A 26-year-old man is brought to the emergency department by a colleague due to anxiety. The patient experienced a 15-minute episode of chest pain, shortness of breath, and dizziness prior to giving a presentation at a regional meeting. He says, "My girlfriend used to help me prepare for all of my meetings. She always knew what to say and how to handle everything. I can't manage at work without her." His girlfriend broke up with him 2 weeks ago after a 9-year relationship. The patient's colleague, who has known him since high school, says, "He did everything to make her happy. He let her choose his car and agreed to get a cat even though he's allergic." The patient reports feeling "lost and on edge" since that time and has avoided leaving his apartment. He is anxious about driving on his own and is planning to move in with his parents when his lease expires. The patient denies prior episodes of chest pain, shortness of breath, or dizziness and has no significant medical history. Family history is significant for generalized anxiety disorder in his mother. Vital signs are within normal limits, and physical examination is noncontributory. ECG is normal. Which of the following is the most likely diagnosis in this patient?

Question

A 26-year-old man is brought to the emergency department by a colleague due to anxiety.  The patient experienced a 15-minute episode of chest pain, shortness of breath, and dizziness prior to giving a presentation at a regional meeting.  He says, "My girlfriend used to help me prepare for all of my meetings.  She always knew what to say and how to handle everything.  I can't manage at work without her."  His girlfriend broke up with him 2 weeks ago after a 9-year relationship.  The patient's colleague, who has known him since high school, says, "He did everything to make her happy.  He let her choose his car and agreed to get a cat even though he's allergic."  The patient reports feeling "lost and on edge" since that time and has avoided leaving his apartment.  He is anxious about driving on his own and is planning to move in with his parents when his lease expires.  The patient denies prior episodes of chest pain, shortness of breath, or dizziness and has no significant medical history.  Family history is significant for generalized anxiety disorder in his mother.  Vital signs are within normal limits, and physical examination is noncontributory.  ECG is normal.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d7e9_71c6_bc81_7fc75ecc2248_MD0003_00 This patient's excessive reliance on his girlfriend, submissive behavior (eg, agreeing to get a cat despite allergies), and inability to make decisions on his own are characteristic of dependent personality disorder (DPD). Individuals with DPD have a need to be taken care of and have others manage their life. They fear separation because they lack self-confidence in their ability to manage their affairs, and they struggle to make decisions without input and approval from others. Patients with DPD often have symptoms of anxiety (such as this patient's panic attack) or depression in the context of a breakup or loss of a relationship, which triggers their sense of inadequacy and fear of being left to fend for themselves. Seeking another source of care and support when a close relationship ends (eg, this patient moving in with his parents) is characteristic. (Choice A) An adjustment disorder would not explain this patient's preexisting pattern of helplessness, indecisiveness, and fear of being alone. Stressors often exacerbate the symptoms of an underlying disorder. (Choice B) In avoidant personality disorder, individuals also experience a sense of inadequacy; however, this leads them to avoid, rather than seek out, close relationships for fear of rejection. (Choice C) Individuals with borderline personality disorder also fear abandonment. However, this is accompanied by emotional reactivity, anger, and splitting (alternately idealizing and devaluing their partners) rather than the clinging and submissive behavior seen in DPD. It is also accompanied by dangerous impulsivity (eg, reckless spending, sexual promiscuity, substance use) and suicidal threats or acts, which this patient does not display. (Choice E) Individuals with generalized anxiety disorder have ≥ 6 months of anxiety about a range of issues (eg: finances, health, work, school). This patient's anxiety is centered on his fear of being alone and left to care for himself. (Choice F) An isolated panic attack can occur in many conditions, whereas a diagnosis of panic disorder requires recurrent unprovoked (ie, spontaneous) panic attacks followed by excessive concern or a change in behavior aimed at avoiding further attacks. This patient has had an isolated panic attack precipitated by fears of inadequacy after his separation. Educational objective: Dependent personality disorder is characterized by a need to be taken care of, leading to submissive and clingy behavior with a fear of separation. Individuals often have symptoms of anxiety or depression in the context of a breakup or loss, with an urgent need to seek out another relationship. References: Dependent personality disorder: a critical review. (http://www.ncbi.nlm.nih.gov/pubmed/24185092) Personality disorder: a disease in disguise. (http://www.ncbi.nlm.nih.gov/pubmed/30539674)

A 26-Year-Old Man Is Brought to the Emergency Department by a Colleague