Psych Case Presentation

PSYCHIATRY II Case

Presentation

Identifying Data

• A.C. is a 31 year old male, with a live-in

partner for 14 years, has two children aged

11 and 7, 5th child in a brood of seven, high

school graduate, pedicab driver, Catholic,

residing in Leveriza St, Manila.

Chief Complaint

• “Masakit sikmura, kinakabog, nanlalamig, at

namamawis kapag hindi ko nakikita ang misis ko

at kapag lumalabas ako”

History of Present Illness

• One year and 2 months PTC

– received news of his elder sister’s sudden death

due to cardiac arrest

– patient suddenly experienced epigastric pain,

palpitations, cold, clammy extremities, excessive

sweating, and difficulty breathing

– No consult done, no meds taken

– He noted such symptoms for a week especially

when travelling to and from work as a janitor in

Makati

– He also noted this when his co-workers were not

around

– During that same week, he also experienced being

trapped in an elevator for two minutes because of

power interruption

– At that time, he experienced the same symptoms of

epigastric pain, palpitations, sweating, and

difficulty of breathing; relieved only when the

elevator door opened

– Since then the patient avoided riding the elevator

for too long because he feared being trapped

inside again

– He also avoided the stairs for fear of being locked

in because it was company policy to lock the

stairwell

– A week after his sister’s death he was unable to

work as a janitor since his attacks would occur while

in travel or when alone

• Eleven months PTC

– patient went to his childhood home in Batangas to

visit his family

– While there he consulted a physician who

prescribed him to take Kremil-S and Inderal

– Patient took the meds when symptoms appear but

with transient relief

– Patient stayed in the province for one week then

returned to Manila. He returned to work as a

pedicab driver

– The patient’s symptoms were present almost every

day and especially when he couldn’t see his wife

– Patient feared that he might collapse if he is alone

and there would be no one to help him

– He had no prior experience of collapsing but

couldn’t help thinking of the probability of

experiencing such

– Since the symptoms usually occur when the partner

is not around, the partner decided to sell cigarettes

near the pedicab terminal

– Patient also experienced difficulty initiating sleep

for fear of recurrence of symptoms and would

have interrupted sleep as well

– He usually sleeps around 8PM but now would sleep

at 12 MN

– He would wake up at around 2 and 4AM due to

the symptoms

• Two months PTC

– The patient’s symptoms have become more

frequent

– He wouldn’t go out as much as he used to unless he

had to work as a pedicab driver

– His symptoms would appear when his partner was

not by his side when at home or when he had to

drive far in his pedicab

– He tried to endure the symptoms but has limited his

working schedule to three times a week

– He continued to take Kremil-S and Inderal but with

little relief

• Few hours PTC

– Patient attended his eldest daughter’s graduation

practice with his partner

– When he was separated from his partner, he

experienced epigastric pain, palpitations,

sweating, and difficulty of breathing

– Patient took Inderal but with little effect.

– Symptoms were only relieved when he saw his

partner again

– Patient sought consult at a nearby health center but

was referred to our institution

Past Medical History

• No previous hospitalizations, on Inderal and

Kremil-S PRN basis, no suicidal ideations, no

known allergies, no DM, HPN, Asthma

Social History

• Non smoker, drinks two bottles of Red Horse

beer once a week, started at age 19.

• Denies use of illicit substances.

Family History

• Non- remarkable

Anamnesis

• Patient was born via normal spontaneous

delivery without birth trauma or complications.

• Patient’s mother had no maternal health

problems during pregnancy and was not using

any illicit substances.

• Patient was both breastfed and bottle fed for

an unknown period of time.

• He was toilet trained at age 3 – 4.

• There was no thumb sucking, temper tantrums,

or head banging.

• He was known to be shy with strangers but an

active child with a good relationship with his

siblings.

• Patient would be reprimanded as a form of

discipline but didn’t experience corporal

punishment.

• He was described as shy and quiet during

school hours but had many friends.

• He had no learning disabilities.

• He was a basketball and volleyball player at

school

• He had a good relationship with peers and

classmates and had no disciplinary actions

against him at school.

• He was more of a follower than a leader.

• During late childhood, he suddenly developed

fear of the dark and would sleep with the

lights on.

• He attributed his fear to an overactive

imagination.

• He had his first relationship at age 16 which

lasted for 3 months.

• They broke up when the girl had to leave for

Manila.

• After high school he took up a vocational

course in Electronics but was unable to finish

due to financial constraints.

