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Anxiety, Obsessive-Compulsive, Trauma- or Stressor-Related, Somatic Symptom and Dissociative Disorders

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A 23-year-old woman arrives at the emergency room complaining that, out of the blue, she had been seized by an overwhelming fear associated with shortness of breath and a pounding heart. These symptoms lasted for approximately 20 minutes, and while she was experiencing them, she feared that she was dying or going crazy. The patient has had four similar episodes during the past month, and she has been worrying that they will continue to recur. Which of the following is the most likely diagnosis?

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a. Acute psychotic episode

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b. Illness anxiety disorder

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c. Panic disorder

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d. Generalized anxiety disorder

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e. Posttraumatic stress disorder

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The answer is c. (DSM-5, pp 208-214.) This patient displays typical symptoms of recurrent panic attacks. Panic attacks can occur under a wide variety of psychiatric and medical conditions. The patient is diagnosed with panic disorder when there are recurrent episodes of panic and there is at least 1 month of persistent concern, worry, or behavioral change associated with the attacks. The attacks are not because of the direct effect of medical illness, medications, or substance abuse and are not better accounted for by another psychiatric disorder. While anxiety can be intense in generalized anxiety disorder, posttraumatic stress disorder, acute psychosis, and illness anxiety disorder, it does not have the typical presentation (ie, a discrete episode or panic attack) described in this question.

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A middle-aged man is chronically preoccupied with his health. For many years he feared that his irregular bowel functions meant he had cancer. Now he is very worried about having a serious heart disease, despite his physician's assurance that the occasional “extra beats” he detects when he checks his pulse are completely benign. Which of the following is the most likely diagnosis?

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a. Somatic symptom disorder

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b. Illness anxiety disorder

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c. Delusional disorder

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d. Somatic symptom disorder with pain as the predominant symptom

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e. Conversion disorder

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The answer is b. (DSM-5, pp 315-322.) Illness anxiety disorder is characterized by fear of developing or having a serious disease, based on the patient's distorted interpretation of normal physical sensations or signs. If there are significant somatic symptoms accompanying this fear, the diagnosis should be made of somatic symptom disorder. The patient with illness anxiety disorder continues to worry even though physical examinations and diagnostic tests fail to reveal any pathological process. The fears do not have the absolute ...

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