Panic Disorders: A Case Study
The hypothesis that social anxiety disorder is associated with heightened self-focused attention has a long lineage and is well supported. Within the Clark and Wells (1995) model, self-focused attention increases the individuals awareness of interoceptive information that is likely to be taken as a sign that they are about to fail, or have failed, to convey an acceptable impression to others. In other words, individuals with social anxiety attend to their own internal experience, monitoring their performance and paying particular attention to signs of anxiety, including physical cues. Physical symptoms of social anxiety commonly reported including: palpitations, trembling, sweating, muscle tension, stomach pain, dry throat, hot or cold flashes, and headaches (Leahy et al., 2011). For some patients the physical symptoms
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can reach the level of a full-blown panic attack (Heckelman & Schneier, 1995; Judd, 1994).
In Sandra’s case, the physical cues that she has identified during the feared situation are indicative of a panic attack rather than meeting the full diagnostic criteria of Panic Disorder. Her panic attacks are accompanied by various physical symptoms (i.e. sweating, trembling, faintness, heat sensations, stuttering, headaches, abdominal distress, and trouble concentrating), and primarily occur in the presence of a feared situation (i.e. executing performance tasks related to her occupation, exposure to unfamiliar people or large crowds). According to the DSM-5, panic attacks are not a mental disorder, however, they can co-occur with several anxiety and mental disorders as well as some medical conditions (American Psychiatric Association, 2013).
A diagnosis of Other Specified Insomnia Disorder has been given to the patient due to her reported acute and short-term insomnia. Sandra’s symptoms have been present for less than three months, but otherwise meet all the criteria with regard to frequency, intensity, distress, and impairment. Sandra experiences difficulty maintaining sleep for at least three nights a week despite having adequate opportunity for sleep. Her insomnia has caused marked distress and impairment in her occupational functioning. In addition, it is not related to another sleep wake or mental disorder as well as the physiological effects of a substance (American Psychiatric Association, 2013). The cognitive model of insomnia hypothesizes that worry activates the sympathetic nervous system, which triggers physiological arousal and distress. The combination of arousal and distress directs the individual into a state of further anxiety that inhibits ones from falling asleep and staying asleep (Tarrier, 2006).
In the case of Sandra Hill, it is known that she experiences heightened fear and anxiety when faced with performance or social situations in which she is exposed to unfamiliar people or possible scrutiny by others. Exposure to the feared situation generally provokes anxiety that is either avoided or endured with intense anxiety, which generally leads to symptoms of a panic attack. The anticipation of engaging in the feared situation inhibits her ability to acquire restorative sleep, which further perpetuates the somatic and cognitive symptoms.
Differential diagnosis.
1. Agoraphobia. In agoraphobia, individuals may fear and avoid social situations similar to individuals with social anxiety disorder. However, individuals with agoraphobia have a marked fear or anxiety about two or more of five possible situations that the DSM-5 lists (i.e. using public transportation, standing in line or being in a crowd, being outside of the home alone, being in open spaces, and being in enclosed places) (American Psychiatric Association, 2013). In social anxiety disorder, the avoided situation always involve social interaction and the fear of judgement, whereas in agoraphobia, individuals fear situations in which they could have an unexpected panic attack or other uncomfortable symptoms and be unable to escape or get help. Therefore, individuals with social anxiety disorder typically feel most comfortable when they are alone, whereas individuals with agoraphobia are typically more comfortable when others are present (Leahy et al., 2011).
2.
Panic Disorder. Although panic attacks can occur in the context of other anxiety disorders, panic disorder is diagnosed if the individual experiences persistent, unforeseen attacks and experiences continual apprehension either about having future attacks or about the repercussion of the attacks. Therefore, when the presence of a panic attack is identified, it is noted as a specifier rather than a primary diagnosis (American Psychiatric Association, 2013). Sandra does experience panic attacks, but her primary concern is about fear of negative evaluation, whereas in panic disorder the concern is about the panic attacks themselves.
3. Depression. Social withdrawal and hypersensitivity to criticism may be present in major depression. However, these symptoms are mood-dependent and remit when the depressive episode resolves. Moreover, the worry related to social anxiety is about being negatively evaluated because of certain social behaviors or physical symptoms. Sandra has not reported or demonstrated any depressive symptoms other than occasional loneliness and insomnia. However, further evaluation is needed in order to assess and quantify her
mood.