• He worked as a janitor at age 19.

• He also had a live in partner at this age with

whom he has two children.

• They have a good marital relationship.

Physical Examination

• Vital Signs:

• BP 120.90, HR 73, RR 17, Temp 37.2 C

• Normal physical and neuro exam

Mental Status on Admission

• Patient is well groomed, cooperative, seated

during the interview.

• Anxious mood with broad and appropriate

affect.

• Speech is spontaneous with normal rate, tone,

and rhythm.

• No perceptual disturbances. Thought processing

is goal directed.

• Though content shows preoccupation that

something will happen to him if the partner is

not around.

• He is alert, oriented to three spheres, intact

memory, able to spell KARNE backwards, can

read and write, able to draw a clock, able to

interpret proverb, adequate fund of

information and intelligence, good impulse

control, insight level 3, good judgement.

Salient Features

• HISTORY OF PRESENT ILLNESS

• One year and 2 months PTC – Patient suddenly experienced epigastric pain, palpitations, cold, clammy

extremities, excessive sweating, and difficulty breathing

– Symptoms occurred especially when travelling to and from work

– He also noted the symptoms when his co-workers were not around

– Trapped in an elevator for two minutes, experienced the same symptoms which

were only relieved when the elevator doors opened

– Avoided riding the elevator for too long because he feared being trapped

inside again

– Also avoided using the stairs

– Unable to work because the attacks would occur in travel or when he was alone

Salient Features

• Eleven months PTC

– Took Kremil-S and Inderal when symptoms

appeared but with transient relief

– Symptoms were present almost every day and

especially when he couldn’t see his wife

– Patient feared that he might collapse if he is alone

and there would be no one to help him

– Patient also experienced difficulty initiating sleep

for fear of recurrence of symptoms and would

have interrupted sleep as well

Salient Features

• Two months PTC

– Increased frequency of symptoms

– Symptoms would appear when his partner was not

by his side when at home or when he had to drive

far in his pedicab

– Continued to take Kremil-S and Inderal but with

little relief

Salient Features

• Few hours PTC

– He experienced symptoms when his partner left his

side

– Took Inderal but with no relief

– Symptoms were only relieved when he saw his

partner again

Salient Features

• ANAMNESIS

• During late childhood, he suddenly developed

fear of the dark and would sleep with the

lights on (attributed to an overactive

imagination)

• MENTAL STATUS ON ADMISSION

• Though content shows preoccupation that

something will happen to him if the partner is

not around

Differential Diagnosis

C:/Users/Erin Keshia/Desktop/DIFFERENTIAL DIAGNOSIS.pdf

Working Impression

• Separation Anxiety Disorder,

cannot completely rule out

Agoraphobia

Case Discussion

Theories on Anxiety

• Psychoanalytic Theory

• Schema Theory

• Semantic Network of Theory of Emotions

Psychoanalytic Theory

2 Types of Anxiety

1. Automatic

2. Neurotic

Schema Theory

• In cases of anxiety, the schemata are sensitive

to threat or danger (Mogg & Bradley, 1998).

• In an individual that is anxiety-prone, activation

of these schemata would increase the tendency

to interpret stimuli as a threatening manner and

thus, more chance of remembering the situation.

Semantic Network Theory of

Emotions

• Bower discussed that each emotion is

represented by a node in the associative

network of memory (Mogg & Bradley, 1998).

Symptoms Experienced During

Attacks

• Anxiety and fear

– alerting signals and act as a warning of an internal

and external threat


Attacks

• Anxiety

• normal and adaptive response that has lifesaving qualities

• warns of threats of bodily damage, pain, helplessness,

possible punishment

• frustration of social or bodily needs

• of separation from loved ones

• of a menace to one's success or status

• and ultimately of threats to unity or wholeness

• (Sadock & Virginia Alcott, 2007)


Attacks

• The experience of anxiety has two components:

– the awareness of the physiological sensations (e.g.,

palpitations and sweating)

– the awareness of being nervous or frightened

(Sadock & Virginia Alcott, 2007)


Attacks

• Freud: anxiety stemmed from a physiological

buildup of libido, but he ultimately redefined

anxiety as a signal of the presence of danger

in the unconscious

• Anxiety

– result of psychic conflict between unconscious sexual

or aggressive wishes and corresponding threats

from the superego or external reality


Attacks

• In response to this signal, the ego mobilized

defense mechanisms to prevent unacceptable

thoughts and feelings from emerging into

conscious awareness

• (Sadock & Virginia Alcott, 2007)

Age, Gender and Genetics

AGE

• Adult separation anxiety disorder has been

under-diagnosed.

