BEHAVIORAL MEDICINE

CASE STUDY:
ANXIETY DISORDERS
Gia Pauline S. Castillo-Mojica, MD, DSBPP, DPCAM, FPPA, FPSMSI, MHA
Raymond Joseph S. Valdez, MD, DSBPP
Objectives:

■ General Objectives:
■ 1. To present cases in relation to the Anxiety Disorders.
■ 2. To review some important topics on Anxiety Disorders.

■ Specific Objectives:
■ 1. To define terms related to Anxiety Disorders.
■ 2. To give differential disorders of Anxiety Disorders.
■ 3. To diagnose using the DSM5 diagnostic criteria.
■ 4. To provide proper management of the cases.
Case 1

■ Cecile, a 36-year-old female presents to the emergency room with a chief complaint
of “I scared that I’m going crazy.” She states that for the past 2 months, she has
been experiencing abrupt episodes of trembling, palpitations, sweating, shortness of
breath, chest pain, dizziness, and feeling as if she is going to die. The first time this
happened she was walking down the street without anything in mind. The episode
lasted approximately 25 minutes.
Case 1

■ Since that time she has had similar episodes twice a day that have occurred
unexpectedly in different situations. As a result she finds herself worrying nearly
continuously regarding when she will have another attack. No other symptoms
reported. She has been to the emergency department twice in the past 2 weeks,
convinced that she is having a heart attack. However, the results of all her physical
and laboratory examinations have been within normal limits.
Case 1

■ She denies drug use and drinks alcohol only “occasionally.” Her alcohol intake has
decreased since the episodes began. Her only medical problem is a 3-year history of
hypothyroidism for which she takes levothyroxine.
Question

■ What is the differential diagnosis?

Answer

■ Anxiety disorder due to another medical condition

■ Medication-induced anxiety disorder
■ Generalized anxiety disorder
■ Panic disorder
Question

■ What is the next diagnostic step?

Answer

■ Request a thyroid profile and look for elevated levels of thyroid hormone, that if
present could explain her symptoms
Definitions

■ PANIC ATTACK: A period of intense fear lasting for a period of time, associated with
at least four of the symptoms
■ AGORAPHOBIA: Anxiety about being in places or situations from which escape might
be difficult (or embarrassing) or in which help cannot be available in the event of
experiencing a panic attack.
DSM-5 Diagnostic Criteria for Panic
Disorder
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense
fear or intense discomfort that reaches a peak within minutes and during which
time four (or more) of the following symptoms occur:
– Note: The abrupt surge can occur from a calm state or an anxious state
– 1. Palpitations, pounding heart, or accelerated heart rate
– 2. Sweating
– 3. Trembling or shaking
– 4. Sensations of shortness of breath or smothering
– 5. Feelings of choking
– 6. Chest pain or discomfort.
DSM-5 Diagnostic Criteria for Panic
Disorder
– 7. Nausea or abdominal distress
– 8. Feeling dizzy, unsteady, light-headed, or faint
– 9. Chills or heat sensations
– 10. Paresthesias (numbness or tingling sensations)
– 11 . Derealization (feelings of unreality) or depersonalization (being detached
from one-self)
– 12. Fear of losing control or "going crazy."
– 13. Fear of dying.
DSM-5 Diagnostic Criteria for Panic
Disorder
– Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache,
uncontrol lable screaming or crying) may be seen. Such symptoms should not
count as one of the four required symptoms.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of
the following:
– 1. Persistent concern or worry about additional panic attacks or their
consequences (e.g., losing control, having a heart attack, "going crazy")
– 2. A significant maladaptive change in behavior related to the attacks (e.g.,
behaviors designed to avoid having panic attacks, such as avoidance of
exercise or unfamiliar situations).
DSM-5 Diagnostic Criteria for Panic
Disorder
C. The disturbance is not attributable to the physiological effects of a substance (e.g.,
a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism,
cardiopulmonary disorders).
D. The disturbance is not better explained by another mental disorder (e.g., the panic
attacks do not occur only in response to feared social situations, as i n social
anxiety disorder; in response to circumscribed phobic objects or situations, as in
specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in
response to separation from attachment figures, as in separation anxiety disorder).
Medical Conditions Causing Panic
Attacks
■ Cardiac ■ Endocrine
– Angina – Cushing disease
– Arrhythmias – Addison disease
– Congestive heart failure – Hyperthyroidism
– Infarction – Hypoglycemia
– Mitral valve prolapse – Hypoparathyroidism
– Premenstrual dysphoric
disorder
Medical Conditions Causing Panic
Attacks
■ Neoplastic ■ Neurologic
– Carcinoid – Seizure disorder
– Insulinoma – Vertigo
– Pheochromocytoma – Huntington disease
– Migraine
– Multiple sclerosis
– Transient ischemic attacks
– Wilson disease
Medical Conditions Causing Panic
Attacks
■ Pulmonary diseases ■ Other diseases
– Asthma – Anaphylaxis
– Obstructive pulmonary disease – Porphyria
– Hyperventilation
– Pulmonary embolus
Treatment

■ Antidepressants such as SSRIs, SNRIs and TCA antidepressants are highly effective
in treating panic disorder
■ Best results are likely obtained when medication is used in combination with a
course of CBT.
■ As in depression, a significant therapeutic effect from medications may not be seen
until 2-6 weeks.
Treatment

■ Treatment with a benzodiazepine is given on a short-term basis to provide more

immediate relief or as PRN medications for panic attacks.
■ Alprazolam is very effective but FDA approved for the treatment of panic disorder
Treatment

■ Cognitive-behavioral therapy teaches the patient about the disorder, helps decrease
or eliminate core fears, and specifically addresses the restrictions on lifestyle
present in individuals with this condition.
Comprehension Questions

■ Alvin, a 28-year-old man describes a persistent fear of speaking in public. He does

not have difficulty with one-on-one situations, when giving a lecture he becomes
extremely anxious, worrying that he will be humiliated. He relates one episode in
which he was forced to speak at the last minute, which resulted in his experiencing
abdominal discomfort, panic, shaking, and a fear that he would defecate on himself.
Because of this problem, he has been held back from promotion at his place of
business. Which of the following is the most likely diagnosis?
Comprehension Questions

Which of the following is the most likely diagnosis?

