PSYCHIATRY II

Case
Presentation

Identifying Data
A.C. is a 31 year old male, with a live-in
partner for 14 years, has two children aged
11 and 7, 5th child in a brood of seven, high
school graduate, pedicab driver, Catholic,
residing in Leveriza St, Manila.

Chief Complaint
Masakit sikmura, kinakabog, nanlalamig, at
namamawis kapag hindi ko nakikita ang misis ko
at kapag lumalabas ako

History of Present Illness

One year and 2 months PTC
received news of his elder sisters sudden death
due to cardiac arrest
patient suddenly experienced epigastric pain,
palpitations, cold, clammy extremities, excessive
sweating, and difficulty breathing
No consult done, no meds taken
He noted such symptoms for a week especially
when travelling to and from work as a janitor in
Makati

 He also noted this when his co-workers were not

around
During that same week, he also experienced being
trapped in an elevator for two minutes because of
power interruption
At that time, he experienced the same symptoms of
epigastric pain, palpitations, sweating, and
difficulty of breathing; relieved only when the
elevator door opened

 Since then the patient avoided riding the elevator

for too long because he feared being trapped
inside again
He also avoided the stairs for fear of being locked
in because it was company policy to lock the
stairwell
A week after his sisters death he was unable to
work as a janitor since his attacks would occur while
in travel or when alone

 Eleven months PTC

patient went to his childhood home in Batangas to
visit his family
While there he consulted a physician who
prescribed him to take Kremil-S and Inderal
Patient took the meds when symptoms appear but
with transient relief
Patient stayed in the province for one week then
returned to Manila. He returned to work as a
pedicab driver

 The patients symptoms were present almost every

day and especially when he couldnt see his wife
Patient feared that he might collapse if he is alone
and there would be no one to help him
He had no prior experience of collapsing but
couldnt help thinking of the probability of
experiencing such
Since the symptoms usually occur when the partner
is not around, the partner decided to sell cigarettes
near the pedicab terminal

 Patient also experienced difficulty initiating sleep

for fear of recurrence of symptoms and would
have interrupted sleep as well
He usually sleeps around 8PM but now would sleep
at 12 MN
He would wake up at around 2 and 4AM due to
the symptoms

 Two months PTC

The patients symptoms have become more
frequent
He wouldnt go out as much as he used to unless he
had to work as a pedicab driver
His symptoms would appear when his partner was
not by his side when at home or when he had to
drive far in his pedicab

 He tried to endure the symptoms but has limited his

working schedule to three times a week
He continued to take Kremil-S and Inderal but with
little relief

 Few hours PTC

Patient attended his eldest daughters graduation
practice with his partner
When he was separated from his partner, he
experienced epigastric pain, palpitations,
sweating, and difficulty of breathing

 Patient took Inderal but with little effect.

Symptoms were only relieved when he saw his
partner again
Patient sought consult at a nearby health center but
was referred to our institution

Past Medical History

No previous hospitalizations, on Inderal and
Kremil-S PRN basis, no suicidal ideations, no
known allergies, no DM, HPN, Asthma

Social History
Non smoker, drinks two bottles of Red Horse
beer once a week, started at age 19.
Denies use of illicit substances.

Family History
Non- remarkable

Anamnesis
Patient was born via normal spontaneous
delivery without birth trauma or complications.
Patients mother had no maternal health
problems during pregnancy and was not using
any illicit substances.
Patient was both breastfed and bottle fed for
an unknown period of time.
He was toilet trained at age 3 4.

 There was no thumb sucking, temper tantrums,

or head banging.
He was known to be shy with strangers but an
active child with a good relationship with his
siblings.

 Patient would be reprimanded as a form of

discipline but didnt experience corporal
punishment.
He was described as shy and quiet during
school hours but had many friends.
He had no learning disabilities.
He was a basketball and volleyball player at
school

 He had a good relationship with peers and

classmates and had no disciplinary actions
against him at school.
He was more of a follower than a leader.
During late childhood, he suddenly developed
fear of the dark and would sleep with the
lights on.

 He attributed his fear to an overactive

imagination.
He had his first relationship at age 16 which
lasted for 3 months.
They broke up when the girl had to leave for
Manila.

 After high school he took up a vocational

course in Electronics but was unable to finish
due to financial constraints.
He worked as a janitor at age 19.
He also had a live in partner at this age with
whom he has two children.
They have a good marital relationship.

