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Transcript of 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
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.