Assessment considerations. Assessing the need of medication for the patient’s anxiety should be considered. Some authors have recommended that beta-blockers and benzodiazepines be considered as first-line medications for patients with performance fears (Belzer et al., 2005). It should be noted that patients often choose to start medication and therapy concurrently and make changes to medication during the course of treatment. Clinicians should be prepared to discuss the possible confounding effects of such choices as patients evaluate and make attributions about their progress within the realm of their competencies. Further evaluation should also include the presence of any comorbid disorders, communication skill deficits, and family factors. Comorbidity is common for social anxiety disorder. The most common coexisting
can reach the level of a full-blown panic attack (Heckelman & Schneier, 1995; Judd, 1994).
In Sandra’s case, the physical cues that she has identified during the feared situation are indicative of a panic attack rather than meeting the full diagnostic criteria of Panic Disorder. Her panic attacks are accompanied by various physical symptoms (i.e. sweating, trembling, faintness, heat sensations, stuttering, headaches, abdominal distress, and trouble concentrating), and primarily occur in the presence of a feared situation (i.e. executing performance tasks related to her occupation, exposure to unfamiliar people or large crowds). According to the DSM-5, panic attacks are not a mental disorder, however, they can co-occur with several anxiety and mental disorders as well as some medical conditions (American Psychiatric Association, 2013).
A diagnosis of Other Specified Insomnia Disorder has been given to the patient due to her reported acute and short-term insomnia. Sandra’s symptoms have been present for less than three months, but otherwise meet all the criteria with regard to frequency, intensity, distress, and impairment. Sandra experiences difficulty maintaining sleep for at least three nights a week despite having adequate opportunity for sleep. Her insomnia has caused marked distress and impairment in her occupational functioning. In addition, it is not related to another sleep wake or mental disorder as well as the physiological effects of a substance (American Psychiatric Association, 2013). The cognitive model of insomnia hypothesizes that worry activates the sympathetic nervous system, which triggers physiological arousal and distress. The combination of arousal and distress directs the individual into a state of further anxiety that inhibits ones from falling asleep and staying asleep (Tarrier, 2006).
In the case of Sandra Hill, it is known that she experiences heightened fear and anxiety when faced with performance or social situations in which she is exposed to unfamiliar people or possible scrutiny by others. Exposure to the feared situation generally provokes anxiety that is either avoided or endured with intense anxiety, which generally leads to symptoms of a panic attack. The anticipation of engaging in the feared situation inhibits her ability to acquire restorative sleep, which further perpetuates the somatic and cognitive symptoms.
Differential diagnosis.
1. Agoraphobia. In agoraphobia, individuals may fear and avoid social situations similar to individuals with social anxiety disorder. However, individuals with agoraphobia have a marked fear or anxiety about two or more of five possible situations that the DSM-5 lists (i.e. using public transportation, standing in line or being in a crowd, being outside of the home alone, being in open spaces, and being in enclosed places) (American Psychiatric Association, 2013). In social anxiety disorder, the avoided situation always involve social interaction and the fear of judgement, whereas in agoraphobia, individuals fear situations in which they could have an unexpected panic attack or other uncomfortable symptoms and be unable to escape or get help. Therefore, individuals with social anxiety disorder typically feel most comfortable when they are alone, whereas individuals with agoraphobia are typically more comfortable when others are present (Leahy et al., 2011).
2.
Panic Disorder. Although panic attacks can occur in the context of other anxiety disorders, panic disorder is diagnosed if the individual experiences persistent, unforeseen attacks and experiences continual apprehension either about having future attacks or about the repercussion of the attacks. Therefore, when the presence of a panic attack is identified, it is noted as a specifier rather than a primary diagnosis (American Psychiatric Association, 2013). Sandra does experience panic attacks, but her primary concern is about fear of negative evaluation, whereas in panic disorder the concern is about the panic attacks themselves.
3. Depression. Social withdrawal and hypersensitivity to criticism may be present in major depression. However, these symptoms are mood-dependent and remit when the depressive episode resolves. Moreover, the worry related to social anxiety is about being negatively evaluated because of certain social behaviors or physical symptoms. Sandra has not reported or demonstrated any depressive symptoms other than occasional loneliness and insomnia. However, further evaluation is needed in order to assess and quantify her
mood.
Assessment considerations. Assessing the need of medication for the patient’s anxiety should be considered. Some authors have recommended that beta-blockers and benzodiazepines be considered as first-line medications for patients with performance fears (Belzer et al., 2005). It should be noted that patients often choose to start medication and therapy concurrently and make changes to medication during the course of treatment. Clinicians should be prepared to discuss the possible confounding effects of such choices as patients evaluate and make attributions about their progress within the realm of their competencies. Further evaluation should also include the presence of any comorbid disorders, communication skill deficits, and family factors. Comorbidity is common for social anxiety disorder. The most common coexisting