Physical Examination
Vital Signs:
BP 120.90, HR 73, RR 17, Temp 37.2 C

Normal physical and neuro exam

Mental Status on Admission

Patient is well groomed, cooperative, seated
during the interview.
Anxious mood with broad and appropriate
affect.
Speech is spontaneous with normal rate, tone,
and rhythm.
No perceptual disturbances. Thought processing
is goal directed.

 Though content shows preoccupation that

something will happen to him if the partner is
not around.
He is alert, oriented to three spheres, intact
memory, able to spell KARNE backwards, can
read and write, able to draw a clock, able to
interpret proverb, adequate fund of
information and intelligence, good impulse
control, insight level 3, good judgement.

Salient Features
HISTORY OF PRESENT ILLNESS
One year and 2 months PTC
Patient suddenly experienced epigastric pain, palpitations, cold, clammy
extremities, excessive sweating, and difficulty breathing
Symptoms occurred especially when travelling to and from work
He also noted the symptoms when his co-workers were not around
Trapped in an elevator for two minutes, experienced the same symptoms which
were only relieved when the elevator doors opened
Avoided riding the elevator for too long because he feared being trapped
inside again
Also avoided using the stairs
Unable to work because the attacks would occur in travel or when he was alone

Salient Features
Eleven months PTC
Took Kremil-S and Inderal when symptoms
appeared but with transient relief
Symptoms were present almost every day and
especially when he couldnt see his wife
Patient feared that he might collapse if he is alone
and there would be no one to help him
Patient also experienced difficulty initiating sleep
for fear of recurrence of symptoms and would
have interrupted sleep as well

Salient Features
Two months PTC
Increased frequency of symptoms
Symptoms would appear when his partner was not
by his side when at home or when he had to drive
far in his pedicab
Continued to take Kremil-S and Inderal but with
little relief

Salient Features
Few hours PTC
He experienced symptoms when his partner left his
side
Took Inderal but with no relief
Symptoms were only relieved when he saw his
partner again

Salient Features
ANAMNESIS
During late childhood, he suddenly developed
fear of the dark and would sleep with the
lights on (attributed to an overactive
imagination)
MENTAL STATUS ON ADMISSION
Though content shows preoccupation that
something will happen to him if the partner is
not around

Differential Diagnosis

Working Impression
Separation Anxiety Disorder,
cannot completely rule out
Agoraphobia

Case Discussion

Theories on Anxiety
Psychoanalytic Theory
Schema Theory
Semantic Network of Theory of Emotions

Psychoanalytic Theory
2 Types of Anxiety
1. Automatic
2. Neurotic

Schema Theory
In cases of anxiety, the schemata are sensitive
to threat or danger (Mogg & Bradley, 1998).
In an individual that is anxiety-prone, activation
of these schemata would increase the tendency
to interpret stimuli as a threatening manner and
thus, more chance of remembering the situation.

Semantic Network Theory of

Emotions
Bower discussed that each emotion is
represented by a node in the associative
network of memory (Mogg & Bradley, 1998).

Symptoms Experienced During

Attacks
Anxiety and fear
alerting signals and act as a warning of an internal
and external threat

Symptoms Experienced During

Attacks
Anxiety
normal and adaptive response that has lifesaving qualities
warns of threats of bodily damage, pain, helplessness,
possible punishment
frustration of social or bodily needs
of separation from loved ones
of a menace to one's success or status
and ultimately of threats to unity or wholeness

(Sadock & Virginia Alcott, 2007)

Symptoms Experienced During

Attacks
The experience of anxiety has two components:
the awareness of the physiological sensations (e.g.,
palpitations and sweating)
the awareness of being nervous or frightened

(Sadock & Virginia Alcott, 2007)

Symptoms Experienced During

Attacks
Freud: anxiety stemmed from a physiological
buildup of libido, but he ultimately redefined
anxiety as a signal of the presence of danger
in the unconscious
Anxiety
result of psychic conflict between unconscious sexual
or aggressive wishes and corresponding threats
from the superego or external reality

Symptoms Experienced During

Attacks
In response to this signal, the ego mobilized
defense mechanisms to prevent unacceptable
thoughts and feelings from emerging into
conscious awareness

(Sadock & Virginia Alcott, 2007)

Age, Gender and Genetics

AGE
Adult separation anxiety disorder has been
under-diagnosed.
Separation anxiety disorder decreases in
prevalence from childhood through adolescence
and adulthood.
Adult form of SAD is described in the psychiatric
literature recently.
lifetime prevalence of 6.6% (Silove, et al.,
2010).

