The patient was a 40-year-old female with a chief complaint of physical immobility. She didn’t have genetic factors, associated with neuropsychiatric diseases. After graduating from high school, she studied abroad at a University College. After graduating from the University, she returned to her hometown and worked in sales and business. She developed uterine cancer and complete remission was achieved postoperatively. She did not have a history of mental illness. Four months prior to her visit to our university hospital, she was at the company’s training center, where she experienced sweating, palpitations, breathlessness, lightheadedness, and weakness. Her symptoms made it difficult to move her extremities. These symptoms were repeatedly observed in similar situations. Her symptoms improved when she moved away from the training center. She began experiencing similar symptoms during online meetings. She consulted with her local physician, who recorded a systolic blood pressure of at least 180 mmHg, plasma aldosterone concentration (PAC) of 69.6 pg/mL (CLEIA method), active renin quantitative concentration (ARC) of 1.4 pg/mL (CLEAR method), and positive PAC/ARC 50 and PA screening tests. She was admitted to the Internal Medicine Department of the University Hospital. She was seen by a hospital physician, and similar symptoms were elicited. Since her attacks were precipitated by specific situations and improved upon avoiding these triggers, a psychiatric disorder was suspected. Thus, the patient was referred to the Department of Psychiatry. The patient’s facial expressions and tone of voice were calm and composed. She experienced attacks in certain situations such as when she entered the company’s training center or during online meetings. During the attacks, she was aware of her lightheadedness, weakness of the upper and lower extremities, inability to stand up for an extended period, palpitations, sweating, and some difficulty in breathing. These attacks frequently occurred when she went to the company’s training centers and online meetings. In the hospital, the same symptoms were observed, when she was in the examination room with a physician. The symptoms lasted for several minutes and improved when the patient moved away from the trigger. She became anxious about these situations and eventually developed an avoidant behavior. The symptoms occurred when the patient went to training center, online meetings, consultations with the doctor, and the examination room. The total score of the Japanese version of the self-rating Panic and Square Fear Scale (PAS) [
7] was 26. The symptoms were possibly caused by PA. However, they were triggered by specific situations and improved upon avoiding these triggers. Moreover, the patient’s weakness was not caused by a documented decrease in her potassium level. Thus, the symptoms were not solely caused by PA. Rather, her symptoms constituted a panic attack. The patient experienced fear and anxiety, when she was placed in the aforementioned situations, and she tended to avoid them. Her symptoms were triggered by situations involving social interactions despite having minimal fear of attracting attention from others. Based on this, a social anxiety disorder was less likely, and the patient was diagnosed with agoraphobia. A positive captopril stress test and furosemide standing test were performed to identify the cause of hypertension, and the patient was diagnosed with PA. Abdominal computed tomography showed no adrenal gland tumors, and elective adrenal vein sampling was considered to determine if surgery was indicated. However, the patient did not wish to undergo surgery. Hence, she received pharmacological treatment. She was given eplerenone (25 mg), an MR antagonist. Five days later, the dosage was increased to 50 mg. After initiating eplerenone therapy, the patient’s panic attacks persisted, albeit less severely. The panic attacks were associated with a feeling of chest heaviness and the duration of the attacks was reduced. Based on this, the treatment improved the patient’s agoraphobia and panic attacks. She was discharged Day22 after admission. Following her discharge, her psychiatric symptoms gradually improved. She still had panic attacks upon entering the training center and during medical examinations. Subsequently, she was prescribed alprazolam (0.4 mg), but it was discontinued after a single dose due to somnolence. Her blood pressure remained at 140/90 mmHg. The dosage of her eplerenone was increased to 75 mg. Four days after the increase dosage, her psychiatric symptoms disappeared, and she has not experienced a panic attack or agoraphobia since then.