The Concept of Panic Disorder and Panic Attacks - Case Study Example

I could be Dying Generate possible diagnosis. List all that are possible. The patient Bill, 52 years of age male, was affected with several symptoms including tachycardia, palpitations, sudden weight loss, sweating, shaking, dyspnea, tiredness, sleep apnea, sweating, nervousness, sleep problems, panic attacks, etc. He had an earlier history of hypertension which had resolved now following sudden weight lost. From the range of symptoms given, the diagnosis points out that it could primarily be a psychiatric disorder, but a cardiac disorder should be ruled out. From the range of symptoms that are present the differential diagnosis that could be present include panic disorder and panic attacks, hyperthyroidism, cardiac arrhythmias, phobias, PTSD, OCD, tachycardia, atrial flutter and premature ventricular contractions. Hyperthyroidism may also produce similar symptoms, but several symptoms positive of hyperthyroidism is ruled out goiter, ophthalmic symptoms, or an elevated thyroxin level. Cardiac arrhythmias are ruled out as chest pain, dizziness and several of the cardiac symptoms are being ruled out, and the ECG findings may not be positive. Atrial fibrillation is a condition in which palpitations occur along with hypertension and chest pain. PTSD may not be present as a traumatic episode may not be present in this patient. OCD is also ruled out as the presence of obsessions and compulsions are not a major symptom of the patient. However, the best possible diagnosis in this case may be panic disorders or panic attacks, due to the alcohol usage patterns of the patient, symptoms, history, previous history of anxiety and family history of agoraphobia (Mayo Clinic 2012). To rule out other conditions as mentioned in the DD, several other procedures are required including laboratory tests, hormone assay, studying for substance abuse, family history of psychiatric disorders, ECG, etc (Jacobson 200). 2. Identify what specific symptoms are evidenced that supports the possible diagnostic choices. Determine a diagnosis or two that you feel has the most potential. The most potential diagnosis for this condition is panic attacks and panic disorder, though hyperthyroidism and agoraphobia are not ruled out. Panic attacks are intense episodes of fear that may develop for no apparent reason. A patient suffering from a panic attack fears that they are dying or suffering from a heart attack. Several episodes of panic attacks that tend to occur within a period of time and creates a feeling that the patient is losing control are known as panic disorder. Bill constantly felt that he was dying and felt of the attacks. He thought that the attacks were in fact heart attacks. He had suffered 3 attacks during the week, and at least the 10th during the last month, and was present since the last 2 years. According to the DSM-IV-TR, an attack of at least one per month is sufficient to fulfill the diagnosis of panic attack (Biological Unhappiness 2012). The other symptoms that clearly point out to panic disorder include:- Sleep problems Palpitations Sudden weight Rapid heart rate Dyspnea Sweating Tachycardia Trembling Chest tightness Worsens with time Difficulty sleeping Family history of panic attack or agoraphobia Previous history of alcohol or drug usage (Jacobson 2001) The other potential diagnosis that could be present is hyperthyroidism. The symptoms include:- Weight loss Rapid heart beat Nervousness Tremors Tiredness, Difficulty sleeping Ophthalmic symptoms Rise in T3 or T4 levels. History of goiter or swelling in the neck (Jacobson 2001) However, the diagnosis of hyperthyroidism may not be right as there is no history of goiter or a rise in T3 or T4 levels. Besides, a diagnosis of panic disorder is more likely due to the presence of alcohol usage and previous family history of similar psychiatric disorders. 3. Evaluate what other relevant information (such as family history, development, specific situations) support the selected diagnosis. The relevant information that may be ideal for this condition is:- There was a history of alcohol abuse (as episodes of alcohol binges followed with the panic attack episode) The patient had a sudden weight loss episode which may be suggestive of a psychiatric disorder The patient feared flying (Pteromerhanophobia) and fear of closed spaces (claustrophobia) Relation to sleep Feared staying or being alone Had a fear of dying during the period of the panic attack Had a family history of agoraphobia (which invariable suggests that the patient could be affected with panic attacks, anxiety disorders or agoraphobia) (Mayo Clinic 2012) 4. Examine what information