Anxiety Case Analysis – Panic Disorder, Agoraphobia, and Generalized Anxiety Disorder

Anxiety Case Analysis – Panic Disorder, Agoraphobia, and Generalized Anxiety Disorder

Mrs. Julie Thomas is a 48-year-old married Caucasian female who presents to her general practitioner (GP) with ongoing complaints related to her heart. Julie works as a bank clerk, and reports increased stress related to new management and a new computer system. She complains of episodes of her heart racing, chest pains, and being unable to catch her breath. Mrs. Thomas states that her first episode happened on her day off work when she was going into town. She reports that these symptoms have been going on for about six months. Mrs. Thomas denies having any episodes like this prior to six months ago. She states that her dad died of a heart attack at age 72, and she relates this to her symptoms and believes that she will also have a heart attack.

Mrs. Thomas reports that she is so worried about having an episode that she is avoiding things that she feels will trigger her. Her husband has been driving her to and from work, she avoids going out in public places, and she is not engaging in any activities that would cause physical exertion, including sex. She reports that her husband has become frustrated with the entire situation.

Julie had an ECG done a couple of months ago, and the results were normal. She does not use tobacco, her blood pressure has been good, and she is only 48 years old. She currently has no major risk factors for heart disease.

Differential Diagnosis

Differential Diagnosis #1: Panic Disorder

Panic disorder is a mental health disorder characterized by recurring unexpected episodes of panic attacks. The hallmark feature of this condition is attacks that occur suddenly without warning. The accompanying features of panic attacks include palpitations, sweating, shaking or trembling, dizziness, shortness of breath, chest pain, nausea, heat sensations, paresthesias, syncope, and others (Kim, 2019). These attacks can occur multiple times a day. According to DSM-V, a positive diagnosis of panic disorder is made in the presence of at least one panic attack, preceded by a month or more of persistent worry or concern about experiencing another attack and the consequences of these attacks (DSM-5-TR, 2022). In the case presented, the client manifested symptoms of palpitation, shortness of breath, chest pains, and accelerated heart rate. These manifestations are indicative of a panic attack. Her attacks were preceded by recurring worries of experiencing another panic attack and the consequences of these attacks. These manifestations are consistent with the DSM-V criteria for panic disorder.

Differential Diagnosis #2: Agoraphobia

Agoraphobia is an anxiety attack that occurs in crowded places, in public, or where a potential escape or help is not readily available. This disorder is characterized by the fear of experiencing panic attacks (Barzegar et al., 2021). According to DSM-V, agoraphobia can occur distinctively from other anxiety spectrum disorders and is characterized by the fear of exposure to public spaces and active attempts by the individual to avoid such places through modifications of behavior and thought process (DSM-5-TR, 2022). In the case presented, the client presented with complaints suggestive of a panic attack when getting to town. Subsequently, she has developed a fear of experiencing panic attacks in public places and even actively avoids public spaces and situations she thinks predispose her to such attacks. These manifestations are consistent with those described in the DSM-V for agoraphobia.

Differential Diagnosis #3: Generalized Anxiety Disorder (GAD)

GAD is a psychiatric illness characterized by intense fear or worry and a persistent feeling of being overwhelmed (DeMartini et al., 2019). As per the DSM-V criteria, a positive diagnosis of GAD is made in the presence of excessive worry for at least six months. The client must have difficulty controlling their worries (DSM-5-TR, 2022). Other accompanying symptoms outlined in DSM-V include sleep disturbances, restlessness, muscle tension, fatigue, irritability, and concentration difficulties. In the case presented, the client manifested with complaints of anxiety. She also demonstrated fear of developing anxiety attacks, for which she had little control.

