Holly's Anxiety

February 12, 2018 Print Friendly Version of this page Print Get a PDF version of this webpage PDF
By David Tang (5th year Medical Student)
Holly Ryman
06/10/1982 (35 years)
I am fit and well. I recently moved to this area with my husband and my son and I am now registered to this practice. I do not have any medical illness as far as I am concerned. Always fit and well. 

[When asked about regular medications] However, I am currently taking 4mg of lorazepam daily for my ‘anxiety’ for two months now. 

[When prompted] I have butterflies in my stomach and difficulty breathing. I also experience numbness and chest discomfort, almost like an out-of-body experience, as though my own body isn’t real. It has been around a year now since I first noticed the issue. 

[Only if asked] The attack comes in episodes and it happens out of the blue and came unprovoked. It stops after 10 minutes or so but it’s difficult to get the timing right when I was in that state. It’s the worst feeling ever, and I wouldn’t wish my worst enemy to go through that. I find it difficult to concentrate because I keep worrying that the ‘episode’ will come back.

No suicidal or self harm ideation. Initially very reluctant to appreciate this might be a "mental health" or "psychiatric" issue but is willing to accept help if persuaded convincingly. Beginning to use alcohol with the lorazepam to extend the effect. 
Past Medical History
Glandular fever during university
Drug History
Vitamin D, Lorazepam
Family History
Father passed away from a stroke
Social History
Occasional alcohol, non-smoker, no support network as only recently moved to area
Introduction & consent

Name, age, occupation

Establishes duration of symptoms

Establishes triggers/stressors/life events

Explores pattern of anxiety

Explores content of obsessions

Screens if they are recurrent and unpleasant

Screens if they are resisted/senseless

Screens for physical symptoms of anxiety (sweating, palpitations, dry mouth, dizziness, nausea)

Screens psychological symptoms of anxiety (sleep, derealisation, fear, hypervigilance)

Explores methods to reveal anxiety (compulsions, substance misuse)

Explores views on consequences of behaviours

Screens for risk to others and self (including suicide)

Screens for depression (low mood, anergia, anhedonia)

Explores impact on occupation or social life

Explores available support

Identifies level of insight and willingness to accept treatment

Looks for substance misuse

Previous medical & psychiatric history

Family history of psychiatric or medical disorders

Drug history, alcohol, smoking and allergies

Ideas "Was there anything you thought it might be?"

Concerns "What about it is worrying you in particular?"

Expectations "Is there anything in particular you were hoping we would to today?"

Communication skills (empathy and avoids jargon)

Summarises back to patient

Gives reasonable differential diagnosis (Panic attack disorder, GAD, Depression, Organic)

Management point:

  • Consider how the patient was dispensed with a 2-month supply of lorazepam (benzodiazepine). It is classed as a controlled drug and it should not be prescribed more than 30 days, unless in special circumstances. Most NHS trusts do not go beyond 14 days for prescriptions of controlled drugs. 
  • Advise and education is important as psychoeducation improves patients’ understanding of their own illness. 
  • A referral for psychotherapy such as cognitive behavioural therapy might benefit some patients.
  • Other medications such as antidepressants and beta blockers can help to control the unpleasant adrenergic symptoms of panic attacks. Benzodiazepines are used to bridge the therapy until the antidepressant takes effect but often it should not be part of the long-term maintenance therapy. Expert psychiatry input can be sought regarding commencement and dosing of the medications. 

Top differentials: 

  1. Panic disorder – characterised by episodes of unprovoked anxiety attacks like in this history rather than constant feelings of anxiety as in GAD. 
  2. Generalised anxiety disorder – often, the feeling of anxiety spans a continuous duration of time in GAD 
  3. Depression – if symptoms of affective disorders, ie depression preceded the panic attack or the criteria for diagnosis has been fulfilled, diagnosis of depression takes precedence. 
  4. Substance abuse – withdrawal symptoms can often mimic episodic panic attacks 
  5. Organic disorders – endocrine disorders such as phaeochromocytoma, paraganglioma, and carcinoid syndrome could mimic panic attacks.