seems to contradict the diagnosis (if any). Please explain why this information is contradictory The main information that may contradict the diagnosis was the presence of sleep apnea that could be related to pulmonary hypertension. The main reasons for identification of this condition includes:- Breathing difficulties noticed during the period of attacks (may occur following period of apnea) Relation or being provoked by alcohol usage Relation or relieved by weight loss Relation to hypertension Absence of any positive sleep laboratory test result 5. Report the additional information you need to verify your likely diagnosis. How would this information be helpful? The additional information that is required to verify the diagnosis of the condition includes:- Studying all the vitals including blood pressure, pulse rate, temperature, etc, related to the attack Studying the heart and the lung fields, abdomen, etc Scan of the neck (to check for goiter) Thyroid tests to examine the T3, T4 and the TSH levels, as there is a likelihood that the patient could be suffering from hyperthyroidism Psychiatric evaluation to obtain clues of the presence of various other psychiatric symptoms such as:- Derealisation (feeling of being detached from reality) Depersonalization (feeling of being detached from one’s personality) Feeling of going crazy Feeling of dying Once these queries are fulfilled, it would be sufficient to classify the disorder and make a basis depending on the DSM-IV-TR classification (Khan 2011) 6. Please describe the best treatment that current research reports is best for this disorder. As per current research reports, is medications along with psychotherapy in combination. To goal of the treatment would be to prevent the symptoms from occurring and the patient should be able to resume day-to-day activities. The doctor would start with the treatment that would likely be effective and help the patient, and over a period of time, both forms of treatment can be combined to ensure greater efficiency and safety. The main medications that are useful for this condition include antidepressants (SSRI’s, SNRI’s, TCA’s, and MAOI’s) and benzodiazepines. Antidepressants help to reduce the panic attacks and can also manage the symptoms of depression that can occur with the condition. SSRI’s are the first choice of drugs as they are found to be effective and safe. TCA’s should be avoided in this patient due to the presence of cardiac problems. Benzodiazepines are very useful for the treatment of acute panic attacks and can control the symptoms almost immediately. Usually the doctor would be using one antidepressant, and in case it does not work, he would shift to another (Jacobson 2001). The other treatment mode that is useful is psychotherapy including the Cognitive behavioral therapy and psychodynamic psychotherapy. CBT would help improve thinking and in this way panic episodes can be avoided. Besides, in times of anxious situations, the behavior of the patient may be altered so that attacks are prevented. The other mode psychodynamic psychotherapy helps the individual to focus on the unconscious thoughts and behaviors so that panic avoidance reactions are prevented (Jacobson 2001). 7. Generate what roadblocks the client may experience while trying to complete your treatment plan. There are several roadblocks that may be present with the treatment of this condition. These include Safety of the antidepressants being administered Chronicity of the condition due to which there are chances that the symptoms may be resistant to treatment Dependency on alcohol Presence of cardiac symptoms which may rule out the use of several medications Management of several other symptoms including cardiac symptoms, sleep apnea, sleep problems Management of coexisting psychiatric disorders Since the symptoms are present since the last 2 years, there are chances that they may be resistant and hence the treatment plan should be carefully monitored for any kind of resistance of the symptoms. Another problem that may be present is the alcohol abuse, which may be needed to be handled separately, though initially it can be clubbed with psychotherapy. There is also a need to evaluate the cardiac situation of the patient and monitor the same carefully. Any kind of therapy should be evaluated for the cardiac effect (Stern 2008). 