• Separation anxiety disorder decreases in

prevalence from childhood through adolescence

and adulthood.

• Adult form of SAD is described in the psychiatric

literature recently.

– lifetime prevalence of 6.6% (Silove, et al.,

2010).

GENDER

• differences are less strong in ASAD

– males are more likely to report first onset in

adulthood (Bogels, S.M. et al., 2013).

• indirect expression of fear of separation may be

more common in males than in females

– limited independent activity, reluctance to be away

from home alone, or distress when spouse or

offspring do things independently or when contact

with spouse or offspring is not possible


GENETICS

• Its heritability was estimated at 73% in a community

sample of 6-year-old twins, with higher rates in girls.

• both adult and childhood separation anxiety

disorders tend to cluster in families, with one study

suggesting an hereditary pattern (Silove, et al., 2010)


Alcohol Use

• People who experience chronic feelings of anxiety often drink beer or a glass of wine to quell the uneasiness

• Alcohol may help people with anxiety cope in the short term, but over time this strategy can backfire.

• Self-medicating with alcohol or drugs can increase the risk of alcoholism and other substance-abuse problems, without addressing the underlying anxiety (Archives of General Psychiatry)

Alcohol Use

• Alcohol

– Drug that depresses the central nervous system

– Initially, alcohol consumption has a sedative effect and produces a sense of euphoria and decreased inhibitions

– Seemingly providing relief

• Self-medication for anxiety is common

• People with diagnosed anxiety disorders who self-medicated at the start of the study were two to five times more likely than those who did not self-medicate to develop a drug or alcohol problem within three years.

Alcohol Use

Tension Reduction Theory of Alcohol Use

• 2 basic testable postulates – First, alcohol will reduce the tension

– Second, a state of anxiety will motivate alcohol use

• There are some contexts in which alcohol does indeed reduce tension.

• However, the linear effect is mediated by a number of other factors: – amount of alcohol consumed, expectations about the

effect of alcohol, and the social context in which alcohol is consumed

Alcohol Use

• Stress-response Dampening Model

– A current incarnation of anxiety reduction theory

– “Pared-down” tension reduction hypothesis

– Focuses in the reinforcing effects of alcohol in

adverse or stressful situations.

– Basic postulate:

• individuals who experience stress-response dampening

effects are more likely to consume greater amounts of

alcohol in stressful situations

Alcohol Use

Other Theories Of Alcohol Use

• Some researchers have proposed that there

may be a genetic link that influences a person’s

anxiety level and alcohol consumption.

– These biological theories suggest that a brain

mechanism is responsible for anxiety symptoms and

drinking behaviors

Alcohol Use

• Other researchers have proposed an expectancy

component in alcohol consumption and anxiety

symptoms.

– One would expect relief of anxiety symptoms after

consuming alcohol due to its effects on the central

nervous system.

– Drinking behaviors are based on one’s level of anxiety

and the expected relief alcohol will provide.

– Relief from very high anxiety levels would be expected

to ease with greater consumption of alcohol

Childhood Experiences

• Significant associations between retrospectively

reported childhood adversities (CAs) and adult

illness have been documented in numerous

studies

• CAs are often nonspecific in their associations

with many different mental disorders (Green et

al. 2010)


• CAs have powerful and often subadditive

associations with the onset of many types of

largely primary mental disorders throughout

the life course, which may include Adult

Separation Anxiety Disorder


• Childhood trauma contributes to the severity of

psychopathology (Hovens et al. 2010).

• Clinically significant separation anxiety

disorder in childhood leads to adult panic

disorder and other anxiety disorders (Milrod et

al. 2014)


• No mention of childhood adversities or

childhood trauma, except that the patient had

achluophobia (fear of the dark) in his late

childhood.

• In line with this, some researchers consider the

fear of the dark as a manifestation of

separation anxiety disorder (Tasman et al.

2011).

Treatment and Management

General Considerations

• Pharmacotherapy

• Psychotherapy

• Pharmacotherapy + Psychotherapy

• Generally:

– Medication (atleast 6-12 months)

– If (+) resolution: Tapering off the medications +

more intensive psychotherapy

Psychotherapy

• Behavioral therapy

• Cognitive Behavioral therapy

• Self-Help Techniques:

– Focus.

– Breathe slowly and deeply.

– Challenging fears.

