Panic Disorder Case

Clinical Case Vignette for Role Plays or Standardized Patients

Author: Joseph A. Himle, Ph.D.

Edited and submitted by Tamara Gay, M.D.

Presenting Situation

Joe Schultz is a 35 year old married father of two who works as a general
manager at a local country club.

Presenting Complaint

Panic attacks and "phobias"

History of presenting complaints

Mr. Schultz is currently experiencing a second substantial episode of panic

attacks and related avoidances. His current complaints include episodes of
anxiety and panic, which include; shortness of breath, rapid heart rate, sweating
palms, dizziness, and chest pain. His current episodes number approximately
three weekly and seem to be especially likely to happen at work. Mr. Schultz
relates that he experiences these situations where these episodes in situations at
work where he feels unable to leave comfortably. These situations include:
special events where he is called upon to give a speech, or is required to be
present, various board and committee meetings where an unexplained absence
or an exit in the middle of the meeting would be unacceptable to membership
and also when there is little staff in the dining room and he is called upon to wait
on tables. Mr. Schultz has a strong urge to flee any situation when the panic
attack begins. Although the episodes typically last only a few minutes, Mr.
Schultz is unable to endure this and feels as if he must get some fresh air. Mr.
Schultz is very concerned he will have a heart attack or pass out or do something
out of control during one of his episodes.
 Mr. Schultz feels that the stress associated with his current job, which he
began approximately eight months ago, is in part responsible for the worsening
of his panic attacks. Although the panic attacks happen more frequently in
certain situations, they can also happen out of the blue or when Mr. Schultz least
expects them. Mr. Schultz is very concerned that he will act in an embarrassing
way or draw attention to himself during one of these episodes, thus the needing
fresh air or avoiding people during one of these attacks. Mr. Schultz has been to
the emergency room on three occasions over the past eight months because of
his attacks of anxiety. During these episodes his anxiety was especially acute
and involved a substantial amount of chest pain. Upon arrival at the emergency
room he had each time been given cardiac test to ensure that his heart function
was appropriate. All of these tests have revealed no cardiac abnormalities. Mr.
Schultz is not completely convinced that the physicians who have seen him have
not missed something, although not likely, it is possible in his mind that he has a
serious medical problem that is responsible for these attacks.

Mr. Schultz is very concerned currently that he will not be able to continue
his current job as a general manager of the country club, given the frequency of
his attacks and his desire to avoid situations when which escape would be
difficult. Apart from concerns about attending work functions, Mr. Schultz has
significant worries about attending other functions in the community in which
escape would be difficult. These would include restaurants, movie theaters,
sporting events, and large malls and grocery stores. The thought of riding on
public transportation, especially an airplane, is especially difficult for Mr. Schultz.
Mr. Schultz is finding his current job as a general manager of the country club
particularly stressful. After a long career in the restaurant business, he and his
family envisioned a somewhat less hectic lifestyle with this job. However, Mr.
Schultz has been busier than ever working long hours for several demanding
members of the country club. He is concerned that it would be a great disruption
for his family if he quit this job because they have relocated to the neighborhood
that includes the country club grounds, a nice house is provided by the country
club. His wife and children are enjoying their new neighborhood/home and it
would be very difficult for Mr. Schultz to have to relocate to another area for work.
Mr. Schultz is resistant about discussing the situation currently with his wife who
seems to have "had enough" of his anxiety problems.

Mr. Schultz has tried two medications for his panic attacks. Approximately
five years ago after Mr. Schultz developed his first panic episode he began a trial
of Prozac at 20 mg. His response to Prozac was unfavorable with Mr. Schultz
experiencing substantial anxiety and tremor, which lead to his discontinuing
Prozac after only two days. At an earlier emergency room visit approximately
five years ago, he was given a prescription for ten tablets of Xanax 0.25 mg, and
he continues to carry this prescription around with him wherever he goes. He
has only taken four of these pills over the last five years, but feels that the Xanax
is an essential safety net in case his panic "gets out of control". Mr. Schultz is at
the same time concerned about his symptoms and the possibility of some serious
medical problem, but also feels embarrassed and regretful about having a likely
emotional problem which has taken over so much of his life. His wife has
complained significantly of late about his avoidances and restrictions and his
"nervous problems".