Differential Diagnosis Mental Status Examination

Panic Disorder

Panic disorder presents with mental examination findings consistent with the following:

• Appearance: Well-groomed and able to maintain eye contact.
• Speech: Goal-directed and coherent
• Mood & Affect: High or low mood. Varies and includes irritability, sadness, anger, and others
• Behavior & Motor Activity: Restlessness. Motor activity intact.
• Thought Process: Logical, linear, and goal-directed
• Thought Content: Logical
• Attention & Concentration: May be inattentive, especially when experiencing discomfort.
• Memory: Intact
• Orientation: Well-oriented to place, time, and event.
• Insight: Intact.
• Judgement: Goal-directed and logical

Agoraphobia

Agoraphobia presents with mental examination findings consistent with the following:

• Appearance: Well-groomed and can maintain eye contact.
• Speech: Coherent, logical, and goal-directed.
• Mood & Affect: Euthymic
• Behavior & Motor Activity: Their behavior is normal, as manifested by their ability to maintain eye contact, follow commands, and answer questions. Motor activity is intact.
• Thought Process: Coherent, logical, and goal-directed.
• Thought Content: Logical
• Attention & Concentration: Intact
• Memory: Intact
• Orientation: Well-oriented to place, time, and event.
• Insight: Intact
• Judgment: Intact.

Generalized Anxiety Disorder

Generalized Anxiety Disorder presents with mental examination findings consistent with the following:

• Appearance: Well-groomed but may be restless and sweaty.
• Speech: May be incoherent
• Mood & Affect: May be euthymic, but sometimes, irritable or depressed.
• Behavior & Motor Activity: Normative as demonstrated by their ability to follow commands and answer questions. They may experience muscle tension.
• Thought Process: Logical and coherent
• Thought Content: Logical
• Attention & Concentration: They may be inattentive, especially when agitated. They may also lose concentration or find difficulty concentrating.
• Memory: Intact
• Orientation: Well-oriented to place, time, and event.
• Insight: Intact
• Judgement: Intact

Differential Diagnosis Etiology

Diagnosis #1: Panic Disorder

Panic disorders have a multifactorial etiology. Chemical imbalances in the brain, genetics, and adverse childhood events are thought to interplay in the development of panic disorders. Genetic predilection is particularly high, with the risk of developing panic disorder up to 40% higher in persons with first-degree relatives with the disease.

Diagnosis #2: Agoraphobia

Agoraphobia is thought to result from parental overprotectiveness, childhood fears, and experiences of grief at an early age. Per DSM-V, traumatic childhood events, neuroticism, and genetics are risk factors for the disorder. There is, however, no consensual finding on the exact cause of the agoraphobia.

Diagnosis #3: GAD

The etiological factors involved in GAD are multivariate. They include genetics, substance abuse disorder, child abuse, and physical conditions such as diabetes.

Differential Diagnosis Diagnostic Screening Tools

Diagnosis #1: Panic Disorder

The panic disorder screener (PADIS) and the panic disorder segment of the patient health questionnaire (PHQ) are some of the diagnostic screening tools available for panic disorders. PADIS is a highly accurate, highly sensitive tool that details the presence of and severity of panic disorder in clinical cases. It is based on subjective findings from the clients and does not require any laboratory testing.

Diagnosis #2: Agoraphobia

The Oxford Agoraphobic Avoidance Scale (OAAS) is a diagnostic screening tool available for screening agoraphobia. This self-report tool has excellent psychometric properties in showing the likelihood of agoraphobia. It is used as a diagnostic aid and relies on the client’s responses. It does not require any laboratory testing.

Diagnosis #3: GAD

The generalized anxiety disorder-7 item tool (GAD-7) is a valuable diagnostic tool in assessing GAD. It details the presence of GAD as well as the symptoms and severity of the disorder. It relies on the subjective findings from the clients and does not require any laboratory testing.

Case Analysis

The case presented was of a 48-year-old female with complaints of anxiety. The presumptive diagnosis in the case is panic disorder. The client’s manifestations were consistent with those described in DSM-V for diagnosis of panic disorder. To begin with, the client had experienced a panic attack as demonstrated by sudden intense fear, accompanied by palpitation, accelerated heart rates, palpitation, and sweating. As evident in the case, the client reported experiencing sudden shortness of breath, chest pains, and increased heart rate on an outing to town. Subsequently, she experienced persistent concern about experiencing another attack. Per the DSM-V criteria for panic disorder, a positive diagnosis is made in the presence of a panic attack, preceded by a month of persistent concern of experiencing another attack. The case thus met this criteria, affirming the panic disorder diagnosis.

