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Cases From DSM-IV-TR® Casebook and Its Treatment Companion

DOI: 10.1176/appi.books.9781585622665.31909
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Evening Shift
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A 30-year-old warehouse worker had experienced episodes of poor sleep for the preceding 5 years whenever he had to work on the evening shift. Every 2 weeks he alternated between working the evening shift (3:00 P.M. to 11:00 P.M.) and the day shift (7:00 A.M. to 3:00 P.M.). When he worked the evening shift, he would go to bed about 2 hours after work, around 1:00 A.M. About half the time it would take him 1–2 hours to fall asleep. When this happened, he typically would awaken at 5:00 A.M., his normal time for getting up to go to work the day shift. He would have a snack and then return to bed and drift in and out of sleep until arising between 8:30 A.M. and 11:00 A.M. On weekends and holidays, however, he would revert to his normal bedtime, approximately 10:00 P.M., when he would fall into bed exhausted.
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When the patient slept poorly at night, he felt sleepy the next day; if he slept well, he felt alert. When he worked the day shift and was on vacation, he slept well and felt alert the next day.
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DSM-IV-TR Casebook Diagnosis of "Evening Shift"& b: ?$ v; M& S1 }4 }: |9 I
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Sleep, like most biological functions, follows a rhythm over a period that lasts about 24 hours (circadian rhythm). The sleep rhythm induced by daytime work in this patient persists when he works the evening shift. At these times the mismatch between his circadian rhythm and the demands of his work schedule results in insomnia (trouble falling asleep and staying asleep). His biological clock causes sleepiness at 10:00 P.M. and awakening at about 5:00 A.M. When he works the evening shift, he is forced to stay awake hours beyond his usual bedtime, and he initially awakens at his usual arising time." |% t/ }) l4 {4 i) b+ K# o( S

2 T% m& L1 Z: `; Z+ O/ BIf the patient were able to stay on the evening shift for several months and maintain the same sleep times, his biological clock would gradually be reset, so that his sleep schedule would harmonize with the hours of his work day. It is because the hours of his shift keep changing and he is apparently particularly intolerant of the mismatch between his circadian rhythm and his daily work schedule that he cannot sleep during desirable hours.
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Sleep problems resulting from a mismatch between the normal sleep–wake schedule for the person's environment and his or her circadian sleep–wake pattern are diagnosed as Circadian Rhythm Sleep Disorder (see DSM-IV-TR). When the disorder is apparently caused by frequently changing sleep and waking times resulting from changes in work shifts, the Shift Work Type is specified. The diagnosis is confirmed, as in this case, by normal sleep and daytime alertness when the internal sleep schedule conforms again to environmental demands.
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The patient was advised to gradually discontinue eating at night in order to stop reinforcing nocturnal appetite and wakefulness. In addition, he was advised to arise at 8:30 A.M. when he worked the evening shift, no matter how tired he felt. In this way it was hoped that he would feel tired enough at 1:00 A.M. to fall asleep immediately and then have a full night's sleep.9 P8 `8 W; v, |" F9 L9 D
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After trying the program, the patient reported that he could not stick to it. He said he became "like a madman" during the night, searching everywhere for his favorite snacks after his wife, with his consent, had hidden them. Nor could he remain awake until 1:00 A.M. on the weekend between the 2 weeks of the evening shift.
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The patient did not return for another appointment, but called several months later to report that he had been able to convince his employer to take him off the evening work shift permanently, which completely relieved his sleep problem.

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DOI: 10.1176/appi.books.9781585622665.31925) V& v$ O7 o! ^' g/ u
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Lovely Rita
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A 36-year-old London meter maid was referred for psychiatric examination by her solicitor. Six months previously, moments after she had written a ticket and placed it on the windshield of an illegally parked car, a man came dashing out of a barbershop, ran up to her, swearing and shaking his fist, swung, and hit her in the jaw with enough force to knock her down. A fellow worker came to her aid and summoned the police, who caught the man a few blocks away and placed him under arrest.9 _5 |8 Z& d4 E

( i; y$ K9 r# q# K2 M- t) K6 P0 b" nThe patient was taken to the hospital, where a hairline fracture of the jaw was diagnosed by X-ray. The fracture did not require that her jaw be wired, but the patient was placed on a soft diet for 4 weeks. Several different physicians, including her own, found her physically fit to return to work after 1 month. The patient, however, complained of severe pain and muscle tension in her neck and back that virtually immobilized her. She spent most of her days sitting in a chair or lying on a bedboard on her bed. She enlisted the services of a solicitor as the Workmen's Compensation Board was cutting off her payments and her employer was threatening her with suspension if she did not return to work.# ^  f  m+ S# E5 B
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The patient shuffled slowly and laboriously into the psychiatrist's office and lowered herself with great care into a chair. She was attractively dressed and well made up and wore a neck brace. She related her story with vivid detail and considerable anger directed at her assailant (whom she repeatedly referred to as "that bloody foreigner"), her employer, and the compensation board. It was as if the incident had occurred yesterday. Regarding her ability to work, she said that she wanted to return to the job and would soon be severely strapped financially, but was physically not up to even the lightest office work.
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& o" {; z) O* v9 J  }* j- q1 E0 FShe denied any previous psychological problems and initially described her childhood and family life as storybook perfect. In subsequent interviews, however, she admitted that as a child, she had frequently been beaten by her alcoholic father, and had once had a broken arm as a result, and that she had often been locked in a closet for hours at a time as punishment for misbehavior.
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% ]2 P( a4 a1 {6 c" GDSM-IV-TR Casebook Diagnosis of "Lovely Rita"
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* K/ d. Q* e- Y% t) H$ D2 wIn this case the first question is: Can this woman's pain be entirely accounted for by the nature of her very real physical injury? Evidently, the answer is no, given the extensive assessment by several physicians. The next question is: Is this woman simply attempting to get continued financial support from Workmen's Compensation so that she will no longer have to earn a living? If the answer is yes, this would be an instance of Malingering—that is, the intentional production and presentation of false or grossly exaggerated symptoms in pursuit of external incentives. The apparent genuineness of her suffering and her desire to return to work makes this unlikely.+ A2 v2 l. ^. b; n) _8 p$ r/ J
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Although the pain was initially caused by her injury, most physicians who examined the patient thought that she was sufficiently recovered physically and that her persistent complaints of pain were excessive. In addition, there is evidence of specific psychological factors contributing to the severity and maintenance of the pain. The history of the patient's having been physically abused by her father as a child probably produced psychological conflict that was revived by the assault. This might account for the continuation of the pain beyond what would be accounted for by her injury. This leaves us with the diagnosis of Pain Disorder Associated With Both Psychological Factors and a General Medical Condition (see DSM-IV-TR), as both are judged to play an important role in this case.

