MAKERERE UNIVERSITY

P.O. Box 7062, Kampala, Uganda Telephone: +256-41-53126

Cables: MAKUNIKA website: www.chs.mak.ac.ug

COLLEGE OF HEALTH SCIENCES
FACULTY OF MEDICINE

DEPARTMENT OF PSYCHIATRY

CASE WRITEUP ON ANXIETY DISORDERS.

STUDENTS NAME:
NIWAGABA PETER MBChB IV

REG.NO:
10/U/1892.


LECTURER:
DR. AKENA D

Patients Bio Data:
Name : Night Mary.
Age : 42 years
Sex : Female
Address : Bulungu Village, Kalambi S/County, Kabalore District
Tribe : Mutooro.
Occupation : House wife-Peasant
Religion : Roman Catholic
Marital status : Married
Informant/Next of Kin : Mercy Gorrette (Daughter)
Level of Education : Primary Four
Date of Review : 10
th
Dec 2013.
Patient Number : MHC 1715/13

Sent from Ward 4A ID for review in Mental Health Clinic
PRESENTING COMPLAINTS:
Excessive Fear x 11 days
Increased heart beats x 10 days

HISTORY OF PRESENTING COMPLAINTS:
Mary was fairly well until eleven days prior to this consultation when she developed excessive
fear and increased heart beats. She developed those symptoms following her 8
th
abdominal
operation done in Mulago Hospital to reduce an incisional abdominal hernia. The symptoms
began suddenly and have been intensifying since onset. There was associated profuse sweating,
trembling of hands and the feeling of going to die. This was not the first time she was feeling
these symptoms, she started feeling them occasionally from 1996 after her 4
th
operation, but they
were not as intense as they are this episode and used to disappear on own. Also previously, she
felt them whenever she went into crowded places like markets and church, but this time round
she didnt have to first go to these places. She reported normal sleep pattern though she often
gets night mares.
She reported no associated history of sadness, loss of interest or having elated mood. There was
no associated hearing of voices or seeing things others were not seeing. There was no history of
adhering to any beliefs that could not be believed by others. There was no history of
experiencing any horrible things, like witnessing many dead people, witnessing fatal accidents or
history of assault or defilement or rape in her life. She doesnt drink alcohol or use any other
drugs of addiction. No history of suicidal ideation or attempt. No history of head trauma or
epilepsy or loss of consciousness.
She reported history of involvement in land wrangle over boundaries with the neighbor but she
feels this had nothing to do with her current problem. However, this incidence preceded her
recent episode by a few days.
PAST PSYCHIATRIC HISTORY:
This was her index medical consultation, but she reported several discrete similar episodes since
1996. She always prayed about them with her Priest but they could come again. She had never
used herbs or consulted traditional healers for her condition.
PAST MEDICAL AND SURGICAL HISTORY.
She was a known Peptic Ulcer Disease patient for 12 years, uses triple therapy (Omeprazole,
Metronidazole and Amoxicillin) when in Pain. HIV Serology done 2 years ago was Non-reactive
and she had no known drug or food allergies.
Mary had 4 cesarean Sections (1993, 1996, 2001 and 2009) while giving birth to her children.
Unfortunately the first C/S was complicated by infection and subsequent Incisional hernias
which routinely followed the rest of cesarean sections thus 4 operations for reducing these
incisional hernias. There was no history of Blood transfusion or trauma.
FAMILY HISTORY:
Mary is married with four children (a boy and three girls), first born is 20years in senior three,
rest of children are healthy and in school. The husband is alive and very supportive; he
completed primary six and operates a bodaboda in Fort portal town as means of generating
income for the family. Mary is comfortable with her marriage.
Mary is the 4
th
born in the family of 8 adults, both her parents and three of his siblings passed on.
Parents are presumed to have passed on due to old age, two of her sisters died of HIV related
complications while one brother who was an alcoholic died of unknown illness. The remaining
three siblings are ok and own families. No history of familial illnesses like DM, Epilepsy,
Hypertension or asthma. No history mental illnesses in family. No history of a close relative
known to have disappeared from home under unknown circumstances. No history of suicidal or
homicidal acts in the family. No history of substance abuse among close relatives other than the
brother above who passed on.
PERSONAL AND SOCIAL HISTORY:
Mary was unable to recall the details of her childhood history, but asserts that she grew up well,
joined a primary school at 10 years and was only able to complete primary four. Stopped in
Primary four because she was asked to take care of her young siblings. She eventually got
married at 18years. She gave birth to her first born 4years after marriage; this caused a lot of
tension in her though the husband was supportive.
She is known to be a social lady in her village, has a lot of friends and is on a Local council
committee member of her village. Used to run a small business enterprise (shop) but stopped 2
years ago because of being weak. She has never attempted suicide or developed a suicidal or
homicidal ideation. She doesnt abuse any substances/drugs.
Forensic history: No history of criminal acts or being found in the wrong side of the law by the
local authorities or police.
MENTAL STATE EXAM:
Appearance and Behavior: Mary was in good general health condition and nutritional state; she
was well groomed and appropriately dressed in clean clothing. Was cooperative through the
interview, was able to maintain direct eye contact and was in upright posture. Had no
mannerisms or disinhibitive behavior. Had nor tremors or any sort of tics.
Speech: she spoke at normal tone, rate and volume. Her words and thoughts were coherent in
pattern. Had no thought block, no flight of ideas or loosening of association.
Mood and Affect: She looked happy and unbothered but this was incongruent with affect. No
associated risks of suicide or homicide were elicited.
Thoughts:
Form; was normal with no loosening of association, no flight of ideas, and no pressure of
thought.
Content; she had no delusions, no overvalued ideas, no obsessions but was preoccupied with her
illness. She had fear/phobia for crowded places like market and church.
Alienation/possession; she reported no thought insertion or withdraw or broad casting. The
thoughts were from her mind.
Perception: she had no hallucinations or illusions. She was neither depersonalized nor
derealised.
Cognition:
Orientation; she was well oriented in time, place and person.
Memory; Her immediate, short term, and long term memories were intact
Attention and Concentration; were ok. She passed the serial subtraction of 3 from 20.
General Knowledge; she knew all recent events like death of Nelson Mandela.
Numeracy; was good, he was able to tell that four cows have 16 legs.
Judgment and abstraction; it was good, was able to tell correctly what she could do if, she
found child in the middle of the road. And how she would handle an emergency of a burning
house with people in.
Insight; she had good insight of her illness and had hope of recovering completely. She was also
willing to accept treatment.
PHYSICAL EXAMINATION:
General Exam; Middle aged lady who looked her age and in good nutritional status. Was
afebrile on touch, had no anemia, no jaundice, no enlarged lymph nodes, no edema and was well
hydrated. There was no finger clubbing or pallor of the palms.
Systemic Exam;
Cardiovascular Exam: No chest deformities seen, No scars in the precordium, Apex beat in the
5
th
intercostal space mid clavicular line. No heaving.
Her pulse rate was 100 beats per minute; it was regular and normal volume. Her blood pressure
was 130/80 mm of mercury. Heart sounds I & II were heard, no added heart sound.
Respiratory System; Respiratory rate was 20 breath per minute, normal chest expansion, no
respiratory distress and normal bronchovesicular sounds heard bilaterally.
Per Abdomen: The abdomen was moderately distended with a fresh midline sub umbilical
incision which was dressed. There was no oozing of either pus or serous fluid. There was mild
tenderness on superficial palpation; deep palpation was thus not done.
There were no significant findings in other systems.

