Anxiety with Panic Attacks
A difficult case of 25 year old doctor with history of 4 years of illness
A 25-year-old male, doctor by profession came to my clinic in January 2018 complaining of severe tension & fear of impending doom.
His complaints started dramatically following the suicide by hanging of his classmate & hostel mate when he was doing his 3rd year of MBBS. Following this tragic incident, my client started to experience severe anxiety characterised by mental tension, worries, restlessness & difficulty sleeping. He had feelings of tension all the time and he was unable to relax and enjoy life as before. He was worried all the time, worried what his future holds for him, fearfully anticipating the worst. He became very anxious and irritable even under slight stress. He began to experience pains & aches all over the body. His friends noticed him grinding his teeth at times when under extreme stress. When answering questions or presenting something in class, his voice became unsteady, had trembling of whole body, dry mouth, pounding heart, rapid breathing, had hot flushes and became dizzy and weak; and sometimes had to discontinue his presentations. He found this particularly embarrassing and awkward.
Because of these worries and tension, he couldn’t concentrate well in the class and was often criticised of day dreaming and and being lazy and disinterested by his teachers. When others criticise or make fun of him, he now became very much worried and was easily moved to tears. During exams he couldn’t concentrate well in his studies, was very anxious, restless, pacing up and down the room. He had difficulty sleeping. He would lie down to sleep, but wouldn’t fall asleep; instead would ruminate on various negative events that had happened & would worry about his future. He used to experience nightmares and would get up in between his sleep. In the morning, when he wakes up, he didn’t find his sleep to be refreshing. He experienced burning sensation inside his stomach. After having food, his abdomen would become distended, full, painful and had to go to toilet frequently to get relief. He failed in 2 subjects in his 3rd year MBBS University exams.
Relationship with his girlfriend also got into rough waters. He would now become irritable & angry very easily and quarrelled even on very silly issues. His sexual appetite also decreased and he experienced difficulty in erection and couldn’t enjoy sex as before. At home, he sometimes found the sound of the television unbearably irritating and would ask the family members to reduce the volume. He found attending church and marriages and other functions difficult as he had to face others, which would make him more nervous and stressful.
He also noticed that at times all of a sudden without any precipitating factors, he would have palpitations, sweating, trembling, shortness of breath, chest pain, nausea, feeling of dizziness, feeling of numbness, feeling of unreality and fear of going crazy/dying. These episodes would come all of a sudden without any warning and would last for about 1-2 minutes. These episodes happened at a frequency of about once per week. He was persistently worried about the possibility of getting another such episode and the possibility of getting a heart attack during such episodes. So in-order to avoid having such an episode, he stopped exercising and going out alone and being in unfamiliar situations.
He consulted psychiatrists at his own medical college and took medications and counselling. He improved slightly but still was far away from a complete recovery. So, at 25 years of age, 2 years after the illness began, he came to my clinic at Podiyadi for Psychiatric consultation.
On clinical examination- Patient was moderately built and nourished, fully conscious & cooperative, rapport was established. Psychomotor activity was increased, he was restless & fidgety. Talk was normal in amount, tone & tempo, reaction time was normal, prosody was maintained, relevant & coherent. Examination of his Thought showed that he had anxious preoccupations & worries. Depressive cognitions- ideas of helplessness, worthlessness and hopelessness were absent. Mood was highly anxious & irritable. Affect was normal in range and reactivity, appropriate with no liability. No perceptual abnormalities like hallucinations were noted. Cognitive functions showed decreased attention and concentration, high distractibility with normal intelligence, memory and abstractability and intact judgement and good insight.
Neuropsychiatric assessment scales- Hamilton Anxiety rating scale (HAM-A): Score was 39 indicating Very Severe Anxiety
Diagnosis of Anxiety Disorder with Panic Attacks were made.
My Client was psychoeducated regarding his illness, a definitive management plan was worked out with. He was started on Pharmacotherapy – anti-anxiety medicines and Psychotherapy (CBT for Anxiety). After 4 weeks – up titration of medicines to therapeutic level & 4 CBT sessions, 75% improvement were noted. HAM-A: 18. But still he had panic attacks in between although the frequency & intensity of the episodes were very much reduced. With further refinement of treatment, after 4 more weeks, he was 95% better & after about 3 months, 100% improvement & full recovery was noted. No side effects to medicines were reported.
Self-Assessment