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DOI: 10.1176/appi.books.9781585622665.31937
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Nightmares ! @$ g; s7 [$ t; d" ?4 n

8 z0 u3 e. s/ R" n& ~' xMartha, a 35-year-old woman, has had nightmares every night, beginning in her early teenage years. She comes to a sleep specialist at the insistence of her husband, who is fed up with her behavior both while sleeping and while awake. One to four times a night, she awakens out of a dream, the content of which is always disturbing. Often she dreams of yelling at other people or of menacing confrontations. In the dreams she feels angry and frustrated. Typically, she awakes from the dreams feeling extremely tense.7 O2 B$ t4 l! a& @" P; l  v) q8 \
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During the day Martha often has uncontrollable outbursts of temper. These can be precipitated by minor frustrations, such as a delay in finding her eyeglasses. In the midst of an outburst she may feel that it is wrong to behave thus, that her outburst is unwarranted, but she is powerless to stop it. After the outburst she apologizes for it.& u2 h! S, e7 q" X# c8 ?! R0 m  |
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Martha sleeps excessively, sometimes 12–13 hours consecutively on weekends, and often takes 3-hour to 4-hour naps. She is sleepy while driving on the turnpike, but manages to stay awake by having the temperature cold and the radio "blasting."& {+ n$ K8 `$ O  c! Q! v% h4 T; O/ q- Y
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She denies having sudden, irresistible attacks of sleepiness, cataplexy (sudden loss of motor power), hypnogogic hallucinations (hallucinations while awakening), or sleep paralysis (motor weakness and brief inability to move upon sudden awakening), all of which are characteristic of narcolepsy. She denies feeling confused or disoriented when she awakens from her dreams (as might be found in impaired arousal states, such as in episodes associated with temporal lobe dysfunction). Her husband notes that she has greatly increased eyelid flutter and eye movements shortly after she has fallen asleep (which might mean abnormally early onset of rapid eye movement [REM] sleep, as is seen in Major Depressive Disorder and drug withdrawal states). She always sleeps restlessly and occasionally hits him suddenly in the middle of the night (a common symptom of Parasomnias).
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At the initial evaluation, Martha appeared downcast but did not cry. She was organized and informative. She made three mistakes on serial sevens, but her sensorium was otherwise intact. She described her work as a registrar in a small college, which she considered enjoyable and her "salvation." Her 4-year-old daughter was bright and well.9 c& b; g+ z0 f# A
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Martha had smoked a pack of cigarettes a day for 25 years and drank a cup of chocolate and 48 oz of cola beverages daily. She took alcohol only a few times per year.
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All-night sleep recording revealed 9 hours of sleep continually interrupted by 10-second to 30-second arousals that frequently began with a K-complex (an arousal pattern) and were mostly unassociated with prior body movements. These happened about 35 times per hour in sleep stages I and II and during REM sleep, but only 4 times per hour during deep sleep. Otherwise, REM latency (the time spent before the initial appearance of REM sleep), density, and amount were normal, and other stages, although interrupted, were of normal pattern and percentage. However, there were no reports of nightmares during the night. (The constant arousals were unusual and possibly related to the abnormalities noted on the electroencephalogram.)
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9 ^4 {7 i: ~) ?$ R! J2 t' \DSM-IV-TR Casebook Diagnosis of "Nightmares"
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Martha's recurrent nightmares are a form of Parasomnia, a group of Sleep Disorders in which the predominant symptom is an abnormal event that occurs during sleep or at the threshold between wakefulness and sleep. Martha has Nightmare Disorder (see DSM-IV-TR), in which there are repeated awakenings from sleep with detailed recall of frightening dreams. These dreams are typically vivid and quite extended and usually include threats to survival, security, or self-esteem. The dreams occur during periods of REM sleep and thus are more likely to appear toward the end of the night.# ~3 S- }7 N0 M1 K

* M1 R$ g* ^9 Q3 }7 oMartha also has unusually prolonged sleep and daytime sleepiness (hypersomnia). Because the cause of the hypersomnia is not another sleep disorder (e.g., Narcolepsy, Breathing-Related Sleep Disorder) or another mental disorder (such as Major Depressive Disorder) and does not result from the direct physiological effects of a general medical condition or substance, the diagnosis of Primary Hypersomnia (see DSM-IV-TR) is also made.% z4 _, }) ~2 z1 A: C  D3 o% L
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It is hard to know how to explain Martha's irritability and temper outbursts. The psychiatrist who treated her suspected that these symptoms might have been manifestations of hypomania.  ~3 P$ \; x7 T8 \8 u

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9 l, {3 J7 w1 t: BTreatment has included psychotherapy, attempts to control dream content through a lucid dreaming routine (in which the dreamer directs the events of the dream or attempts to converse with the characters in it), and trials of an antidepressant and of an anticonvulsant, neither of which helped. A trial of lithium significantly lessened the temper outbursts for a period of 2 weeks, but they then returned, despite dosage increases.+ A6 H/ ]: r/ q, ?
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After being seen for 8 months, the patient became discouraged and angry with the therapist and refused further treatment.

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DOI: 10.1176/appi.books.9781585622665.31957) E0 z  L/ N4 k

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Paul and Petula have been living together for the last 6 months and are contemplating marriage. Petula describes the problem that has brought them to the sex therapy clinic.% c* f2 q* n# D2 W( r

6 G1 I" e1 J& T& u8 O8 D& u+ x8 e"For the last 2 months he hasn't been able to keep his erection after he enters me."
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  O& `2 e3 S" e& K2 u  \The psychiatrist turns to Paul and asks him how he sees the problem. Paul, embarrassed, agrees with Petula and adds, "I just don't know why."5 V  ^" z$ w6 m1 l* {% S+ `
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The psychiatrist learns that Paul, age 26, is a recently graduated lawyer, and that Petula, age 24, is a successful buyer for a large department store. They both grew up in educated middle-class suburban families. They met through mutual friends and started to have sexual intercourse a few months after they met and had no problems at that time.
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( l( R: G5 E7 i; Y# TTwo months later, Paul moved from his family home into Petula's apartment. This was her idea, and Paul was unsure that he was ready for such an important step. Within a few weeks, Paul noticed that although he continued to be sexually aroused and wanted intercourse, as soon as he entered his partner, he began to lose his erection and could not stay inside. They would try again, but by then his desire had waned, and he was unable to achieve another erection.
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After the first few times this happened, Petula became so angry that she began punching him in the chest and screaming at him. Paul, who weighs 200 pounds, would simply walk away from his 98-pound lover, which would infuriate her even more.
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The psychiatrist learned that sex was not the only area of contention in the relationship. Petula complained that Paul did not spend enough time with her and preferred to go to baseball games with his male friends. Even when he was home, he would watch all the sports events that were available on TV and was not interested in going to foreign movies, museums, or the theater with her. Despite these differences, Petula was eager to marry Paul and was pressuring him to set a date.* k- A0 ~; |; {; a# Y
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Physical examination of the couple revealed no abnormalities, and there was no evidence that either partner was persistently depressed.
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DSM-IV-TR Casebook Diagnosis of "Paul and Petula"
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% P* U6 A% ^7 p8 k, S% ]7 gPaul and Petula have many problems that a family-oriented clinician would want to focus on, such as Paul's ambivalence about committing himself to a relationship with Petula and her frantic efforts to obtain that commitment. The effect of these problems on Paul's sexual functioning is clear: he is unable to maintain his erection until the completion of sexual activity.
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When there is no evidence that the disturbance is caused exclusively by a general medical condition (such as by diabetic neuropathy or certain medications), the diagnosis of Male Erectile Disorder, Due to Psychological Factors, is made (see DSM-IV-TR). We note that the disorder is Acquired (recent onset), not Lifelong. (Note: When an erectile dysfunction is caused by a general medical condition, the medical condition would be coded as a physical disorder on Axis III.)/ I% ~% D. ^. u* B3 L% d( r0 ]

