COURSE PROGRESS NOTES The patient initially sought psychiatric consult two days after an episode of generalized stiffening

of the extremities, with associated headache, stomach pain and difficulty of breathing, which prompted her to absent herself from work. Upon history taking, it was found that this was her fourth episode of the above mentioned symptoms. Her first attack occurred five months prior to current admission and was preceded by intense feelings of worry over not being allowed by her boss to attend her daughters school play. Consult was sought from various physicians and various diagnostic exams were done, and no primary medical condition was found that could be associated with the symptoms the patient was presenting with. Unrecalled medications were taken, which produced diarrhea and light-headedness, and which helped the patient sleep. These medications were eventually discontinued, since the patient experienced these undesirable side effects. No suicidal ideations were noted. History taking revealed previous gastritis, while physical exam yielded no remarkable findings. Mental status examination yielded a middle-aged woman who was well groomed, of sound judgment, with good thought process and fund of information, level 3 insight, intact sensorium and cognition, no perceptual disturbances, but with a propensity to talk rapidly and with preoccupation about her work and the recurrence of her symptoms. Clinical Diagnosis: The main feature of the case is the recurrent episode of generalized stiffening of the extremities, with associated headache, stomach pain, and difficulty of breathing. These episodes were noted to occur within 10-15 minutes, and, according to medical diagnostics, were not attributable to any medical condition. The attacks occurred two times five months prior to consultation, once one month prior to consultation, and once two days prior to consult. Neither substance abuse nor any diagnosable medical condition was apparent upon history taking. The case gives the impression of panic disorder without agoraphobia. According to the DSM-IV-TR, the following criteria need to be met to ascertain the diagnosis of a panic disorder without agoraphobia: Table 1. DSM-IV-TR Diagnostic Criteria for Panic Disorder Without Agoraphobia A) Both (1) and (2) (1) Recurrent unexpected Panic Attacks (2) At least one of the attacks has been followed by one (1) month (or more) of one (or more) of the following: (a) Persistent concern about having additional attacks (b) Worry about the implications of the attack or its consequences (e.g. losing control, having a heart attack, going crazy) (c) A significant change in behavior related to the attacks B) The Panic Attacks are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g. hyperthyroidism). C) The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia, (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on

exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives). From the history, we find that patient MVs panic attacks consisted of a complex of symptoms, led primarily by stiffening of the extremities, with associated headaches, stomach pains and difficulty of breathing. Following the DSM-IV-TR criteria, we find that both items (1) and (2) under category A are satisfied. For item (1) under category A, the attacks may be considered unexpected, since no prodromal symptoms or auras were observed or experienced prior to the onset of the panic attacks. For item (2) under category A, the third attack was followed by a month of significant behavioral change, in that the patient started to absent herself frequently from work, as well as feeling of laziness and loss of motivation to go to work. According to the patient, no history of substance abuse was present. Since several medical diagnostic tests were undertaken and subsequently yielded negative results, we may conclude that no outstanding medical condition contributed to the formation of the aforementioned symptoms. Hence, category B of the DSM-IV-TR has also been satisfied. The condition of the patient started five months prior to consult, ruling out the possibility of a generalized anxiety disorder. Patient also did not manifest with specific phobias or social phobia. Patient did appear to be preoccupied about missing work, however, no compulsions or obsessions were noted that would lead to the diagnosis of obsessive-compulsive disorder. No history of traumatic experience or separation from close relatives was noted, as well. No other psychiatric condition seems to explain the patients condition further, hence, we may consider category C of the DSM-IV-TR fro panic disorder without agoraphobia as satisfied.