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

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

Symptoms Experienced During

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)

Symptoms Experienced During

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)

Symptoms Experienced During

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

Symptoms Experienced During

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

Age, Gender and Genetics

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)

Age, Gender and Genetics

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)

Childhood Experiences

• 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 Experiences

• 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)

Childhood Experiences

• 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.