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Neither partner was willing to discuss nonsexual problems. They were treated with Masters and Johnson's sensate focus exercises over the next several months. In these exercises, the couple explored nongenital ways of giving physical pleasure to each other without the psychological demands of demonstrating sexual competence. Petula continually pressured Paul to translate the therapy into action. She saw herself as a therapist and teacher and Paul as patient and pupil. Paul passively avoided doing the exercises on many occasions; but over a period of 8 months, Paul's problem with maintaining an erection was gradually resolved. They were married within 3 months after treatment ended.* m  M3 D+ Z* W, _3 u

, W4 f2 b8 S% yThe Petersens sought treatment twice more over the next 8 years. On both occasions the underlying issue was again Paul's ambivalence about further committing himself to the relationship (buying a house, having children). Paul had a recurrence of erectile problems and, in addition, a complaint of premature ejaculation on the rare occasions when he could maintain an erection intravaginally. During the treatment, greater attention was given to their relationship, rather than simply focusing on the sexual problem. At last report they had two children and had bought a house in the suburbs, and the sexual problem had again been resolved.

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DOI: 10.1176/appi.books.9781585622665.31977
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9 W! @! g) W7 L1 t3 }; @+ HThe Bully ! [* v* b# I3 x

+ E+ n( b+ ^( pJ.P. is a muscular 24-year-old man who presented himself to the admitting office of a state hospital. He told the admitting physician that he had taken thirty 200-mg tablets of chlorpromazine in the bus on the way over to the hospital. After receiving medical treatment for the "suicide attempt," he was transferred to the inpatient ward.
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2 @- _# h. ^( ZOn mental status examination, the patient told a fantastic story about his father's being a famous surgeon who had a patient die in surgery. The patient's husband then killed J.P.'s father. J.P. stalked his father's murderer several thousand miles across the United States and, when he found him, was prevented from killing him at the last moment by the timely arrival of his 94-year-old grandmother. He also related several other intriguing stories involving his $64,000 sports car, which had a 12-cylinder diesel engine, and about his children, two sets of identical triplets. All these stories had a grandiose tinge, and none of them could be confirmed. The patient claimed that he was hearing voices, as on the TV or in a dream. He answered affirmatively to questions about thought control, thought broadcasting, and other unusual psychotic symptoms; he also claimed depression. He was oriented and alert and had a good range of information except that he kept insisting that it was the Iranians (not the Iraquis) who had invaded Kuwait (referring to the Gulf War that took place in 1990–1991). There was no evidence of any associated features of mania or depression, and the patient did not seem either elated, depressed, or irritable when he related these stories.
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4 X$ a4 z) k. U8 bIt was observed on the ward that J.P. bullied the other patients and took food and cigarettes from them. He was very reluctant to be discharged, and whenever the subject of his discharge was brought up, he renewed his complaints about "suicidal thoughts" and "hearing voices." It was the opinion of the ward staff that the patient was not truly psychotic, but merely feigned his symptoms whenever the subject of further disposition of his case came up. They thought that he wanted to remain in the hospital primarily so that he could bully the other patients and be a "big man" on the ward.
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DSM-IV-TR Casebook Diagnosis of "The Bully"
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' K# N! g- X, o0 TAlthough this patient would have us believe that he is psychotic, his story, almost from the start, seems to conform to no recognizable psychotic syndrome. That his symptoms are not genuine is confirmed by the observation of the ward staff that he seemed to feign them whenever the subject of discharge was brought up.6 k/ }8 a* j$ r0 ?; D
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Why does this fellow try so hard to act crazy? His motivation is not to achieve some external incentive, such as, for example, avoiding the draft, as would be the case in Malingering; his goal of remaining a patient is understandable only with knowledge of his individual psychology (the suggestion that he is motivated to assume the sick role because he derives satisfaction from being the "big man" on the ward). The diagnosis is, therefore, Factitious Disorder With Predominantly Psychological Signs and Symptoms (see DSM-IV-TR).

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DOI: 10.1176/appi.books.9781585622665.31988- R" _' S5 C5 ~! n; r
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Toughing It Out, with treatment discussion
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Mindy Markowitz is an attractive, stylishly dressed 25-year-old art director for a trade magazine who presents to an anxiety clinic after reading about the clinic program in the newspa-per. She is seeking treatment for "panic attacks" that have occurred with increasing frequency over the past year, often 2 or 3 times a day. These attacks begin with a sudden intense wave of "horrible fear" that seems to come out of nowhere, sometimes during the day, sometimes waking her from sleep. She begins to tremble, is nauseated, sweats profusely, feels as though she is choking, and fears that she will lose control and do something crazy, like run screaming into the street.& F( i* p+ W# @: c7 T5 e' D) ?

5 d1 d. F2 y; J/ aMindy remembers first having attacks like this when she was in high school. She was dating a boy her parents disapproved of and had to do a lot of "sneaking around" to avoid confrontations with them. At the same time, she was under a lot of pressure as the principal designer of her high school yearbook and was applying to Ivy League colleges. She remembers that her first panic attack occurred just after the yearbook went to press and she was accepted by Harvard, Yale, and Brown. The attacks lasted only a few minutes, and she would just "sit through them." She went to her family physician because she thought she might have something seriously wrong with her heart. After a complete physical examination and an electrocardiogram, he reassured her that it was "just anxiety."1 B& _# h7 @5 n2 V" l' v
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Mindy has had panic attacks intermittently over the 8 years since her first attack, sometimes not for many months, but sometimes, as now, several times a day. There have been extreme variations in the intensity of the attacks, some being so severe and debilitating that she has had to take a day off from work.
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Mindy has always functioned extremely well in school, at work, and in her social life, apart from her panic attacks and a brief period of depression at age 19 when she broke up with a boyfriend. She is a lively, friendly person who is respected by her friends and colleagues both for her intelligence and creativity and for her ability to mediate disputes.
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Mindy has tried to ignore the attacks and has rarely limited her activities because of them. There have been a few times, even during the brief periods that she was having frequent, severe attacks, when she stayed at home from work for a day because she was exhausted from multiple attacks. She has never associated the attacks with particular places. She says, for example, that she is as likely to have an attack at home in her own bed as on the subway, so there is no point in avoiding the subway. Whether she has an attack on the subway, in a supermarket, or at home by herself, she says, "I just tough it out."
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DSM-IV-TR Casebook Diagnosis of "Toughing It Out"/ C9 C7 ^) g* [1 S: a5 d5 B$ s+ A

- \) l; i3 t) ?, E6 Q  iMindy describes classic, unexpected panic attacks. They hit her unpredictably with a sudden burst of fear and the characteristic symptoms of autonomic arousal: sweating, trembling, nausea, and choking, all severe enough to make her fear she will lose control. Unlike most patients who have such severe panic attacks, she has never associated particular situations, such as crowded places or public transportation, with having the attacks. Therefore, she does not show any symptoms of agoraphobic avoidance. Thus, the diagnosis is Panic Disorder Without Agoraphobia (see DSM-IV-TR).6 d- \; Y, j; W# o

