, not a diagnosis for a trainee to fix. The attacks are recurrent, peak within minutes, and are followed by persistent concern. Alternatives to rule out include medical causes such as thyroid disorder, arrhythmia, caffeine or energy-drink use, and medication effects; substance use, which he denies; social anxiety disorder, where attacks occur only in social-evaluation situations; specific phobia of the metro or lift; OCD; PTSD; and depression. The two attacks while alone argue against a purely social-evaluative trigger. Normal basic tests reduce but do not eliminate medical causes, so a physician should review the results.
2. Apply the relevant criteria-unexpected versus situationally bound attacks, duration of concern, avoidance and impairment-to this case.
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Unexpected attacks, such as the two while alone in his room, point toward panic disorder. Situationally bound attacks in the metro and lift may be panic attacks in the context of agoraphobic fear. The worry has lasted at least three weeks and is already causing avoidance and role impairment, with 6 of 20 labs missed. For panic disorder, the worry or behavioural change typically persists for at least one month, so the timeline is close and needs a careful chronology. Avoidance of the metro, the canteen and being alone, plus dependence on the roommate, indicates agoraphobic avoidance. Impairment is clear. The parents' attribution to 'stress' is culturally common but should not delay assessment.
3. What should a psychology trainee do next, and what should the trainee avoid doing?
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Next, provide warm, non-judgemental psychoeducation that panic symptoms are distressing but not lethal; explain the fear-of-fear cycle and how avoidance maintains anxiety; obtain a detailed timeline, medical history and caffeine or substance review; with consent, coordinate with a physician and refer to a clinical psychologist or psychiatrist for a structured interview. Do not issue a solo diagnostic label, do not promise confidentiality that excludes risk, and do not begin crude exposure without assessment. Avoid reinforcing reassurance-seeking through repeated medical checks; instead agree on a plan. Screen for suicide risk and depression. If the trainee is a student, supervision is mandatory.