Age, Gender and Genetics

GENDER
differences are less strong in ASAD
males are more likely to report first onset in
adulthood (Bogels, S.M. et al., 2013).
indirect expression of fear of separation may be
more common in males than in females
limited independent activity, reluctance to be away
from home alone, or distress when spouse or
offspring do things independently or when contact
with spouse or offspring is not possible

Age, Gender and Genetics

GENETICS
Its heritability was estimated at 73% in a community
sample of 6-year-old twins, with higher rates in girls.
both adult and childhood separation anxiety
disorders tend to cluster in families, with one study
suggesting an hereditary pattern (Silove, et al., 2010)

Alcohol Use
People who experience chronic feelings of anxiety often
drink beer or a glass of wine to quell the uneasiness

Alcohol may help people with anxiety cope in the short

term, but over time this strategy can backfire.
Self-medicating with alcohol or drugs can increase the
risk of alcoholism and other substance-abuse problems,
without addressing the underlying anxiety (Archives of
General Psychiatry)

Alcohol Use
Alcohol
Drug that depresses the central nervous system
Initially, alcohol consumption has a sedative effect and
produces a sense of euphoria and decreased inhibitions
Seemingly providing relief

Self-medication for anxiety is common

People with diagnosed anxiety disorders who selfmedicated at the start of the study were two to five
times more likely than those who did not self-medicate
to develop a drug or alcohol problem within three
years.

Alcohol Use
Tension Reduction Theory of Alcohol Use
2 basic testable postulates
First, alcohol will reduce the tension
Second, a state of anxiety will motivate alcohol use

There are some contexts in which alcohol does

indeed reduce tension.
However, the linear effect is mediated by a
number of other factors:
amount of alcohol consumed, expectations about the
effect of alcohol, and the social context in which alcohol
is consumed

Alcohol Use
Stress-response Dampening Model
A current incarnation of anxiety reduction theory
Pared-down tension reduction hypothesis
Focuses in the reinforcing effects of alcohol in
adverse or stressful situations.
Basic postulate:
individuals who experience stress-response dampening
effects are more likely to consume greater amounts of
alcohol in stressful situations

Alcohol Use
Other Theories Of Alcohol Use
Some researchers have proposed that there
may be a genetic link that influences a persons
anxiety level and alcohol consumption.
These biological theories suggest that a brain
mechanism is responsible for anxiety symptoms and
drinking behaviors

Alcohol Use
Other researchers have proposed an expectancy
component in alcohol consumption and anxiety
symptoms.
One would expect relief of anxiety symptoms after
consuming alcohol due to its effects on the central
nervous system.
Drinking behaviors are based on ones level of anxiety
and the expected relief alcohol will provide.
Relief from very high anxiety levels would be expected
to ease with greater consumption of alcohol

Childhood Experiences
Significant associations between retrospectively
reported childhood adversities (CAs) and adult
illness have been documented in numerous
studies
CAs are often nonspecific in their associations
with many different mental disorders (Green et
al. 2010)

Childhood Experiences
CAs have powerful and often subadditive
associations with the onset of many types of
largely primary mental disorders throughout
the life course, which may include Adult
Separation Anxiety Disorder

Childhood Experiences
Childhood trauma contributes to the severity of
psychopathology (Hovens et al. 2010).
Clinically significant separation anxiety
disorder in childhood leads to adult panic
disorder and other anxiety disorders (Milrod et
al. 2014)

Childhood Experiences
No mention of childhood adversities or
childhood trauma, except that the patient had
achluophobia (fear of the dark) in his late
childhood.
In line with this, some researchers consider the
fear of the dark as a manifestation of
separation anxiety disorder (Tasman et al.
2011).

Treatment and Management

General Considerations
Pharmacotherapy
Psychotherapy
Pharmacotherapy + Psychotherapy
Generally:
Medication (atleast 6-12 months)
If (+) resolution: Tapering off the medications +
more intensive psychotherapy

Psychotherapy
Behavioral therapy
Cognitive Behavioral therapy
Self-Help Techniques:

Focus.
Breathe slowly and deeply.
Challenging fears.
Creative visualisation.
Don't fight an attack.