1 h$ n# F. r" x. b+ e5 p' ?& QNote: This case is discussed first by Dr. Martin M. Antony and then by Dr. Donald Klein.
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& p; I$ W' Y" \0 y+ PDiscussion of "Toughing It Out" by Martin M. Antony, Ph.D.*9 W+ {4 E% w# \  P
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In many ways, Mindy's condition is an example of a typical case of Panic Disorder Without Agoraphobia. She is experiencing unexpected panic attacks and worries about the consequences of the attacks (e.g., that she might lose control). There doesn't appear to be any significant comorbidity other than a brief period of depression experienced 6 years earlier that was triggered by the breakup of a relationship.
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In the treatment of Panic Disorder, there are three empirically supported approaches—cognitive-behavioral therapy (CBT), pharmacotherapy (e.g., imipramine, selective serotonin reuptake inhibitors [SSRIs], alprazolam, clonazepam), and a combination of CBT and pharmacotherapy. Studies on the relative efficacy of these approaches have been somewhat inconsistent, but generally, there is little evidence to suggest that any of these three approaches is more effective than the others, at least for the acute treatment phase (Antony and Swinson 2000; van Balkom et al. 1997).
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9 h: _0 j- V# j; D" rIn the long term, however, after treatment has been discontinued, there is evidence that patients who receive CBT fare better than patients who receive either medication or combined treatments (Barlow et al. 2000; Marks et al. 1993). Therefore, my preference for a case such as Mindy's would be to start with a course of CBT, assuming that she is interested in that option. If treatment with CBT is not effective after 8–10 sessions, or if it leads to only a partial response after 10–15 sessions, my recommendation would be to augment treatment with medication (probably an SSRI)./ |& L8 }& ]% \$ G9 J; Q! k# Z! K

2 v* s0 \; c4 ~There are a number of effective cognitive-behavioral protocols for treating panic disorder (e.g., Clark et al. 1994; Craske and Barlow 2001). My own approach is adapted from David Barlow and Michelle Craske's panic control treatment, which includes psychoeducation, breathing retraining, cognitive restructuring, and exposure. However, in light of recent evidence showing that breathing retraining does not contribute significantly to outcome (Schmidt et al. 2000), I typically don't include it (unless a patient is bothered by hyperventilation).
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: ~- |& }2 W, k' mCBT for panic disorder typically has 10–15 weekly sessions, each one lasting about 1 hour. The final few sessions often occur less frequently (e.g., every 2 weeks). The initial few sessions are focused on assessment and on providing education about the nature and treatment of panic. These sessions are followed by several sessions focusing almost exclusively on cognitive therapy strategies. Although the cognitive strategies are used throughout treatment, exposure techniques are introduced at around the fifth session. The final sessions are spent discussing termination of treatment and strategies for maintaining gains.2 S1 K" V/ t. L8 {% H& @* t

4 d/ Y7 G# K- a* Q! n3 c6 |) J" dTo start, I would begin with a thorough assessment. In addition to the features measured during a typical psychiatric assessment (e.g., diagnostic symptoms, family history, course of illness), there are other aspects of the problem that are of particular interest in a CBT-focused assessment for panic disorder. These include a detailed assessment of the patient's panic attacks, including their frequency, intensity, triggers, symptoms, associated cognitions, coping strategies, and other features., \' D6 {; C* u6 j/ K9 w

: c# [# {3 o( d" VIn preparation for using cognitive strategies, it is important to understand the beliefs, predictions, and assumptions underlying the attacks. In Mindy's case, these seem to be thoughts about losing control or doing something crazy in public. In preparation for using exposure-based strategies, it is important to understand the triggers for Mindy's attacks. Although she doesn't have agoraphobia and her attacks are not triggered by particular places, it is still likely that triggers can be identified. These may include particular symptoms that she fears (e.g., trembling, nausea, sweating) or activities that trigger symptoms of arousal (e.g., exercise, drinking caffeine, sex, scary movies).) n& n3 \4 k7 w8 d: K2 w' E
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The treatment rationale would also be presented during the early sessions. This part of treatment is designed to educate the patient about the nature of panic attacks and panic disorder, to provide the patient with a model for understanding the problem, and to provide an overview of the treatment procedures. From a cognitive-behavioral perspective, Panic Disorder is thought to be maintained by a tendency to be fearful of benign physical sensations. Although most people tend to ignore symptoms such as dizziness or heart rate changes, individuals with Panic Disorder tend to interpret these symptoms as signs of impending danger.
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As Mindy's therapist, I would discuss with her the notion that anxiety and fear are normal emotions experienced by everyone. Normalizing the experience of fear helps patients to become more accepting of their panic symptoms, which is the first step to overcoming the intense fear of having panic attacks. Mindy would also be encouraged to recognize that panic attacks are time limited. Although they are uncomfortable and frightening, panic attacks always come to an end, and they are almost never dangerous. Any misconceptions about panic that Mindy holds (e.g., that panic attacks could cause her to lose control) would be discussed, and corrective information would be presented.
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Mindy would also be encouraged to think of her fear and anxiety in terms of three components—physical, cognitive, and behavioral. The physical component of fear includes all of the physical arousal symptoms that she experiences during the attacks. The cognitive component includes her fearful misconceptions, predictions, and beliefs about the dangers of panic attacks and symptoms (e.g., "I will lose control"), as well as her tendency to attend to threat-related information (e.g., scanning her body for feared symptoms). The behavioral component includes any actions that Mindy takes to control her fear or prevent her panic attacks. For many individuals with Panic Disorder, these behaviors include avoidance of panic triggers (e.g., exercise, caffeine) and engaging in various safety behaviors (e.g., carrying a mobile phone in case of an "emergency," lying down whenever the slightest symptom is experienced, checking one's pulse repeatedly). Once Mindy understands her symptoms in terms of these three components, the treatment procedures would be introduced.
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- j5 O) A# N" ZCognitive therapy is designed to target the cognitive component of fear by changing fearful thoughts about panic attacks. Exposure targets fearful behaviors (e.g., avoidance, safety behaviors) by compelling patients not to use their typical avoidance strategies, thereby showing them that their symptoms are not dangerous. Other strategies (e.g., breathing retraining, medications) are designed to influence the physical component. Intervening at any of these levels is assumed to lead to changes in the other two components. To reinforce the material discussed in the initial sessions, Mindy would be encouraged to read a self-help manual that describes the nature and treatment of panic from a cognitive-behavioral perspective (Zuercher-White 1997).& j1 k" q/ t: B; g8 G

