As described in appendix A, Joan is a 22 year old woman that has been referred for psychological evaluation from her doctor after presenting somatic complaints. Although in the doctors’ opinion no apparent physical basis can be found for the complaints presented, Joan highlights that she has nausea, rapid heart palpitations and sweating.
An initial interview reveals Joan is a current university student and has been in a relationship with her current boyfriend (Nevin) for the past three years. Joan admits to using cannabis for the initial purposes of making her feel relaxed; however claims that recently her use had increased to a more frequent level.
Specifically identifying a trigger point for her complaint, Joan explained that during a regular exercising routine; four days after stopping her cannabis habit, she visited a local shop and experienced several abnormal feelings. She encountered feelings of being nauseated, ill, sweaty and a feeling of her chest tightening. She further states that within a few minutes of these symptoms presenting, she experienced a sensation of gasping for air and a sense of getting out of control.
Joan claims to have re-experienced these symptoms when she went past the shop and once at university when she was required to publicly speak during class. Due to the fear of relapsing she has neither returned back to the shop or her university class. As a result of this continuous fear, Joan now insists that Nevine accompany her to major public places such as library, malls, classes and even to this consultation. Joan does not present any other physical instabilities and is appears to be alert to her surroundings and appearance. However it must be noted that she has insisted that she be positioned near the door during the interview progress and did show signs of distractibility.
This essay will try to evaluate all possible differential diagnoses for Joan based on the information provided. The differentials will be evaluated describing why they should be considered as part of the preliminary diagnoses. Using the diagnostic and statistical manual of mental disorders (DSM-IV-TR), the essay will try to correlate all differential diagnoses back to the information provided.
The DSM-IV-TR is a publishing which entails a list of all possible mental health disorders that can be attributed due to specific symptoms presented. From a psychological perspective, a therapist matches up the symptoms presented to that of the disorder symptoms presented in the DSM-IV-TR. This helps therapists to develop all potentials disorders that may classify the mental status of the patient they are treating (First, Frances, & Pincus, 2002).
According to First, Frances and Pincus (2002), the DSM-IV-TR further classifies disorders as being part of a multiaxial scale. Axis I is categorised as being clinical disorder including such items as panic disorders and generalised anxiety disorder. Axis II is categorised as being personality disorders or mental retardation and include items such as borderline personality disorder and obsessive-compulsive personality disorder. Axis III is categorised as general medical/physical conditions or disorders, and include such items as hyperthyroidism. Axis IV is categorised as psychosocial and environmental problems and include items such as social issues or educational problems. Axis V lastly is classified as being global assessment of functioning which tests your general, overall health and test items such as interpersonal social interactions and/or academic performance.
All differential diagnoses can be established through the means of using psychological assessments, questionnaires as well as talking to family members and friends. The DSM-IV-TR also contains a flow chart approach called a decision tree in order to establish possible diagnoses for different disorders. Once all differential diagnoses have been considered, a provisional diagnosis will be identified. The appraisal of why other diagnoses have been rejected will also be discussed, along with the implications and prognosis of the provisional diagnosis based on relevant literature.
Identification of differential diagnoses
Social phobia. Social phobia is part of axis I and is considered to be a form of anxiety disorder. Social phobia is the fear of being able to interact with your social surrounding. The fear is considered to be irrational and involves the ideology that the persons actions are being scrutinised and therefore will result in self humiliation or self embarrassment (Thobaben, 2004; Valente, 2002).
According to First, Frances and Pincus (2002), in order to classify a client as having social phobia, they must meet the following criterias; (a) show persistent fear of being in a social situation where they feel their actions will be scrutinised or result in embarrassment; (b) being in the feared situation incites feeling of anxiety displayed through symptoms of panic attacks; (c) fear is recognised by person as being excessive and/or unreasonable; (d) the social situations causing the fear are avoided or undergone with anguish; (e) the avoidance or distress of the feared situation causes significant interruption to the person normal routine; (f) the fear is not due to other reasons such as substance use and is not better explained by another condition.
This diagnosis is considered possible for Joan because it was found that, Joan has a persistent fear of losing control and hence causing embarrassment to herself (criteria a); the envision of being in the anxiety causing situations produces causes symptoms such as nausea, sweating, tightening of the chest, palpitations, gasping for breath, dizziness, and feeling of losing control, similar to that described as panic attacks(criteria b). Joan recognised that her fear was too extreme from her normal level and therefore avoided going out alone for a fear of embarrassment (criteria c & d). Hence it caused a significant impact to her routine whereby she stopped attending classes, ceased jogging and being able to independently go to public places (criteria e).
However a point that maybe used to dismiss this as a provisional diagnosis is the fact that Joan’s system maybe be due to her substance use (cannabis). Whether the substance use is influential or not will need to be evaluated. Therefore at this stage this diagnosis will be considered as a differential diagnosis until other diagnoses can be further evaluated.
Substance – induced anxiety disorder with panic attack. This axis I diagnosis states that symptoms which are presented and best described as being similar to that of anxiety disorders (i.e panic attacks), may in fact be caused due to the ingestion or withdrawal of an illicit substance (Psyweb.com, n.d).
