A 35-year-old woman comes to the office due to anxiety; she is accompanied by her husband. The patient describes having several panic attacks while driving over a suspension bridge. She suddenly felt faint and shaky, and had to stop the car in the middle of the bridge and get assistance. The patient moved to the suburbs 7 months ago, requiring that she now drive to work. Since having the panic attacks, she has taken an alternate route to work that requires her to drive miles out of her way to avoid bridges. She avoids traveling to the city when possible and has anxiety for days beforehand if a planned trip necessitates taking a bridge. The patient has a history of mitral valve prolapse and asthma. She drinks a glass of wine on weekends and 3 or 4 cups of coffee daily. Blood pressure is 110/60 mm Hg and pulse is 88/min. Auscultation reveals a late systolic click and a grade 2/6 late systolic murmur. Mental status examination shows an anxious mood and tense affect. Which of the following is the most likely diagnosis?

Question

A 35-year-old woman comes to the office due to anxiety; she is accompanied by her husband.  The patient describes having several panic attacks while driving over a suspension bridge.  She suddenly felt faint and shaky, and had to stop the car in the middle of the bridge and get assistance.  The patient moved to the suburbs 7 months ago, requiring that she now drive to work.  Since having the panic attacks, she has taken an alternate route to work that requires her to drive miles out of her way to avoid bridges.  She avoids traveling to the city when possible and has anxiety for days beforehand if a planned trip necessitates taking a bridge.  The patient has a history of mitral valve prolapse and asthma.  She drinks a glass of wine on weekends and 3 or 4 cups of coffee daily.  Blood pressure is 110/60 mm Hg and pulse is 88/min.  Auscultation reveals a late systolic click and a grade 2/6 late systolic murmur.  Mental status examination shows an anxious mood and tense affect.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d807_cf57_bc81_cb19be2ccea2_MD0003_00 This patient's marked anxiety about driving over bridges (the specific phobic stimulus) and resulting avoidance behavior are characteristic of a specific phobia. Common phobic fears include animals, insects, heights, water, driving, flying, blood, and injections. This patient was likely able to avoid driving over bridges while living in the city but has become symptomatic since her move. The degree of phobic anxiety varies with proximity to the feared object or situation and can reach the level of a full or limited panic attack, as in this patient. In contrast to panic disorder, panic attacks in specific phobia are always triggered by the phobic stimulus and do not occur unexpectedly. Cognitive-behavioral therapy that includes exposure (in vivo, imaginal, virtual reality) is the first-line treatment. (Choice A) Although this patient has mitral valve prolapse and a history of asthma, these conditions are an unlikely cause of her anxiety symptoms, which are clearly triggered by a specific situation. A previously reported association of mitral valve prolapse and panic disorder has not been substantiated. (Choice B) This patient's avoidance behavior is a consequence of her bridge phobia. Avoidant personality disorder is a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. (Choice C) Generalized anxiety disorder is characterized by excessive anxiety about multiple issues, whereas this patient's anxiety is specific to her fear of driving across bridges. (Choice D) A diagnosis of panic disorder requires that at least some panic attacks occur spontaneously with no trigger and are not limited to a specific situation. Patients with a specific phobia may experience anxiety that reaches the level of a panic attack when exposed to the phobic stimulus. (Choice F) Excessive caffeine consumption can result in increased generalized anxiety but would not explain this patient's anxiety and avoidance in response to a specific phobic stimulus. Educational objective: Specific phobia is a common anxiety disorder characterized by a clinically significant fear of a specific object or situation, leading to avoidance behavior. Exposure-based cognitive-behavioral therapy is the treatment of choice. References: Specific phobias. (http://www.ncbi.nlm.nih.gov/pubmed/19716991)

A 35-Year-Old Woman Comes to the Office Due to Anxiety;