5 f2 ]7 V2 C3 O' |" J" o; @2 ^Around the time of the third session, Mindy would be taught to use cognitive restructuring to challenge anxious thinking—in particular, her tendency to overestimate the likelihood of negative consequences occurring (probability overestimations) and her tendency to exaggerate the impact of such consequences if they were to occur (catastrophic thinking). She would be encouraged to record her anxious thoughts in diaries and to use a variety of techniques to examine the evidence for her thoughts. Mindy would also be encouraged to conduct behavioral experiments to test out the accuracy of her predictions. For example, if she is convinced that unless she escapes during a panic attack she will lose control and run screaming into the street, Mindy would be encouraged to stay where she is during her next attack to learn that she will not, in fact, lose control. Although cognitive strategies would be introduced over a period of two sessions, she would be encouraged to continue using the strategies throughout the remaining sessions (and between sessions, for homework), and some time at the start of each session would be spent reviewing her use of the cognitive therapy techniques.! V; n/ o( w* I/ M: m; p* l

( @% I& M7 G  b+ K; ~Exposure would be introduced at around the fifth session. Because Mindy does not report any agoraphobic avoidance, her treatment would not include much situational exposure. However, if she does avoid any arousal-producing activities, such as exercise or sex, she would be encouraged to begin to incorporate these into her routine. In addition, Mindy would be taught to use interoceptive exposure, which essentially involves exposure to feared physical symptoms. Initially, Mindy would attempt a series of exercises designed to trigger panic-like sensations (e.g., hyperventilation, aerobic exercise, breathing through a straw, spinning in a chair), and her responses would be recorded. The exercises that most strongly triggered feelings similar to her panic attacks would be noted, and Mindy would be instructed to repeat these exercises until they no longer produced fear. Exposure practices would occur in the therapist's office and during homework, between sessions, both at her home and in situations in which she typically experiences panic-like feelings (if any such situations can be identified).
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Over the next few sessions, Mindy would continue to practice both the cognitive therapy and exposure strategies. If she reports a tendency to hyperventilate, breathing retraining might be included to teach her to slow down her breathing. The last few sessions would focus on helping Mindy to plan for the future. She would be encouraged to continue to use the cognitive-behavioral strategies after treatment has ended and to call her therapist for a booster session if the need arises.
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0 ^8 }6 {; Y' f, O0 i9 QAlthough most patients respond well to CBT alone, some require other treatment approaches. If Mindy did not respond to CBT, I would recommend adding medication. In all likelihood, I would suggest starting with a low dosage of an SSRI and increasing the dose gradually (agitation and anxiety can be side effects of SSRI treatment in the first few weeks). While waiting for the SSRI to begin working, a low dosage of a benzodiazepine (e.g., clonazepam) would help to decrease her anxiety, although I would gradually discontinue the benzodiazepine after 4–6 weeks.
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# \* @8 T) p, BMindy's prognosis is very good. Most of the predictors of negative outcome in the treatment of Panic Disorder (e.g., chronic life stress, severe agoraphobia, comorbid personality disorders) do not appear to be an issue for her. There is a good chance that Mindy could completely beat her panic attacks in a relatively short time. If this does not happen, chances are very good that her symptoms would at least be significantly improved by the end of treatment.
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  Y: C3 _! f1 a5 w- @* v/ }, P. E*Dr. Antony is Associate Professor in the Department of Psychiatry and Behavioural Neurosciences at McMaster University. He is also Chief Psychologist and Director of the Anxiety Treatment and Research Centre at St. Joseph's Healthcare in Hamilton, Ontario. Dr. Antony has published 11 books, including the Handbook of Assessment and Treatment Planning for Psychological Disorders (2002), Practitioner's Guide to Empirically Based Measures of Anxiety (2001), and Phobic Disorders and Panic in Adults: A Guide to Assessment and Treatment (2000).- M- |0 q2 e" J2 H1 r
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References# n" p6 ^, S! T; d! v8 j
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Antony MM, Swinson RP: Phobic Disorders and Panic in Adults: A Guide to Assessment and Treatment. Washington, DC, American Psychological Association, 2000 & L+ Z& h4 j. x1 l, V; C; I8 f0 K
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Barlow DH, Gorman JM, Shear MK, et al: Cognitive-behavioral therapy, imipramine, or their combination for panic disorder. JAMA 283:2529–2536, 2000  [PubMed] ! w% u. \1 H! m

: p$ [$ a' r# @% R3 YClark DM, Salkovskis PM, Hackmann A, et al: A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. Br J Psychiatry 164:759–769, 1994  [PubMed] . ]1 U+ n9 A, r, u& y5 l

+ z6 x5 e* A# r) _Craske MG, Barlow DH: Panic disorder and agoraphobia, in Clinical Handbook of Psychological Disorders, 3rd Edition. Edited by Barlow DH. New York, Guilford Press, 2001, pp 1–59 3 J) ^' u, s% |) W# z: c
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Marks IM, Swinson RP, Basoglu M, et al: Alprazolam and exposure alone and combined in panic disorder with agoraphobia: a controlled study in London and Toronto. Br J Psychiatry 162:776–787, 1993  [PubMed]
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! z+ d* w# k6 t9 z9 TSchmidt NB, Woolaway-Bickel K, Trakowski J, et al: Dismantling cognitive-behavioral treatment for panic disorder: questioning the utility of breathing retraining. J Consult Clin Psychol 68:417–424, 2000  [PubMed] ( o  p! W7 z9 r% z1 e; y  l
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van Balkom AJLM, Bakker A, Spinhoven P, et al: A meta-analysis of the treatment of panic disorder with or without agoraphobia: a comparison of psychopharmacological, cognitive-behavioral, and combination treatments. J Nerv Ment Dis 185:510–516, 1997
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Zuercher-White E: An End to Panic: Breakthrough Techniques for Overcoming Panic Disorder, 2nd Edition. Oakland, CA, New Harbinger Publications, 1997 5 ?# }) @1 ^0 n4 \' J, a

! c' I! v1 Y7 V# M8 M7 QDiscussion of "Toughing It Out" by Donald Klein, M.D.** p1 p. p( s0 h( t/ S

1 A* ]1 y& `# {  zMindy may have been asked about, or is only telling, half of the story. Whoever provided this skimpy history apparently refrained from probing. The problem is the inconsistencies between the unbelievably stoical history, the hair-raising symptomatic description, and the intelligent, educated patient.
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# B7 {; c; j5 |+ V* r1 B' c9 h8 @This Ivy League graduate has waves of "horrible fear" for 8 years, with distressing physical and mental symptoms and apprehensions about losing her mind, but she accepts her doctor's reassurance that it's "just anxiety" because she is otherwise perfectly healthy. What is worse is that this statement is the reason accepted by the mental health professional who evaluated her. In my experience, it is extremely unlikely that a patient who has been experiencing severe panic attacks for 8 years would be reassured by proclaiming that it is just anxiety. Obvious inconsistencies in a patient's history always require a more detailed evaluation, accompanied by gentle confrontation if necessary (e.g., "these panic attacks were so bad you felt like you were losing your mind. . . .  I'm surprised that simple reassurance from your doctor would have been so effective.")/ \( O# M+ P6 v; ]2 H
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Mindy's panic attacks are called "classic," but they are not exactly classic. Sudden dyspnea, experienced as air hunger, is the common salient somatic feature of recurrent spontaneous panics. This is not apparent in the case description, although "choking" may actually be the label for dyspnea used by the patient. It should not be assumed that the terms the patient uses to describe her experience of her symptoms are identical to those used by the evaluator. Spontaneous panic attacks without dyspnea do occur, but they are usually sporadic rather than recurrent, less severe, and more frequent in males. (They also respond best to high-potency benzodiazepines.) The reason given for the absence of phobic avoidance is not a counterexample of agoraphobic reasoning. The travel restrictions of patients with agoraphobia are not due to having more panic attacks when away than when at home but rather to the feared lack of access to ready help if severe panic should strike (e.g., "going crazy," one of the patient's perceived possibilities).
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6 e. b; @7 c% k: H) ]( t) }Somehow, the attacks are perceived as not likely to be catastrophic by this patient despite the described symptoms. What disorders should be considered besides Panic Disorder?. L/ A, @; k7 h9 C4 x, V
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Number one is covert drug abuse—probably marijuana, possibly mixed with cocaine. This hypothesis is consonant with these features:9 r& w( m% m, d, U0 N: U