According to First, Frances and Pincus (2002), in order to be diagnosed under this disorder the criteria’s to be met include; (a) prominent anxiety or panic attacks are apparent in the client; (b) evidence in the history of the client that criteria “a” occurred within one month of the client either ingesting the drug or from cessation of drug intake; (c) the disturbance is not more appropriately distinguished by an anxiety disorder that is non-substance induced.
Joan meets this diagnosis criteria because she has symptoms which are described as being part of a panic attack such as nausea, sweating, tightening of the chest, palpitations e.t.c (criteria a). Although we are not certain if the panic attack happened as a result of her taking cannabis, she has stated that within four days of stopping the cannabis use the symptoms of the panic attack were initiated (criteria b). However at this stage it would be considered that this diagnosis can be dismissed because this diagnosis is superseded better by the social phobia disorder. The social phobia disorder was able to justify more criteria that directly related to Joan’s history. The symptoms presented by Joan corresponded more to do with problems associated with being able to interact in the social environment and have self independence. Another point to consider is that the second time Joan had this panic attack symptom (class presentation), it was not caused due to not smoking cannabis prior, and therefore it suggests that Joan’s condition is more to do with her social surroundings rather than substance induced. Therefore it is safe to say that criteria “c” has not been met and therefore this diagnosis is rejected while social phobia is retained for the present moment.
Specific phobia (situational type). Similar to a social phobia, specific phobia is an axix 1 phobia described as the presence of a fear response to a specific object or situation. The focus of the fear in most cases has minimal danger or none at all. For the client, the fear can lead to feelings of intense distress causing avoidance of the specific situation or object (Thobaben, 2004).
According to First, Frances and Pincus (2002), the disorder for situational type is characterised by; (a) having a persistent fear to a situation that can be considered as being excessive or unreasonable due to being in the actual feared situation or expectancy of the specific situation; (b) the presence of the feared situation incites feeling of anxiety displayed through symptoms of panic attacks; (c) the client determine the fear as being excessive and/or unreasonable; (d) the specific feared situation is avoided or encountered with anguish; (e) the evasion of the specific situation causes hindrance to normal routine of the person; (f) the phobia is not better accounted for by another mental disorder.
Joan meets these criteria because she exclusively stated that she has a specific fear of losing control and hence embarrassing herself. Based on the fact that she avoids social situations based on this specific fear, it can be said that she posses a specific phobia of a situational basis (criteria a). Joan also states that when she has this specific fear of losing control and embarrassing herself, she experienced panic attack symptoms of nausea, sweating, tightening of the chest, and dizziness (criteria b). She has also confirmed that she considers the fear as being excessive, which forces her to avoid the specific situation and hence interrupt her normal routine (criteria c,d,e). Similarly to the social phobia, at this stage a more accountable diagnosis has not been established and therefore this differential diagnosis has been retained with the social phobia for the present moment (criteria f).
Panic disorder with agoraphobia. This disorder is an axis I disorder that describes a person who has a persistent occurrence of panic attack like symptoms. Along with this they also have trouble of either being in a public environment or encountering another sort of feared situation because they feel escape might be impossible if they have a panic attack episode (Andrews, 2003).
According to First, Frances and Pincus (2002), to meet the criteria for this disorder it entails meeting criteria for both panic attacks and agoraphobia. This is distinguished by meeting the following criteria’s. (a) meets both the following; (1) has at least four repetitive and unexpected symptoms of a panic attack (palpitations, sweating, shortness of breath, choking sensations, chest discomfort, nausea, dizziness, fear of losing control, fear of dying, paresthesias, chills or hot flushes) within a 10 minute time frame; and (2) following the panic attack the person has either (i) had constant worry about further panic attacks, (ii) concerns of the attacks consequences, (iii) modification in behaviour because of the attack.
Another criterion to meet includes (b) the presence of agoraphobia. This is classified as meeting the following; (1) concern of being in a feared situation because they feel escape might be impossible if they have another panic attack; (2) potential situations where the panic attack may happened are avoided; (3) the avoidance is not better accounted for by another mental disorder. The final two criteria’s include (c) the panic attacks are not due to substance abuse and (d) the panic attacks are not better accounted for by another disorder (First, Frances & Pincus, 2002; Psyweb.com, n.d).
This diagnosis of panic disorder with agoraphobia (DSM IV TR code 300.21) has been established as being the provisional diagnosis for Joan’s circumstances. Joan meets all these criteria because it has already been ascertained that she has panic attack symptoms and that she has had one month of worry about recurring attacks and its consequences (criteria a). She has also showed signs of agoraphobia because she insists sitting near the door and avoids situations where she may lose control and thus embarrassing herself (criteria b). It has already been concluded that the panic attack was not primarily due to substance use but due to situational factors (criteria c), and that no other disorder can be ascertained that better describes Joan’s symptoms (criteria d).
Additionally the differential diagnoses of social phobia and specific phobia can be dismissed because panic disorder with agoraphobia has accounted for both these differentials. Specifically this provisional diagnosis has met the requirements of social phobia’s fear of being able to interact with her social surrounding due to her panic attack. It has also met the requirements of the specific phobia’s fear of losing control and embarrassing self in response to a specific object or situation.