SUMMARY:
Night Mary a 42 years old female and peasant housewife from Bulungu Village, Kalambi
S/county, Kabarole District. Who was sent to Mental Health Clinic from New Mulago Ward 4A
Infectious Diseases with complaints of Excessive fear and increased heart palpitations for ten
days. The excessive fear and heart palpitations followed her 8
th
surgical operation. She had been
discretely feeling similar symptoms since 1996 but was not as severe as the current episode. She
reported associated profuse sweating, hand tremors, and a feeling of going to die. There was no
associated diarrhea, headache or light headedness. There were no associated features of
depression, mania or schizophrenia. And there was no associated history of substance abuse or
head trauma. She had never thought medical attention for her problem; she only used to pray
about it. She is a known to have Gastritis and has had 8 surgical operations.
She was happily married with 4 children who are all ok and in school, lost her parents and three
of her siblings and one of her brothers was an alcoholic before his death.
She appeared well groomed and in good nutritional status, was co-operative and attentive. Her
speech, mood, perception, thought and cognition were normal. She had good insight of her
illness. Her Blood pressure was normal and the abdominal exam revealed a fresh midline sub-
umbilical surgical incision, with clean dressings in place.
DIAGNOSIS.
Axis I: Panic Disorder with Agoraphobia - In View of discrete periods of intense fear
accompanied by Palpitations, sweating, trembling, and fears of dying
Differential Diagnosis:
1. Generalized anxiety Disorder
2. Phobic disorders-Social Phobia
3. Anxiety disorder due to general medical condition
Axis II: Normal Personality
Axis III:
Abdominal Incisional Hernia.
Peptic Ulcer Disease/Gastritis.
Axis IV:
Predisposing factors: Frequent surgical operations, low socio-economic status, age, being
female.
Perpetuating factors: Peptic ulcer disease, low socio-economic status, not starting treatment
early.
Precipitating factors: Land wrangles over boundaries, frequent surgical operations, and low
socio-economic status
Protective factors: Supportive family, Caring Husband, Being HIV Negative, Having Insight
for her illness
Axis V: Global assessment of functioning is above 70 %.



















