PSYCHOPATHOLOGIES
TEXTBOOKS:
Barlow, D., & Durand, V. M. (2014). Abnormal Psychology: An Integrative Approach (7th ed.). Stamford, CT: Cengage. With Coursemate/ISBN: 9781285755618.
Diagnostic and statistical manual of mental disorders (5th ed.). (2013). Arlington, VA: American Psychiatric Association.
ISBN: 978-0-89042-555-8.
ASSIGNMENT: (TWO PAGES TOTAL)
ANXIETY DISORDERS:
1. What questions might you ask to determine if your client meets the criteria for having experienced:
a. A panic attack
b. Obsessions
c. Compulsions
2. What do you need to know to determine if your client meets the criteria for PTSD?
3. In the PsychiatryOnline database, click on DSM Library at the top, then click on the DSM-5 Clinical Cases Tab. Choose Chapter 5, Anxiety Disorders. You will
find six case studies. Choose one and answer the following:
ATTENTION: SEE CASE STUDY “PANIC” I HAVE CHOSEN BELOW. THANK YOU
a. What did you find to be your biggest challenge in determining an accurate diagnosis when considering the client described in the case study?
b. What was the most significant “take home” lesson you learned from this case study?
Case 5.2Panic
Carlo Faravelli, M.D.
Maria Greco was a 23-year-old single woman who was referred for psychiatric evaluation by her cardiologist. In the prior 2 months, she had presented to the emergency
room four times for acute complaints of palpitations, shortness of breath, sweats, trembling, and the fear that she was about to die. Each of these events had a rapid
onset. The symptoms peaked within minutes, leaving her scared, exhausted, and fully convinced that she had just experienced a heart attack. Medical evaluations done
right after these episodes yielded normal physical exam findings, vital signs, lab results, toxicology screens, and electrocardiograms.
The patient reported a total of five such attacks in the prior 3 months, with the panic occurring at work, at home, and while driving a car. She had developed a
persistent fear of having other attacks, which led her to take many days off work and to avoid exercise, driving, and coffee. Her sleep quality declined, as did her
mood. She avoided social relationships. She did not accept the reassurance offered to her by friends and physicians, believing that the medical workups were negative
because they were performed after the resolution of the symptoms. She continued to suspect that something was wrong with her heart and that without an accurate
diagnosis, she was going to die. When she had a panic attack while asleep in the middle of the night, she finally agreed to see a psychiatrist.
Ms. Greco denied a history of previous psychiatric disorders except for a history of anxiety during childhood that had been diagnosed as a “school phobia.”
The patient’s mother had committed suicide by overdose 4 years earlier in the context of a recurrent major depression. At the time of the evaluation, the patient was
living with her father and two younger siblings. The patient had graduated from high school, was working as a telephone operator, and was not dating anyone. Her family
and social histories were otherwise noncontributory.
On examination, the patient was an anxious-appearing, cooperative, coherent young woman. She denied depression but did appear worried and was preoccupied with ideas of
having heart disease. She denied psychotic symptoms, confusion, and all suicidality. Her cognition was intact, insight was limited, and judgment was fair.
Diagnosis
• Panic disorder
Discussion
Ms. Greco has panic attacks, which are abrupt surges of fear and/or discomfort that peak within minutes and are accompanied by physical and/or cognitive symptoms. In
DSM-5, panic attacks are seen as a particular kind of fear response and are not found only in anxiety disorders. As such, panic is conceptualized in two ways within
DSM-5. The first is as a “panic attack” specifier that can accompany any DSM-5 diagnosis. The second is as a panic disorder when the individual meets the more
restrictive criteria for the disorder.
Ms. Greco appears to satisfy the multiple criteria required for panic disorder. First, her panic attacks are recurrent, and she more than meets the requirement for
four of 13 panic symptoms: palpitations, sweating, trembling, smothering, chest pain, and a persistent fear of dying. The diagnosis also requires that the panic
attacks affect the person between episodes. Not only does Ms. Greco constantly worry about having a heart attack (despite medical workups and frequent reassurance),
she avoids situations and activities that might trigger another panic attack. These symptoms also have to last at least 1 month (Ms. Greco has been symptomatic for 2
months).
The diagnosis of panic disorder also requires an evaluation for the many other causes of panic. These include medications, medical illness, substances of abuse, and
other mental disorders. According to the history, this 23-year-old woman takes no medications, has no medical illness, and denies use of substances of abuse. Her
physical examinations, electrocardiograms, routine lab results, and toxicology screens are either normal or negative. It might be useful to ask Ms. Greco specifically
about herbal and complementary medications, but it appears that her symptoms are psychiatric in origin.
Many psychiatric disorders are associated with panic, and Ms. Greco may have been primed for panic attacks by another condition. She reports a childhood history of
anxiety and “social phobia,” although those symptoms appear to have remitted. Her mother killed herself 4 years earlier in the context of a recurrent major depression.
Details are unknown. Such a traumatic event would undoubtedly have some sort of effect on Ms. Greco. In fact, there would likely be two different traumas: the abrupt
effects of the suicide and the more long-standing effects of having a chronically or recurrently depressed mother. Further exploration might focus on the psychosocial
events leading up to these panic attacks.
For example, Ms. Greco’s “school phobia” may have been a manifestation of undiagnosed separation anxiety disorder, and her recent panic may have developed in the
setting of dating, sexual exploration, and/or a move away from her father and younger siblings. She does not present a pattern of panic in response to social anxiety
or a specific phobia, but she also denies that her symptoms are psychiatric, and so may not recognize the link between her panic symptoms and another set of symptoms.
It might be useful to assess Ms. Greco for anxiety sensitivity, which is the tendency to view anxiety as harmful, and for “negative affectivity,” which is the
proneness to experience negative emotions. Both of these personality traits may be associated with the development of panic.
Because certain symptom clusters are often not recognized spontaneously by patients as either symptoms or clusters of symptoms, it would be useful to look more
specifically for such disorders as posttraumatic stress disorder and obsessive-compulsive disorder. In addition, it might be helpful to explore the sequence of
symptoms. For example, the patient’s panic seems to have led to her worries about heart disease. If the illness worries preceded the panic, she might also have an
illness anxiety disorder or somatic symptom disorder.
Frequently comorbid with panic are depressive and bipolar disorders. Ms. Greco does have depressive symptoms, including insomnia and a preoccupation with death, but
otherwise her symptoms do not appear to meet criteria for a depression diagnosis. Her symptoms would, however, need to be observed longitudinally. Not only does her
mother’s history of depression increase her risk for depression, but she may not be especially insightful into her own emotional states. It would also be useful to
specifically look for symptoms of bipolar disorder. Mania and hypomania are often forgotten by patients or are not perceived as problematic, and a missed diagnosis
could lead to inappropriate treatment and an exacerbation of bipolar symptoms. Furthermore, the development of panic appears to increase the risk of suicide.
Although more should be explored, Ms. Greco does appear to have a panic disorder. DSM-5 suggests the assessment of whether the panic is expected or unexpected. It
appears that Ms. Greco’s initial panic attacks occurred in situations that might have been seen as stressful, such as while driving and at work, and so may or may not
have been expected. Her last episode happened while she was asleep, however, so her panic attacks would be classified as unexpected.
DSM-5 has delinked agoraphobia from panic disorder. They can be comorbid, but agoraphobia is now recognized as developing in a variety of situations. In Ms. Greco’s
case, her active avoidance of driving, exercise, and caffeine is better conceptualized as a behavioral complication of panic disorder rather than a symptom of
agoraphobia. Accurate diagnosis and treatment are important to prevent her symptoms from becoming more severe and chronic.
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