3 {5 V. ^  f/ g* ?' K6 ?0 l* o 1. Onset during association with disreputable boyfriend
) g, P9 D1 b3 d/ y- Y 2. Marked irregularity of attack pattern
6 g1 c5 g0 t7 [7 E& G" c: S, L 3. Apparent avoidance of medical attention, which may indicate covert knowledge of probable precipitant and fear of detection , E+ S& H" _2 ?* z1 c0 T
4. Absence of phobia, indicating possible knowledge that the attacks are precipitated by drugs rather than indicative of some impending catastrophe
. ]* B+ O; }) w. a 5. Unpersuasive rationalization for the absence of phobia
7 W) m; h- }( b2 ^) i 6. Marijuana and cocaine are frequent precipitants of recurrent panics , ~5 _* E- h' d8 y" @9 O/ Q: S

+ _7 r  \* _$ h3 t7 X  GThe diagnostic assessment apparently did not include queries about drug use and abuse or about smoking tobacco, which is now known to be a major risk factor for Panic Disorder (as is being female and having a history of depression)./ y8 F* H7 @0 k" w$ ^# K% _' f, ~
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Atypical depression (i.e., depression characterized by symptoms such as oversleeping and overeating) is occasionally associated with recurrent panic attacks that often do not incite phobic reactions. However, atypical depression is usually chronically problematic and not brief and infrequent, as described by this patient. Yet another problem with this assessment is that it is based entirely on the patient's narrative. Depressed patients, particularly those who aspire to "tough it out," often deny and minimize.
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Temporal lobe epilepsy should also be considered in the differential diagnosis. In temporal lobe disorder, patients frequently have waves of fear. Surprisingly, temporal lobe disorder is often associated with creative activities. Exploring the possibility of temporal lobe epilepsy, I would want to know the following: Does the patient keep a journal or diary? Is she shy? Is she hypergraphic? Is she cosmically or mystically inclined? Does she have olfactory hallucinations? Just what is her social and sex life like? We know nothing about Mindy's family history, premenstrual exacerbations, or nocturnal attacks.: ?' A: N! c: Y- i5 U7 i$ t! C- \

. j4 h# N. W' C( n# i7 ZIn my practice, patients are asked to come to the first interview with the person who knows them best, usually a spouse but maybe a parent, child, or friend. Patients are also sent forms before their appointment and are asked to provide a narrative summary of their illness, a detailed record of past treatments and medications, general medical and psychiatric symptomatology, and doctor and hospital records. After reviewing this material, I initially see the patient and informant together, pointing out that it is valuable to obtain another person's perspective. Both minimization and dramatization, which would only be guesswork if the patient was seen alone, become apparent in a joint interview. After 15–20 minutes I thank the informant and continue with the patient for the next hour. On rare occasions, review of the written material prompts seeing the patient alone at first.
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The initial review takes 1.5 hours. This amount of time usually suffices for a working diagnosis and treatment plan but not always. (Expressions of shocked indignation may now be heard from managed-care aficionados!) Is this economical?
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6 H" K- Q% ^; H" a0 e1 RI believe that the major difference between good and bad care is the thoroughness of evaluation and close monitoring of treatment. Many so-called refractory cases benefit from quite simple interventions for which indications had been missed. Others benefit from discontinuing toxic medication regimens.
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Critical attention to the level of evidence that justifies the use of particular diagnostic and therapeutic techniques is crucial. However, my emphasis on thoroughness should not be used as a rationalization for indefinitely prolonged, goal-less explorations. Comparative treatment outcome data is, unfortunately, rare and heavily influenced by the allegiance of the treatment providers to particular forms of treatment.
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( P, S0 I1 [/ G*Dr. Klein is Professor of Psychiatry at Columbia University, College of Physicians and Surgeons, as well as Director of Research at the New York State Psychiatric Institute. In 1962, Dr. Klein and Dr. Max Fink at Hillside Hospital found, in a placebo-controlled, randomized trial, that depressed patients benefited from the antipsychotic chlorpromazine, as did patients treated with the first tricyclic antidepressant, imipramine. This finding challenged the watertight distinction between antipsychotics and antidepressants.) _; H( [- @( k3 `2 D8 @

: n( q$ n; m+ zTwo years later, in 1964, on the basis of a double-blind, placebo-controlled trial, Dr. Klein suggested that "anxiety" was not a single affect. Spontaneous panic and anticipatory anxiety are distinguished by their distinct responses to medication. The first American textbook in clinical psychopharmacology, Diagnosis and Drug Treatment of Psychiatric Disorders (1969), was coauthored by Dr. Klein and Dr. John M. Davis.
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Dr. Klein fostered innovative recategorizations of depressive and anxiety disorders, including atypical depression and social anxiety disorder, while demonstrating the unique benefits of the neglected monoamine oxidase inhibitors. His recent suffocation false-alarm theory of "spontaneous" panic has generated much controversy due to the claim that panic is not fear because of the lack of hypothalamic-pituitary-adrenal activation, the distinctive acute air hunger that does not occur in danger-engendered fear, and the lack of effect of tricyclic antidepressants on ordinary fear." o+ H9 f$ S" ~2 ]. w
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Suggested Reading
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Fyer AJ, Mannuzza S, Chapman TF, et al: Effects of specific phobia comorbidity on the familial transmission of panic disorder. Am J Med Genetics (submitted)  D, S7 j2 j/ V

6 a7 P$ @( ~9 {- S; a3 d: sGoetz RR, Klein DF, Papp LA, et al: Acute panic inventory symptoms during CO2 inhalation and room-air hyperventilation among panic disorder patients and normal controls. Depress Anxiety 14(2):123–136, 20018 a8 {' M! G) G/ y
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Klein DF: Evidence for the validity of the concept of panic disorder. Eur Neuropsychopharmacol 8 (suppl 2):S57–S60, 19985 G% L. c2 c. v5 n% j
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Klein DF: Panic and phobic anxiety: phenotypes, endophenotypes, and genotypes. Am J Psychiatry 155(9):1147–1149, 1998
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Klein DF, Preter M: Panic, suffocation false alarms, separation anxiety and endorphins. Behav Brain Sci (submitted)8 B, Q& h2 Z2 M" C" D) p5 o

