A 32-year-old woman comes to the office due to overwhelming anxiety and stress. The patient is an accountant and has been under increasing job-related pressure for the past 6 weeks due to an upcoming tax deadline. She says, "The worst part is that I get really nervous all of a sudden and then feel shaky, dizzy, and nauseated and start to sweat. It happened while I spoke to my boss a few weeks ago, and I had to excuse myself." The patient is especially worried about having an episode during a work meeting, although she notes that her symptoms have also occurred while she was relaxing at home. She says, "I've stopped going out with my friends because I never know when I'm going to feel this way." The patient has no significant medical history and does not use alcohol or drugs. Blood pressure is 120/70 mm Hg, pulse is 72/min, and respirations are 18/min. Physical examination and laboratory evaluation show no abnormalities. Which of the following is the most likely diagnosis?

Question

A 32-year-old woman comes to the office due to overwhelming anxiety and stress.  The patient is an accountant and has been under increasing job-related pressure for the past 6 weeks due to an upcoming tax deadline.  She says, "The worst part is that I get really nervous all of a sudden and then feel shaky, dizzy, and nauseated and start to sweat.  It happened while I spoke to my boss a few weeks ago, and I had to excuse myself."  The patient is especially worried about having an episode during a work meeting, although she notes that her symptoms have also occurred while she was relaxing at home.  She says, "I've stopped going out with my friends because I never know when I'm going to feel this way."  The patient has no significant medical history and does not use alcohol or drugs.  Blood pressure is 120/70 mm Hg, pulse is 72/min, and respirations are 18/min.  Physical examination and laboratory evaluation show no abnormalities.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_3633_f9e4_9249_7b6f2f266091_MD0001_00 This patient's repeated episodes of acute-onset anxiety accompanied by physical symptoms (shaking, dizziness, nausea, sweating) are characteristic of panic disorder. Diagnosis requires recurrent, unexpected panic attacks, typically reaching a peak within minutes and followed by persistent concern about additional attacks and/or changes in behavior (eg, patient may restrict activities due to fear of an attack). Characteristic physical symptoms include chest pain, shortness of breath, tachycardia, and gastrointestinal and neurological symptoms. A key feature is that at least some of the attacks are spontaneous with no obvious trigger (eg, when an individual is relaxing or emerging from sleep [ie, nocturnal panic attack]). Diagnosis of panic disorder requires first ruling out medical and substance-related causes (eg, hyperthyroidism, alcohol withdrawal). Physicians should also differentiate panic disorder from other anxiety and mental disorders with panic attacks as an associated feature. Panic-like symptoms that occur as part of other disorders are typically triggered by, and limited to, specific situations. (Choice A) Acute stress disorder involves exposure to a traumatic event followed by development of characteristic symptoms (eg, re-experiencing, avoidance, arousal) lasting from 3 days to 1 month. (Choice B) Although this patient experiences work-related stress, her description of unexpected panic attacks at home makes panic disorder more likely. Adjustment disorder requires that symptoms develop in response to an identifiable stressor and do not meet criteria for another mental disorder. (Choice C) In generalized anxiety disorder, individuals experience chronic, excessive worry for at least 6 months about multiple issues (eg, work, health, finances), which may or may not precipitate panic attacks. In panic disorder, the content of anxious thoughts is more specific (concern about having future panic attacks) and panic attacks are unexpected. (Choice E) Patients with social anxiety disorder may experience panic attacks in response to social situations (identifiable stimulus) and fear negative evaluation by others rather than the panic symptoms themselves. (Choice F) Specific phobia is characterized by fear of a specific object or situation, such as flying, heights, or animals. Panic symptoms are triggered by the phobic stimulus and are not spontaneous. Educational objective: Panic disorder involves recurrent, unexpected panic attacks characterized by an abrupt surge of fear accompanied by physical and cognitive symptoms. Individuals experience persistent worry about future attacks and typically restrict their activities as a result. __________ References: Panic disorder and agoraphobia: an overview and commentary on DSM-5 changes. (http://www.ncbi.nlm.nih.gov/pubmed/24865357)

A 32-Year-Old Woman Comes to the Office Due to Overwhelming