■ A. Generalized anxiety disorder
■ B. Panic disorder with agoraphobia
■ C. Panic disorder without agoraphobia
■ D. Social phobia
■ E. Specific phobia
Comprehension Questions

■ Aida, a 40-year-old woman presents with complaints of not being able to leave her
house. For the past 5 years, she has had increasing difficulty traveling far from
home. She constantly worries that she will not be able to get help if she “freaks out.”
In fact, she has had numerous unprovoked episodes of intense fear, associated with
shortness of breath, chest pain, diaphoresis, and dizziness, lasting for 20 minutes.
She is convinced that if she goes too far from home, she will have an attack and not
be able to obtain help. Which of the following is the most likely diagnosis?
Comprehension Questions

■ A. Generalized anxiety disorder

■ B. Panic disorder with agoraphobia
■ C. Panic disorder without agoraphobia
■ D. Social phobia
■ E. Specific phobia
Comprehension Questions

■ Karen, a 25-year-old woman describes a lifelong history of being “scared of heights.”

She becomes uncomfortable when at an elevation higher than five stories and
whenever traveling or shopping becomes preoccupied with knowing the heights of
buildings. On finding herself at a significant distance from the ground, she has
severe anxiety symptoms including tremors, lightheadedness, numbness and
tingling, and a fear of dying. Which of the following is the most likely diagnosis?
Comprehension Questions

■ A. Generalized anxiety disorder

■ B. Panic disorder with agoraphobia
■ C. Panic disorder without agoraphobia
■ D. Social phobia
■ E. Specific phobia
Comprehension Questions

■ Alvin, a 33-year-old man has the chief complaint of “I’m going to have a heart attack like my
father.” He explains that his father died of a myocardial infarction at 55 years of age. He is
convinced that he is experiencing anginal attacks consisting of nervousness, sweating,
palpitations, flushing, and numbness in his hands lasting for several minutes. He is anxious
about having these symptoms and, despite negative results from a cardiology workup,
remains certain that he will suffer a heart attack. His behavior and lifestyle have not been
otherwise affected. Which of the following is the most likely diagnosis?
Comprehension Questions

■ A. Generalized anxiety disorder

■ B. Panic disorder with agoraphobia
■ C. Panic disorder without agoraphobia
■ D. Social phobia
■ E. Specific phobia
Clinical Pearls

■ Panic disorder is characterized by recurrent, unexpected panic attacks with worry

about having additional attacks, the consequences of attacks, or a change in
behavior as a result of attacks.
■ Any medical conditions, medications, or substance use that can cause panic attacks
should be ruled out.
■ Major depressive disorder is commonly seen in patients with panic disorder.
Clinical Pearls

■ SSRIs, SNRIs or other antidepressants, in combination with cognitive behavioral

therapy, are used in the pharmacologic treatment of panic disorder.
■ If benzodiazepines are also administered, they should be used in as low a dose and
for as short a time as possible since they are PRN medications.
Watch these videos:
Psychiatry- Anxiety Disorders by: Nikola Grujich, MD
■ https://www.youtube.com/watch?v=_MtLaiCThT0
Panic disorder - panic attacks, causes, symptoms, diagnosis, treatment & pathology
■ https://youtu.be/YxELZyA2bJs
Generalized anxiety disorder (GAD) - causes, symptoms & treatment
■ https://www.youtube.com/watch?v=9mPwQTiMSj8&t=1s
Obsessive compulsive disorder (OCD) - causes, symptoms & pathology
■ https://www.youtube.com/watch?v=I8Jofzx_8p4
Posttraumatic stress disorder (PTSD) - causes, symptoms, treatment & pathology
■ https://www.youtube.com/watch?v=hzSx4rMyVjI
DSM5 Generalized Anxiety Disorder
■ https://www.youtube.com/watch?v=Q_lryMERmS8&t=27s
Types of Anxiety Disorders
■ https://youtu.be/Y1JFfEkyoqc
References
Kaplan & Sadock’s Synopsis of Psychiatry 11th Edition Copyright 2015

Psychiatry- Anxiety Disorders by: Nikola Grujich, MD

■ https://www.youtube.com/watch?v=_MtLaiCThT0

Panic disorder - panic attacks, causes, symptoms, diagnosis, treatment & pathology

■ https://youtu.be/YxELZyA2bJs

Generalized anxiety disorder (GAD) - causes, symptoms & treatment

■ https://www.youtube.com/watch?v=9mPwQTiMSj8&t=1s

Obsessive compulsive disorder (OCD) - causes, symptoms & pathology

■ https://www.youtube.com/watch?v=I8Jofzx_8p4

Posttraumatic stress disorder (PTSD) - causes, symptoms, treatment & pathology

■ https://www.youtube.com/watch?v=hzSx4rMyVjI

DSM5 Generalized Anxiety Disorder

■ https://www.youtube.com/watch?v=Q_lryMERmS8&t=27s

Types of Anxiety Disorders

■ https://youtu.be/Y1JFfEkyoqc
Thank you!