INVESTIGATIONS AND THEIR RESULTS:
Social investigations: Collateral history was taken from her daughter
Biological Investigations:
HIV Serology: Negative
TPHA Test: Non-Reactive
Blood slide: No malaria parasites seen
Random Blood sugar: 8.87mmol/l
CBC Results: All parameters were in normal
ECG and ECHO: normal findings in all
TREATMENT:
Immediate Short term Long term
Social Psych-education;
Re assurance;
Psycho education, Adherence to treatment,
counseling, follow up,
support counseling,
explaining drug side effects.
Psychological Initiation of Cognitive
Behavioral Therapy(CBT)
which combines both
exposure to the feared
stimulus with relaxation,
and work around the
patients false cognition &
giving information about
the panic attack.
Continuation of sessions
in cognitive behavioral
therapy.
Continuation of sessions in
cognitive behavioral therapy.
Biological Initiation of SSRIs &
Benzodiazepines;
Tabs.Fluoxetine 5 mg
Tabs Diazepam 5mg OD

Continue with Caps
fluoxetine 10mg OD x 2
weeks &
Tabs.Diazpam5mg
nocte x 2 weeks
Step up SSRIs to;
Caps Fluoxetine 20mg OD x
1month&Stop
Benzodiazepine Follow up is
continued and these
medications they should be
given at least 8 to 12 weeks to
exert their full
effects and be continued for 8
to 12 months.


DISCUSSION OF ANXIETY DISORDERS-
(Panic Disorder with Agoraphobia)
Anxiety is a state of tension and apprehension with hyperactivity of the autonomic nervous
system as a natural response to perceived threat.
In anxiety disorders the frequency and intensity of anxiety responses are out of proportion when
compared to situations that trigger them.
Anxiety disorders have 3 components;
i) Cognitive component: subjective feelings of apprehension, a sense of impending danger and a
feeling of inability to cope.
ii) Physiological responses: increased heart rate, blood pressure, muscle tension, rapid breathing,
nausea, dry mouth, diarrhea and frequent urination.
iii) Behavioral responses: avoidance of certain situations and impaired task performance.
Anxiety disorders may be classified as follows;
Generalized anxiety disorder (GAD) - at least 6 months of persistent and excessive
anxiety and worry.
Panic disorder- Recurrent unexpected panic attacks about which there is persistent
concern, Marys anxiety was this type.
Phobic disorders where clinically significant anxiety is provoked by exposure to certain
feared object or situation often leading to avoidance behavior.
Obsessive Compulsive disorder (OCD) obsessions (which cause marked anxiety or
distress) or compulsions (which serve to neutralize anxiety).
Post-traumatic stress disorder (PTSD) re-experiencing of an extremely traumatic event
accompanied by symptoms of increased arousal and by avoidance of stimuli associated
with the trauma.
My patient (Mary) had Panic disorder with agoraphobia, thus panic disorders will be discussed
here under.
Panic Disorder is the presence of recurrent, unexpected panic attacks, followed by at least one
month of persistent concern about having additional attacks, worry about the implication of the
attack or its consequences or significant change in behavior related to attacks.