# V; q; y* K% q+ FMarshall R, Blanco C, Printz D, et al: A pilot study of noradrenergic and HPA axis functioning in PTSD vs. panic disorder. Psychiatry Res 110(3):219–230, 2002( Y: O' _/ A( ~+ M

, e. _" I6 \* p& dMartinez JM, Coplan JD, Browne ST, et al: Respiratory variability in panic disorder. Depress Anxiety 14:232–237, 20010 Z  Q) u" v* j' y1 E6 @
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Sheikh JI, Leskin GA, Klein DF: Gender differences in panic disorder: findings from the National Comorbidity Survey. Am J Psychiatry 159:55–58, 2002% I+ w* {# c, n# J( y- }) W+ P

6 v& X7 D2 i, m% x, aSinha SS, Coplan JD, Pine DS, et al: Panic induced by carbon dioxide inhalation and lack of hypothalamic-pituitary-adrenal axis activation. Psychiatry Res 86:93–98, 1999
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6 P" E9 R- B5 ]$ ~/ {( W3 K, ESlattery MJ, Klein DF, Mannuzza S, et al: Relationship between separation anxiety disorder, parental panic disorder, and atopic disorders in children: a controlled high-risk study. J Am Acad Child Adolesc Psychiatry 41(8):947–954, 2002

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DOI: 10.1176/appi.books.9781585622665.32048
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Toy Designer
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A 45-year-old toy designer was admitted to the hospital following a series of suicidal gestures culminating in an attempt to strangle himself with a piece of wire. Four months before admission, his family had observed that he was becoming depressed: when at home he spent long periods sitting in a chair, he slept more than usual, and he had given up his habits of reading the evening pa-per and puttering around the house. Within a month he was unable to get out of bed in the morning to go to work. He expressed considerable guilt, but could not make up his mind to seek help until forced to do so by his family. He had not responded to 2 months of outpatient antidepressant drug therapy and had made several half-hearted attempts to cut his wrists before the serious attempt that precipitated the admission.
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* ?* ~9 v) G- b; \Physical examination revealed signs of increased intracranial pressure, and a computed tomographic scan showed a large frontal-lobe tumor.
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& Y, \( g9 Q" a" `3 j8 r  h- QDSM-IV-TR Casebook Diagnosis of "Toy Designer"
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1 g* p: a( G- a' i! YDepressed mood, suicidal gestures, increased sleep, loss of interest, and guilt all suggest a Major Depressive Episode. Although the patient's symptoms are identical to those seen in a Major Depressive Episode, it is reasonable to infer that the disturbance is caused by the frontal-lobe tumor; thus, the diagnosis is Mood Disorder Due to Brain Tumor, With Major Depressive–Like Episode (see DSM-IV-TR).
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% V- @5 b. ~  xSome clinicians might prefer to consider this diagnosis provisional, pending the results of surgery. If the depression lifts after removal of the brain tumor, the diagnosis of a Mood Disorder caused by the brain tumor would be supported. If the depression persists following surgery, the diagnosis would remain equivocal, as there would be no way to definitely rule out a Major Depressive Disorder that developed coincidentally.
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5 c+ E- ^/ u3 ]* O& mThe frontal-lobe tumor is, of course, noted on Axis III.
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Follow-Up
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The patient underwent surgery, and the tumor was removed. Two years following surgery, his wife described to the surgeon how hopeful she initially was following the surgery because her husband's depression seemed to lift. However, he never regained interest in returning to work and has spent all of his time at home. Although the patient makes few complaints, his wife describes him as lacking his former enthusiasm and "spark." In addition, he seems to have trouble concentrating while reading the pa-per.( B+ T; E$ J; Y& w7 J7 {% |
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The diagnosis at follow-up is changed from the original diagnosis of Mood Disorder Due to Brain Tumor. The predominant disturbance now is a marked change in personality, as manifested by the patient's apathy and indifference. Personality changes are common in Dementia; but in this patient, despite some difficulty in concentrating, there is no evidence of a global deterioration in intellectual functioning. Thus, the follow-up Axis I diagnosis is Personality Change Due to Brain Tumor, Apathetic Type (see DSM-IV-TR). The general medical condition, postsurgical removal of the frontal-lobe tumor, is noted on Axis III.

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DOI: 10.1176/appi.books.9781585622665.32063
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Freaking Out : Q8 w, Q. `8 d& T

8 S1 F- I" o& W8 eIn the middle of a rainy October night in 1970, a family doctor in a Chicago suburb was awakened by an old friend who begged him to get out of bed and come quickly to a neighbor's house, where he and his wife had been visiting. The caller, Lou Wolff, was very upset because his wife, Sybil, had smoked some marijuana and was "freaking out."
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The doctor, extremely annoyed, arrived at the neighbor's house to find Sybil lying on the couch looking quite frantic, unable to get up. She said she was too weak to stand and that she was dizzy, having palpitations, and could feel her blood "rushing through [her] veins." She kept asking for water because her mouth was so dry she could not swallow. She was sure there was some poison in the marijuana. Sybil was relieved to see the doctor, because she had believed the neighbors would not let her husband call him for fear of being arrested for possession of marijuana, and she was sure that without medical help, she would die.! F/ ?2 W: P& t
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Sybil, age 42, was the mother of three teenage boys. She worked as a librarian at a university. She was a very controlled, well-organized woman who prided herself on her rationality. She had smoked marijuana, a small amount, only once before, and the only reaction she had detected was that it made her feel "slightly mellow." It was she who had asked the neighbors to share some of their high-quality homegrown marijuana with her, because marijuana was a big thing with the students and she "wanted to see what all the fuss was about."
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" Z) n9 s, L) y* uHer husband said that she took four or five puffs of a joint and then wailed, "There's something wrong with me. I can't stand up." Lou and the neighbors tried to calm her, telling her she should just lie down and she would soon feel better; but the more they reassured her, the more convinced she became that something was really wrong with her and that her husband and neighbors were just trying to cover it up.1 H7 I, p6 Y- c2 y) C, ?

$ x: x+ W# F* E* s* hThe doctor examined her. The only positive findings were that her heart rate was increased and her pupils dilated. Adopting his best bedside manner, he said to her, "For Christ's sake, Sybil, you're just a little stoned. Go home to bed and stop mak-ing such a fuss." Sybil seemed reassured. He then walked into another room and told Lou, "If that doesn't work, we'll have to take her to the emergency room."% w) s1 m% C6 k+ U
   
! g4 T6 ?" |0 e  R; a5 X& i, ~DSM-IV-TR Casebook Diagnosis of "Freaking Out"
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9 K# F8 D5 k5 h! SSybil's bad experience with marijuana (cannabis) included characteristic physical symptoms such as dry mouth and increased heart rate. It was the mental symptoms, however, that caused her husband to seek help. Sybil became extremely anxious and had paranoid ideation (thinking that the marijuana was poisoned and that her neighbors would not let her husband call the doctor). This maladaptive reaction to the recent use of cannabis indicates Cannabis Intoxication (see DSM-IV-TR).6 e& t6 w  W7 `) r' W

* Q& b: ?! D7 f. gIn diagnosing this case, we considered whether Sybil's paranoid ideation could justify a diagnosis of Cannabis-Induced Psychotic Disorder; we decided the answer was no. First of all, the neighbors might well have been reluctant to call the doctor as they would have had to admit that they were smoking an illegal substance. Second, Sybil was reassured by the doctor that the marijuana did not contain poison, whereas, by definition, a delusion is a false belief that is firmly held, even despite evidence to the contrary.
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; k, w, k; y  D, b, M' {4 [Follow-Up7 Y5 W4 f1 D! t  K3 i
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Sybil was helped into her car by Lou (she still couldn't stand up) and went home to bed. She stayed in bed for 2 days, feeling "spacey" and weak, but no longer terribly anxious. She realized that, because the marijuana was homegrown, there was no reason to think that it contained any poison. However, she still believed her neighbors did not want to call the doctor because they were afraid of the police. She vowed never to smoke marijuana again.