8. Determine what theory the treatment plan you have recommended is based. (E.g. psychodynamic, behavioral, cognitive, etc.) Describe how this theoretical orientation believes the symptoms initially developed. CBT aims at understanding the problems through a scientific basis, reduce emotional distress, improve daily functioning and improve the manner in which the individual thinks and behaviors. It helps to correct maladaptive learning and improves learning. Psychodynamic therapy on the other hand tries to understand the life experiences, dynamics and the personality traits that may be causing emotional distress, and makes an attempt to reshape the same the thinking in such a way that the symptoms would be able to reduce (Welch 2009). Both CBT and Psychodynamic therapy help to provide relaxation and help managing any kind of catastrophic or distorted thinking processes. By challenging these thought processes anxiety is reduced. Usually 12 to 20 sessions are needed to manage the condition (Welch 2009). 9. Evaluate the potential recovery for this individual. What are the recovery rates? Report the current research. The prognosis of people with panic disorder is troubling and is present with several challenges, though effective management of these challenges can help manage the condition better. Hence, regular follow-up and monitoring of the patient is essential. In a study conducted by Maier et al (1988) it was that the symptoms remitted in 43% of the 77 patients who were managed in the study. Amongst the symptoms that persistent the most were anxiety and avoidance behavior during the 1st year. In fact the most common predictor of anxiety was avoidance behavior. In patients who also had symptoms of depression, the most prominent prognostic factor was depression. The outcome and recovery in males was better than in females (Maier 1988). 10. If one day you woke up with this disorder, how would your life is impacted? (e.g. family, friends, work, school, basic functioning) Illustrate using 3 specific examples. Stand in your clients shoes and look around. I do not think that the condition may be caused suddenly, as often there is a provoking factor such as the presence of phobias, traumatic life event, death or loss of a loved one, serious changes in life, or previous abuse. Hence, for example, if a traumatic event has occurred, there are chances that the disorder may occur and several other factors may be involved including genetic, biological and environmental. In the first situation, for example, if I got up with a serious panic attack of something catastrophic that is going to happen in my life, and if I begin to develop physical and mental signs of panic attacks, I would immediately consume a benzodiazepine pill so that the symptoms can reduce immediately. In a second situation, I know for sure that several alternative techniques such as breathing exercises and yoga are very useful in managing or even preventing the symptoms of the disorder. Hence, the first thing that I would do is sit in a relaxed position on my bed, fold my legs together, place my hands on my lap, close my eyes, keep my head straight, and forget all the things that may be present or are troubling me for a moment. I would slowly and very calmly breathe in and feeling the warmness of the air, and slowly breathe out feeling the release of all tensions of my life. I would do the same for at least 20 times over the course of 5 minutes. After doing this, I would then think of a realistic way of solving the problem In a third situation, I would use problem-solving and decision-making techniques to solve the problem in a more professional and realistic manner, keeping in mind that there is a solution to every problem. References Biological Unhappiness (2012). DSMIV Panic Disorder Criteria. Retrieved on April 14, 2012, from Web: http://www.biologicalunhappiness.com/DSMpanic.htm Jacobson, T. (2001). Pscyhaaitric Secrets, 2nd Ed, Philadelphia: Hanley & Belfus. Khan, S. (2011). Panic Disorder & Agoraphobia. Retrieved on April 14, 2012, from Web: http://prezi.com/runnamniezcm/panic-disorder-and-agoraphobia/ Maier, W. (1988). ‘One-year follow-up of panic disorder. Outcome and prognostic factors.’ Eur Arch Psychiatry Neurol Sci. 238(2):105-9. http://www.ncbi.nlm.nih.gov/pubmed/2905266 Mayo Clinic (2012). Panic attacks and panic disorder. Retrieved on April 14, 2012, from Web: http://www.mayoclinic.com/health/panic-attacks/DS00338/DSECTION=causes Mayo Clinic (2012). Symptom Checker. Retrieved on April 14, 2012, from Web: http://www.mayoclinic.com/health/symptom-checker/DS00671/SYMPTOM=43DB0361-2A5D-9994-E5DA0A65D72A13BC Stern, T. A. (2008). Stern: Massachusetts General Hospital Comprehensive Clinical Psychiatry, 1st ed, Philadelphia: Elsevier. Welch, G. & Samson, J. A. (2009). Chapter 42 – Behavior Tehrapy. Retrieved on April 14, 2012, from Web: http://www.mdconsult.com/books/page.do?eid=4-u1.0-B1-56053-418-4..50045-5--cesec20&isbn=1-56053-418-4&sid=1295854244&uniqId=329597813-4#4-u1.0-B1-56053-418-4..50045-5--cesec20 Read More