Treatment Plan

Comprehensive management of panic disorder utilizes psychotherapeutic and pharmacotherapeutic modalities. Psychological interventions such as cognitive behavioral therapy (CBT) maintain effectiveness in alleviating panic symptoms (Kim, 2019). They may also help the clients correct defective thought processes that interplay in the development of panic attacks. Pharmacotherapeutic modalities are preferred in the presence of comorbidities and severe cases. Antidepressant medications and benzodiazepines are the mainstay pharmacotherapies in the management of panic disorder. Selective serotonin reuptake inhibitors such as fluoxetine are the first line in the management of panic disorder (Kim, 2019). The patient in the case will be scheduled for CBT. She is expected to return for a follow-up after two weeks.

Patient and family education is integral to the management of panic disorders. The patient will be educated on the disease process. She will be informed that the symptoms are not life-threatening. She will also be educated on the available therapeutic modalities and the need to comply with treatment. The patient will also be educated on the expected side effects during pharmacotherapy. In case the symptoms fail to improve, she may be referred to a psychiatrist to rule out the involvement of other psychiatric illnesses.

References

Barzegar, H., Farahbakhsh, M., Azizi, H., Aliashrafi, S., Dadashzadeh, H., & Fakhari, A. (2021). A descriptive study of agoraphobic situations and correlates on panic disorder. Middle East Current Psychiatry, 28(1). https://doi.org/10.1186/s43045-021-00110-y

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of Internal Medicine, 170(7). https://doi.org/10.7326/aitc201904020

DSM-5-TR. (2022). Diagnostic and statistical manual of mental disorders: DSM-5-TR. American Psychiatric Association Publishing.

Kim, Y.-K. (2019). Panic disorder: Current research and management approaches. Psychiatry Investigation, 16(1), 1–3. https://doi.org/10.30773/pi.2019.01.08

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Watch the video below and as you are watching, collect the following information (if possible):
• Chief Complain
• History of Present Illness
• Psychiatric History
Past Medical History
Surgical History – none Social History Family History
• Social History
• Educational/Occupational History
• Review of Systems
• Medications – none
• Allergies – NKDA
• VS (provided: BP 120/78, HR 98, T 98.5, RR 20, Wt 171 and increased recently)

Link to YouTube Interview

https://youtu.be/Ii2FHbtVJzc?si=B-IPI-U6RxFgVFpB

Information for mental status exam

Mrs. Thomas is sitting upright with her hands in her lap. She is alert and oriented to person, place, time, and situation. Her memory appears to be intact. She is well-groomed and appropriately dressed. Her speech is clear and noted to be of normal rate, volume, and tone. Eye contact was noted to be good. She reports her mood to be “anxious.” Mrs.  Thomas appears guarded and anxious though attentive and cooperative throughout the interview. Her mood is congruent with her affect. Julie’s insight is good and her thought process is logical, organized, and goal-directed.

Differential Diagnoses Chosen

1. Panic Disorder
2. Agoraphobia
3. Generalized Anxiety Disorder

 

Required Textbooks

DSM-5-TR(tm) Classification

ISBN: 9780890425831

Authors: American Psychiatric Association

Publisher: American Psychiatric Publishing

Publication Date: 2022-03-18

Kaplan & Sadock’s Synopsis of Psychiatry

ISBN: 9781975145576

Authors: Robert Boland, Marcia Verdiun, Pedro Ruiz

Publisher: Lippincott Williams & Wilkins

Publication Date: 2021-02-09

Prescriber’s Guide

ISBN: 9781108915755

Authors: Stephen M. Stahl

Publication Date: 2020-11-18