Other Non-pharmacologic Mgt.

Diet and Activity

Discourage caffeine intake

Minimize alcohol intake
Encourage usual activities
Exercise to release stress and relieve tension

Long-Term Monitoring
In-patient management not indicated for this case (only for
severe phobic disorders with suicidal ideations/attempts)
Out-patient follow-up
Monitor his response to treatment
Monitor his tendency for relapse

Pharmacologic Treatment

Selective Serotonin Reuptake Inhibitos

The selective serotonin reuptake inhibitors (SSRIs)
represent a chemically diverse class of agents that
have as their primary action the inhibition of the
serotonin transporter (SERT).
It has little or no affinity for alpha-adrenergic,
histamine or cholinergic receptor.
Overall, SSRIs appear to be more effective than
MAOIs for the treatment of social anxiety
disorder.
SSRIs and venlafaxine are generally considered
first-line agents

1. Fluoxetine
Given 20-60mg/day.
Fluoxetine is metabolized to an active product,
norfluoxetine,
which
may
have
plasma
concentrations greater than those of fluoxetine.
The elimination half-life of norfluoxetine is about
three times longer than fluoxetine and contributes
to the longest half-life of all the SSRIs.
As a result, fluoxetine has to be discontinued 4
weeks or longer before an MAOI can be
administered to mitigate the risk of serotonin
syndrome.

Serotonin- Norepinephrine Reuptake

Inhibitors
They are potent inhibitors of the reuptake of
serotonin and norepinephrine.
They are better tolerated, with less anticholinergic
effects and weight gain than Tricyclic
Antidepressants.
They are efficacious for a wide array of mood
and anxiety disorders, in particular panic
disorders.
Abrupt discontinuation of SNRIs is ill- advised
because it may cause discontinuation syndrome
that is similar with SSRIs.

1. Duloxetine
Given daily 60 120 mg/ day
Rapidly absorbed following oral administration
and is absorbed after 2 hours with a maximum
concentration achieved in approximately 6 hours
Effective in improving not only anxiolytic symptoms
but also painful physical symptoms such as
abdominal pain, pain severity and patient
functioning
generally well tolerated with no significant effect
on weight reported

2. Venlafaxine
Effective for panic disorders
Effective in the range of 75 225 mg/ day
Initiated gradually to reduce the likelihood of sideeffects
Dosing is usually initiated at 37.5 mg for the first 3
7 days and is subsequently increased to a
minimum of 75-mg/ day
Side- effects and increase in blood pressure should
be monitored

Tricyclic Antidepressants
Inhibit the reuptake of the biogenic amines,
mostly norepinephrine (NE), as well as serotonin
(5HT)
Up until they were supplanted by the SSRIs and
SNRIs,
Tricyclic
Antidepressants
were
considered
the
gold
standard
pharmacotherapy for panic disorders.
Relegated to second- line use due to their
greater side- effects burden

1. Clomipramine
started at doses substantially lower than those for
patients with depression or other psychiatric
conditions
effective in lower doses than imipramine and can
be used effectively in doses ranging from 50
150 mg/ day
effective in lower doses than imipramine and can
be used effectively in doses ranging from 50
150 mg/ day

Psychotherapy
Controlled studies have found behavioral
therapy and cognitive behavioral therapy
(CBT) to be effective in treating phobic
disorders.
Psychodynamic therapy (or insight-oriented
therapy) is rarely indicated as an exclusive
treatment for phobias and is now mostly
reserved for cases of phobic disorders that
overlap personality disorders.

 For treatment of social anxiety disorder, selfexposure monotherapy has been shown to work
as well as computer-based exposure training,
clinician-led exposure, or combination therapies
of self-exposure and CBT/self-help manual.
A CBT-based approach, including gradual
desensitization, is the most commonly used
treatment for specific phobia. Other treatments
include relaxation and breathing control
techniques.

Diet and Activity

The patients intake of caffeine (eg, in coffee,
caffeinated teas, or sodas) should be assessed; even
moderate amounts of caffeine may exacerbate the
anxiety response and symptoms.
A tryptophan-rich diet was shown to have a positive
effect on social anxiety disorder.
Dietary restrictions (a tyramine-free diet) are necessary
for patients taking MAOIs.
Activity should not be restricted.
Patients should be encouraged to confront anxietyproducing stimuli in the context of a behavioral therapy
treatment plan.