A 32-year-old woman is brought to the office by her husband due to his concern about her increasing social withdrawal. The patient prefers to stay at home. When she must run errands, she insists that her husband accompany her. She stopped working 2 years ago due to severe episodes of anxiety that would occur unpredictably for no apparent reason. Since that time, the patient has continued to experience these episodes several times a week and has become more socially isolated due to fears of having another episode. She avoids seeing her friends except for the rare occasions when they come to her home. The patient feels badly that she is no longer working and contributing to the household finances. She has occasional difficulty falling asleep and problems with concentration. Although she is not looking for work, she keeps her home clean, cooks nightly, and enjoys watching television. Which of the following is the most likely cause of this patient's social withdrawal?

Question

A 32-year-old woman is brought to the office by her husband due to his concern about her increasing social withdrawal.  The patient prefers to stay at home.  When she must run errands, she insists that her husband accompany her.  She stopped working 2 years ago due to severe episodes of anxiety that would occur unpredictably for no apparent reason.  Since that time, the patient has continued to experience these episodes several times a week and has become more socially isolated due to fears of having another episode.  She avoids seeing her friends except for the rare occasions when they come to her home.  The patient feels badly that she is no longer working and contributing to the household finances.  She has occasional difficulty falling asleep and problems with concentration.  Although she is not looking for work, she keeps her home clean, cooks nightly, and enjoys watching television.  Which of the following is the most likely cause of this patient's social withdrawal?

Quizplus · Accepted Answer

The patient's history of recurrent, spontaneous anxiety attacks and development of avoidance behavior are most consistent with panic disorder. Patients with panic attacks frequently develop agoraphobia, which is anxiety and avoidance of ≥2 situations in which it may be difficult to escape or get help (eg, being outside the home or in enclosed spaces, using transportation) in the event of a panic attack. In severe cases, patients can become homebound or leave home only when accompanied by others, resulting in marked social and occupational impairment. Agoraphobia can also be diagnosed independently of panic disorder. Avoidance behavior and agoraphobia are best treated with cognitive behavioral approaches. (Choices A, B, and E) Although this patient has become socially avoidant and dependent on her husband, these behaviors are better explained as complications of her 2-year history of panic disorder. Personality disorders involve long-standing patterns of behavior dating back to adolescence. Patients with avoidant personality disorder fear negative evaluation and do not have panic attacks. Dependent personality disorder involves a pattern of submissive and clinging behavior in order to be cared for by others. Individuals with schizoid personality disorder are socially isolated by choice. (Choice D) This patient has insufficient symptoms to diagnose persistent depressive disorder. (Choice F) Although patients with social anxiety disorder may also avoid certain public places, their fear is of social humiliation and criticism and they do not experience spontaneous panic attacks. Educational objective: Panic disorder is characterized by recurrent, unexpected panic attacks and fears about future attacks and/or maladaptive behavior related to the attacks. Some patients will develop agoraphobia, which is the avoidance of ≥2 situations in which escape or obtaining help may not be possible. References: Disability and comorbidity: diagnoses and symptoms associated with disability in a clinical population with panic disorder. (http://www.ncbi.nlm.nih.gov/pubmed/24829902) A discussion of various aspects of panic disorder depending on presence or absence of agoraphobia. (http://www.ncbi.nlm.nih.gov/pubmed/27423353)

A 32-Year-Old Woman Is Brought to the Office by Her