Ahn Ming, aged 23 years presents with her mother. Her mother states that Ahn has become withdrawn and refuses to leave the house. It took a lot of trouble to get her to attend to see you today. Ahn states that if she tries to leave the house she feels like she is going to die and have a heart attack. She states that 6 months earlier she went to a party and on the way home a group of males followed her and yelled names at her. Whilst they did not actually hit or hurt her she was very frightened. Before this time, she had attended University and had been planning to look for a job, but now she was fearful of leaving her home.
Symptoms of Anxiety Disorder include: Psychological (apprehension, irritability, worry, poor concentration, fear of impending disaster, depersonalisation) and Somatic (palpitations, tremor, fatigue, dizziness, sweating, diarrhoea, frequency, chest pain, breathlessness, initial insomnia, headache) symptoms of sympathetic arousal.
The broad categories of anxiety disorders are divided into three main subtypes: phobic, paroxysmal (panic) and generalised. Obsessive compulsive disorder is also an anxiety disorder, although different from these and is studied separately. The nature and prominence of the somatic symptoms often lead the patient to present initially to medical services with physical complaints. Anxiety may be stress-related and phobic anxiety may follow an unpleasant incident. Patients often also have depression.
Differential Diagnosis of Anxiety includes:
Note: Depression can present with anxiety/panic, particularly early on
Medical causes of anxiety include:
From Ahn:
Phobia: an abnormal or excessive fear of an object or situation, which leads to avoidance of it.
Panic attack: attacks of severe anxiety, not restricted to any particular situation or circumstances and is therefore unpredictable. Somatic symptoms e.g. chest pain and palpitations are common. The symptoms are in part due to involuntary hyperventilation. Patients often fear they are suffering from a serious illness, e.g. heart attack or CVA and may seek emergency medical attention.
Generalised anxiety: chronic anxiety associated with uncontrollable worry. Somatic symptoms of muscle tension and bowel disturbance often lead to a medical presentation.
Obsessions: unwanted, intrusive, inappropriate thoughts, images or impulses that cause marked anxiety and distress e.g., recurrent thoughts that one's hands are contaminated/dirty after shaking hands.
Compulsions: repetitive behaviours (e.g., washing hands, checking, tidying up) or mental acts (eg, counting, repeating words silently) with object of reducing anxiety. These behaviours are excessive or not logically related to what they are intended to prevent. Mostly, compulsions are performed to reduce the distress accompanying an obsession (eg, repeated washing of hands as response to thoughts of contamination). The most common involve washing, cleaning, counting, checking and ordering. Obsessions and compulsions are the key symptoms of obsessive-compulsive disorder (OCD).
Panic disorder with agoraphobia is the most likely (she has all the characteristic symptoms)
She may have underlying GAD, depression, social phobia or be naturally shy.
The events at the party may be sufficiently severe to evoke a post-traumatic response or to reinforce any of the above. She may also have a psychotic episode and be misperceiving some of the events, and substance use would have to be ruled out. Social anxiety may have led her to misperceive the interaction but all this needs further enquiry. She is also at a life transition/may be moving away from her mother, which may be creating separation issues.
Psychological treatments are the first treatment of choice in most cases, particularly when disorders are not severe. Explanation and reassurance are essential, especially when patients fear they have a serious medical condition.
Specific psychological treatments may be needed for those who do not respond, including relaxation, graded exposure (desensitisation) to feared situations for phobic disorders, and CBT for panic. This can be face to face, in books or online. With the added impact of the events after the party, face to face best. There may also be elements of trauma to be addressed.
Drug treatment: In severe cases, drug treatment may be necessary and helpful. However, medication reduces symptoms but rarely change behaviour, usually achieved through psychological treatments, which should be administered concurrently in most cases, particularly in phobias. Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants are the drugs of choice. Benzodiazepines may produce symptom relief in the short term but long-term use can lead to dependence. A β-blocker such as propranolol can help when peripheral somatic symptoms are prominent.
Using a biopsychosocial framework, you can ask these questions and treat accordingly:
Biological: rule out any medical causes noted above, consider any changes in her habits/sleep substances/medications (e.g. prednisone, xs coffee/stimulant drinks intake)
Psychological: Explore more of her thoughts and feelings around the panic attacks. CBT looks at the negative thoughts and is very useful here.
Social: Consider her relationship with her mother (Is there some change? Is her mother encouraging her to stay home as she is lonely?) How did she get on at Uni? Was she involved or isolated? Is she worried about starting a job? Being more independent? Does she have friends/partner? Interests? A problem solving or IPT approach would be more appropriate here.