A 33-year-old man is unable to leave his city to do his business because of fear. This has affected his job as an executive.
What is the most likely diagnosis?
Correct Answer A:
Agoraphobia is fear of and anticipatory anxiety about being trapped in situations or places without a way to escape easily and without help if intense anxiety develops. The situations are avoided or they may be endured but with substantial anxiety. Agoraphobia can occur alone or as part of panic disorder.
Common examples of situations or places that create fear and anxiety include standing in line at a bank or at a supermarket checkout, sitting in the middle of a long row in a theater or classroom, and using public transportation, such as a bus or an airplane. Some people develop agoraphobia after a panic attack in a typical agoraphobic situation. Others simply feel uncomfortable in such a situation and may never or only later have panic attacks there. Agoraphobia often interferes with function and, if severe enough, can cause people to become housebound.
Which one of the following is more characteristic of anxiety disorder than of depressive disorder?
Correct Answer D:
Trying to distinguish between anxiety and depression can be difficult because there is a high incidence of depressive symptoms in patients with anxiety disorders, and a significant number of individuals with major depression have anxiety symptoms. A number of symptoms are characteristic of both disorders, such as sleep disturbance, appetite changes, difficulty concentrating, irritability, fatigue, thoughts of suicide or death, and nonspecific gastrointestinal or cardiac complaints.
Features that are more characteristic of anxiety include difficulty falling asleep, apprehensive expectations or feelings of dread, tremors or palpitations, phobic avoidance behavior, rapid pulse and other autonomic hyperactivity, breathing disturbances, sweating spells, feeling faint or dizzy, depersonalization (feelings of detachment from one’s body), or derealization (a sensation that the immediate environment is unreal or unfamiliar). Findings more characteristic of depression include early morning awakening, diurnal variation (feeling worse in the mornings), sad and downcast facial expressions, psychomotor retardation (slowed speech, slowed thought processes), chronic unexplained pain, sadness, feeling guilty, hopelessness, feelings of worthlessness, despair, loss of interest in usual activities, anhedonia (inability to experience pleasure), and difficulty in making decisions.
A 26-year-old female consults you because she becomes quite anxious in many social situations, often panicking when she must lead discussions at work. She states that she is increasingly uncomfortable in social situations and is spending more time alone at home. She has asthma and notes that her symptoms increased when she used albuterol.
Which one of the following would be the most appropriate therapy?
SSRIs, SNRIs, and other pharmacologic therapies are useful in generalized social anxiety disorders, and often require higher doses to be effective. This patient meets the criteria for a performance-type social anxiety disorder with significant impairment, and an SSRI such as sertraline is indicated.
→ Buproprion is an antidepressant that is not useful in managing anxiety disorders.
→ A benzodiazepine or a ß-blocker could be used for mild, intermittent performance anxiety, but would not be appropriate in this situation.
→ Beta-blockers (like propranolol) taken in low doses, may control the physical manifestation of anxiety and can be taken before a public performance. However, they could aggravate her asthma.
→ Hydroxyzine is an antihistamine with sedating properties that is not useful for treating anxiety disorders of this type.
Note:
Some side effects with albuterol inhalers include but are not limited to: worsening breathing problems; arrhythmia, tachycardia, hypertension, anxiety, diabetes, allergic reaction.
A 27-year-old man is suspicious of others, superstitious, believes he possesses telepathic powers, and has no friends.
Which one of the following is most likely to be associated with this clinical description?
Correct Answer C:
Those with schizotypal personality disorder (choice C) may share symptoms of schizophrenia, but they are generally not so severe as to meet the criteria for psychosis. People with this disorder tend to be shy and to isolate themselves and may show mild auspiciousness and other disturbances in thinking. Genetic studies indicate that schizotypal personality disorder may be a mild form of schizophrenia.
→ Passive-aggressive personality disorder (choice A) is a long-term (chronic) condition in which a person seems to actively comply with the desires and needs of others, but actually passively resists them. In the process, the person becomes increasingly hostile and angry. People with this disorder resent responsibility and show it through their behaviors, rather than by openly expressing their feelings. They often use procrastination, inefficiency, and forgetfulness to avoid doing what they need to do or have been told by others to do.
→ Histrionic personality disorder (choice B) is one of a group of conditions called dramatic personality disorders. People with this disorder have intense, unstable emotions and distorted self-images. They have an overwhelming desire to be noticed, and often behave dramatically or inappropriately to get attention.
→ People with avoidant personality disorder (choice D) are preoccupied with their own shortcomings. They form relationships with others only if they believe they will not be rejected. Loss and rejection are so painful that these people will choose to be lonely rather than risk trying to connect with others.
→ Obsessive-compulsive personality disorder (choice E) is a condition in which a person is preoccupied with rules, orderliness, and control.
A 28-year-old unemployed white female presents to a psychiatrist for the treatment of anxiety. She states that for the last ten years, she has felt anxious in social situations because other women stare at her. When asked why they stare at her, she states “I’m not sure, but they might be jealous of my beautiful hair.” She denies auditory or visual hallucinations, thought broadcasting, insertion, or withdrawal, but admits that she has “a sixth sense” about people, and that she can sometimes make events happen by thinking about them. She has no friends, though she wishes she did, and in fact has no social contacts other than her mother. As she relates this, she is smiling. She speaks with a British accent, though she states she grew up in Ohio and has never been outside the Midwest.
Her speech is organized and coherent, however. What is the likely diagnosis?
Individuals with schizotypal personality disorder appear eccentric, with their odd ideas, magical thinking, inappropriate affect, and persistent social anxiety. They are usually socially isolated, but may gravitate toward fringe groups or subcultures, where their personality style may appear less unusual.
A. Schizophrenia by DSM-IV definition must include two or more symptoms of delusions, hallucinations, disorganized speech or behavior, and negative symptoms (affective flattening, avolition, etc.). The patient is uncertain of her belief that other women might be jealous of her hair, and therefore this does not qualify as a delusion.
B. Patients with paranoid personality disorder are suspicious of others without basis, but do not have the odd ideas, magical thinking, and other eccentricities of schizotypal patients.
C. In social phobia, anxiety is associated with negative evaluations of the self, rather than with the paranoid fears about others typically seen with schizotypal personality disorder.
E. Unlike this patient, schizoid patients do not desire to have friends.
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