This is second period of time in Mr. Schultz's life where panic attacks and
phobias have interfered. At age 30, just after the death of his father, from a heart
attack, also during a time of difficulty at the work place, Mr. Schultz began having
panic attacks. These panic attacks were initially quite severe and occurred daily.
They persisted for approximately months and it was during this time that Mr.
Schultz began avoiding large crowds, shopping malls, and public transportation.
Mr. Schultz sought counseling during this period of time with a psychologist who
spent time talking about his family life and his relationship with his parents when
he was a boy. This treatment was not particularly helpful for Mr. Schultz. Mr.
Schultz did report that he was helped somewhat by a book that he read about
panic disorder during this time. After approximately six months his panic attacks
dissipated. He did remain avoidant of some activities however; especially large
crowded sporting events. Mr. Schultz has been especially concerned with his
recent panic attacks, since chest pain has been a very strong component. He
reports that he feels pain in his chest and some radiation down his left arm when
he experiences a panic attack. Mr. Schultz reports that he does not experience a
worsening of chest pain and pressure during exercise, but that he has avoided
exercise to some degree because it can trigger panic attacks. He also reports
that his panic attacks appear to occur more regularly when he has not eaten. If
he skips a meal or is late with his lunch he sometimes feels shaky which will
often trigger a panic attack for him. Mr. Schultz reports that he is very
embarrassed about his panic disorder and seeks to hide it from others. He is
very concerned about showing his anxiety to his children and passing on phobias
and panic attacks to them.

Mr. Schultz sometimes uses alcohol to quell his anxiety problems,

reporting that he drinks one to two drinks nearly every day. He also reports
drinking up to three or four drinks on some weekend days. He has no history of
withdrawal symptoms or patterns for signs and symptoms of alcohol abuse and
dependence. He does report that drinking to make his anxiety improve is
somewhat of a concern to him. He has no history of drinking and operating
dangerous machinery, drinking at work, or having people complain about his
drinking. He has built up no tolerance to alcohol. In addition to his panic attacks,
Mr. Schultz is visibly during a good portion of today's interview. He feels
generally anxious and uptight and on edge in between his panic attacks.

Most of his concern has to do with dread about his next panic attack and
concerns about whether he will be able to continue working, given his desire to
avoid situations from which escape would be difficult.
Personal Psychiatric History:

Apart from Mr. Schultz's panic attacks, he reports some general demoralization
about his situation. He reports feeling down in the dumps and sad sometimes
but generally manages to keep a positive outlook. He still maintains interest in
activities and pastimes, especially his interest in playing golf. He also reports
that he enjoys his children and that he enjoys spending time with his wife. He
does report that it has been somewhat stressful lately, given that he lives in the
same neighborhood where he works and making it difficult for him to feel free to
relax while out in the yard or out with his children walking the dog in the
neighborhood because many of the club members also live within the
neighborhood. Mr. Schultz has never been especially depressed for any more
than a day at a time.

Medical History:

Mr. Schultz reports that he feels jittery if he does not eat well enough and he is
concerned about whether he might have cardiac problems due to his chest pain.
However, his physician is not worried about either metabolic or cardiac problems.
Apart form these concerns Mr. Schultz is a healthy person and he is taking no
medications apart from carrying around a bottle of old Xanax tablets.

Personal/Social History

Mr. Schultz is a college graduate in hotel and restaurant management and has
worked several years in the restaurant business. He has been married to his
wife for ten years and they have two children, both girls, ages 5 and 3. He
reports a generally good relationship with his wife although she complains about
his panic attacks and avoidances. He is getting along very well with his children
and enjoys spending time with them. He reports a good circle of friends and that
he has generally gotten along well with people. He has done well in school and
has always had several recreational interests.