– Creative visualisation.

– Don't fight an attack.

Other Non-pharmacologic Mgt.

• Diet and Activity – Discourage caffeine intake

– Minimize alcohol intake

– Encourage usual activities

– Exercise to release stress and relieve tension

•

• Long-Term Monitoring – In-patient management not indicated for this case (only for

severe phobic disorders with suicidal ideations/attempts)

– Out-patient follow-up • Monitor his response to treatment

• Monitor his tendency for relapse

Pharmacologic Treatment

Selective Serotonin Reuptake Inhibitos

• The selective serotonin reuptake inhibitors (SSRIs) represent a chemically diverse class of agents that have as their primary action the inhibition of the serotonin transporter (SERT).

• It has little or no affinity for alpha-adrenergic, histamine or cholinergic receptor.

• Overall, SSRIs appear to be more effective than MAOIs for the treatment of social anxiety disorder.

• SSRIs and venlafaxine are generally considered first-line agents

1. Fluoxetine

• Given 20-60mg/day.

• Fluoxetine is metabolized to an active product, norfluoxetine, which may have plasma concentrations greater than those of fluoxetine.

• The elimination half-life of norfluoxetine is about three times longer than fluoxetine and contributes to the longest half-life of all the SSRIs.

• As a result, fluoxetine has to be discontinued 4 weeks or longer before an MAOI can be administered to mitigate the risk of serotonin syndrome.

Serotonin- Norepinephrine Reuptake

Inhibitors

• They are potent inhibitors of the reuptake of serotonin and norepinephrine.

• They are better tolerated, with less anticholinergic effects and weight gain than Tricyclic Antidepressants.

• They are efficacious for a wide array of mood and anxiety disorders, in particular panic disorders.

• Abrupt discontinuation of SNRIs is ill- advised because it may cause discontinuation syndrome that is similar with SSRI’s.

1. Duloxetine

– Given daily 60 – 120 mg/ day

– Rapidly absorbed following oral administration

and is absorbed after 2 hours with a maximum

concentration achieved in approximately 6 hours

– Effective in improving not only anxiolytic symptoms

but also painful physical symptoms such as

abdominal pain, pain severity and patient

functioning

– generally well tolerated with no significant effect

on weight reported

2. Venlafaxine

– Effective for panic disorders

– Effective in the range of 75 – 225 mg/ day

– Initiated gradually to reduce the likelihood of side-

effects

– Dosing is usually initiated at 37.5 mg for the first 3

– 7 days and is subsequently increased to a

minimum of 75-mg/ day

– Side- effects and increase in blood pressure should

be monitored

Tricyclic Antidepressants

• Inhibit the reuptake of the biogenic amines, mostly norepinephrine (NE), as well as serotonin (5HT)

• Up until they were supplanted by the SSRIs and SNRIs, Tricyclic Antidepressants were considered the “gold standard” pharmacotherapy for panic disorders.

• Relegated to second- line use due to their greater side- effects burden

1. Clomipramine

– started at doses substantially lower than those for

patients with depression or other psychiatric

conditions

– effective in lower doses than imipramine and can

be used effectively in doses ranging from 50 –

150 mg/ day

– effective in lower doses than imipramine and can

be used effectively in doses ranging from 50 –

150 mg/ day

Psychotherapy

• Controlled studies have found behavioral therapy and cognitive behavioral therapy (CBT) to be effective in treating phobic disorders.

• Psychodynamic therapy (or insight-oriented therapy) is rarely indicated as an exclusive treatment for phobias and is now mostly reserved for cases of phobic disorders that overlap personality disorders.

• For treatment of social anxiety disorder, self-

exposure monotherapy has been shown to work

as well as computer-based exposure training,

clinician-led exposure, or combination therapies

of self-exposure and CBT/self-help manual.

• A CBT-based approach, including gradual

desensitization, is the most commonly used

treatment for specific phobia. Other treatments

include relaxation and breathing control

techniques.

Diet and Activity

• The patient’s intake of caffeine (eg, in coffee, caffeinated teas, or sodas) should be assessed; even moderate amounts of caffeine may exacerbate the anxiety response and symptoms.

• A tryptophan-rich diet was shown to have a positive effect on social anxiety disorder.

• Dietary restrictions (a tyramine-free diet) are necessary for patients taking MAOIs.

• Activity should not be restricted.

• Patients should be encouraged to confront anxiety-producing stimuli in the context of a behavioral therapy treatment plan.

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Psych Case Presentation