Etiological theories.
Cognitive; concerns about physical illness are more common in anxious patients who experience
panic attacks than in those who do not. This suggests a spiraling effect in which anxiety leads to
physical symptoms which lead to anxiety and so on. In Marys case, the most plausible etiology
is this cognitive theory because of frequent surgical interventions.
Other theories that may apply to Marys case include the following;-
Genetic; first degree relatives of those with panic disorder have an eight times greater likelihood
than members of the general population of developing the disorder.
Biochemical; panic attacks can be easily induced in this group by yohimbine, and this suggests
an abnormality of noradrenergic receptors, as does the effectiveness of treatment with
imipramine.
Hyperventilation; spontaneous attacks arise from involuntary hyperventilation.
Clinical features.
Panic attacks are sometimes associated with agoraphobia (anxiety about, or the avoidance of,
places or situations from which escape might be difficult or embarrassing, or in which help may
not be available in the event of a panic attack or panic like symptoms).
The essential feature of a panic attack is a discrete period of intense fear or discomfort that is
accompanied by at least 4 of the 13 physical symptoms that include;
Palpitations or increased heart rate or pounding heart,
Sweating,
Trembling or shaking,
Sensations of shortness of breath or smothering,
Feeling of choking,
Chest pain or discomfort,
Nausea or abdominal distress,
Dizziness or unsteadiness or light headedness or fainting,
De-realization or de-personalization,
Fear of losing control or going crazy,
Fear of dying, paresthesias (numbness or tingling sensation) and
Chills or hot flashes.
Mary had the essential feature of discrete period of intense fear, palpitations, sweating, fear of
dying, trembling or shaking and the tingling sensation. These features categorize her to have a
panic disorder.
In addition, Mary had fear for crowded places like the market; this further classifies her to have
a panic disorder with agoraphobia.
Epidemiology.
The life time prevalence of panic disorder is between 1.5-3.5%, Female to male ratio is 3:1 and
up to one-half of panic disorder patients have agoraphobia.
Panic disorders usually develop in early adulthood with peak onset in the mid-twenties, in my
patient this disorder developed when she was around 24 years.
First degree relatives have an 8fold increase in panic disorder though non among the first degree
relatives was reported by Mary.
The course of the illness is often chronic but symptoms may wax or wane depending on the
presence of stressors. In the case of Mary, frequent surgical procedures seem to be the stressors
that trigger onset of these panic attacks. This time round, land boundary wrangle with the
neighbor might have as well contributed.
Fifty percent of panic disorder patients are only mildly affected while 20% have marked
symptomatology.
Suicide risk is said to be markedly increased especially in untreated patients like Mary, however,
her risk assessment was not in agreement. She did not have any suicidal ideation.
Also, substance abuse especially alcohol may occur in up to 40% of patients with panic disorder,
luckily, Mary is not known to abuse alcohol or other drugs.
Differential diagnoses of panic disorders include;
1. Generalized Anxiety Disorder; In my patient, the panic attacks were discrete, yet they
are always continuous for at least 6 months in GAD.
2. Anxiety due to a general medical condition especially Pheochromocytoma, Cardiac
arrhythmias, Hyperthyroidism, insulinomas, Pulmonary Embolism and Hypoxia are
known to be associated with panic disorders. In my patient, thyroid function tests were
not done, this is a probable differential.
Treatment.
Cognitive Behavioral therapy aims at breaking the spiraling thought patterns of the person by
learning to control the symptoms and reattribute them so that the panic does not develop.
Cognitive behavioral therapy also combines both exposure to the feared stimulus with relaxation,
and work around the patients false cognition and giving information about the panic attack. This
alone can effectively treat mild cases of panic disorder whereas it should be supplemented with
pharmacotherapy in patients who have marked distress from panic attacks and are experiencing
impairment in work or social functioning as it had become the case with Mary.
Various pharmacological agents are effective.
Benzodiazepines (short and long term) may be used for symptomatic relief.
Antidepressants especially the Selective Serotonin Reuptake Inhibitors (SSRIs) like fluoxetine,
sertraline and paroxetine.
Tricyclic Antidepressants (TCAs) like imipramine are used for long term management.
For both SSRIs and TCAs, they are initiated in small doses and then gradually increased as
tolerated to minimize the potential of exacerbating panic symptoms by these drugs.
Course and prognosis
30-40 % of patients appear to be symptom free at long term follow up,
50 % have very mild symptoms,
10-20 % continue to have disabling symptoms,
poor outcome predicted by lower social class and long duration of illness,
depression may occur in 40 - 80 % of panic patients,
alcohol and substance dependency may occur in up to 20 - 40 % of patients,
increased risk of suicide compared to the normal population.
REFERENCES.
1. Linford R, Maurice L, and Chris B; Text Book of Psychiatry ,1st Edition (1997), pgs. 99-107.
2. David M, Christopher P, John M, Musisi S, et al, The African text book of Clinical psychiatry
and Mental Health (2006). Pgs. 214-227
3. Diagnostic Statistical Manual of Mental Disorders (DSM IV) pgs 40-45.
4. Neurotic Disorders PDF, down loaded. pgs 1-34.