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DOI: 10.1176/appi.books.9781585622665.32079* u5 c" k# }  b0 [# ~

+ ^. e$ K$ n; w. O3 b: }Charles
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7 I; J& `# u+ b' ?% m8 BA 25-year-old patient, who called himself Charles, requested a "sex change operation." He had for 3 years lived socially and been employed as a man. For the last 2 of these years, he had been the housemate, economic provider, and husband-equivalent of a bisexual woman who had fled from a bad marriage. Her two young children regarded Charles as their stepfather, and there was a strong affectionate bond between them.
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In social appearance the patient passed as a not-very-virile man whose sexual development in puberty might be conjectured to have been extremely delayed or hormonally deficient. His voice was pitched low, but not baritone. His shirt and jacket were bulky and successfully camouflaged tightly bound, flattened breasts. A strap-on penis produced a masculine-looking bulge in the pants; it was so constructed that, in case of social necessity, it could be used as a urinary conduit in the standing position. Without success the patient had tried to obtain a mastectomy so that in summer he could wear only a T-shirt while working outdoors as a heavy construction machine operator. He had also been unsuccessful in trying to get a prescription for testosterone to produce male secondary sex characteristics and suppress menses. The patient wanted a hysterectomy and oophorectomy and as a long-term goal looked forward to obtaining a successful phalloplasty." i6 ~& ^* j; F$ _6 V! G
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The history was straightforward in its account of progressive recognition in adolescence of being able to fall in love only with a woman, following a tomboyish childhood that had finally consolidated into the transsexual role and identity.
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; H% V; z4 w* z" g3 gPhysical examination revealed normal female anatomy, which the patient found personally repulsive, incongruous, and a source of continual distress. The endocrine laboratory results were within normal limits for a female.% k* d. U7 p# S5 G" F
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DSM-IV-TR Casebook Diagnosis of "Charles"8 V- n; r5 N$ k' O

" q+ P& b0 e+ R0 i, I) X% _The diagnosis of Gender Identity Disorder (see DSM-IV-TR) is certainly suggested by the first sentence, which indicates that the person desperately wants to get rid of his primary sex characteristics and acquire the sex characteristics of the other sex because of persistent discomfort and sense of inappropriateness about his assigned sex. This case also demonstrates the other characteristic features of the disorder when present in an adult: a strong and persistent cross-gender identification manifested by dressing, living socially, and being employed as a man. As is almost always the case, there is no evidence of physical intersex or genetic abnormality.& |! z, D4 K3 m, ?$ |1 L+ k
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The diagnosis is further specified as Adult Type to indicate current age and, with regard to the predominant history of sexual orientation, Sexually Attracted to Females.' L5 z" t% k. d! P$ ~

' ]3 b7 }3 C9 Q/ m* QAdults who have developed the desire to physically change their sex (previously referred to as Transsexualism) almost invariably report having had a gender identity problem beginning in childhood, although the onset of the full syndrome is (as with Charles) most often in late adolescence or early adult life.

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DOI: 10.1176/appi.books.9781585622665.32092# u) O/ e3 s% g6 q# t# h. z/ O/ T

, V1 d- ?% b( o" Y7 SCat Naps
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' s3 O0 Y0 I- UNora, a 24-year-old graduate student, complained of episodes of severe sleepiness that forced her to take naps. Sometimes when she attempted to stay awake, she was unable to do so; she had fallen asleep at the dinner table and even when walking. She had trouble staying alert enough to get off at the right bus stop. In fact, she was unable to remain seated without becoming sleepy, slept through classes, and failed her courses in graduate school.- o: z; }. }+ I( M
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Nora is bothered by frequent cataplexy, in which she becomes limp and briefly unable to move after sudden emotional arousal. This occurred, for example, when she discovered that her cat had urinated on her rug and when she had become enraged with her roommate. On another occasion she almost had a car accident when another driver did something that annoyed her and she almost lost control of the car.
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As she falls asleep at night, Nora sees vivid scenes that seem real and feels that someone else is in the room. She still feels awake, however, and knows that there is really no one there. Her sleep is frequently punctuated by nightmares. She then wakes up feeling very hungry and has a snack.
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2 P, r2 C9 z6 o: Y8 m7 l4 h3 gExtremely bothersome to Nora is her continual automatic behavior, in which she suddenly discovers that she has accomplished very little after a lengthy period of work on a task. For example, she spent 2 hours unsuccessfully trying to fix her glasses and was unaware of this until her roommate interrupted her and pointed it out. The automatic behavior makes it difficult for her to change from one task to another, so it sometimes takes her 2 hours to get out of the house in the morning or to get ready for bed at night. Delays in getting to bed prevent her from getting a good night's sleep, which further aggravates her daytime sleepiness. Her roommates grew weary of her undependability, and she had to move back to her parents' home.
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2 y0 V7 k  c! g! X' WPrevious treatment with a drug regimen consisting of an antidepressant, a stimulant, and a bedtime sedative was unsuccessful.1 _/ l* [; O, F& ]7 ^
   
7 w, L3 T) b* Q$ F4 p* Q* QDSM-IV-TR Casebook Diagnosis of "Cat Naps"
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/ `( K& Z  C  q! N2 `, h" BNora's problem of sleep attacks and excessive daytime sleepiness is an example of hypersomnia. Her daytime sleep attacks, cataplexy, hypnogogic (when falling asleep) hallucinations, automatic behavior, nightmares, and disturbed sleep are the characteristic features of Narcolepsy (see DSM-IV-TR). Although traditionally this disorder has been regarded as a neurological disorder, to facilitate the differential diagnosis of hypersomnia, in DSM-IV-TR it is included in the Sleep Disorders section as an Axis I disorder.4 e1 B: Q* v% _! l1 z# p) c. G; D; U" e
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Follow-Up+ t) ~4 |3 L7 W4 a6 }4 i1 M
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Nora was instructed to keep records of her in-bed times, nap times, cataplexy attacks, episodes of night eating, and automatic behavior. Psychotherapy was focused on examining the details of her failure to adhere to prescribed bedtimes, forgetting to take medication, and other behaviors that worsened her situation. She was withdrawn from the sedative, and her treatment with an antidepressant and a stimulant was empirically adjusted on the basis of the record she kept of her behavior.
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Nora's symptoms gradually disappeared, and she was able to move out of her parents' house, get a job, reestablish a social life, and return to graduate school.

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