clinical psychopathology:extensive multiaxial case study

MASSEY UNIVERSITY

SCHOOL OF PSYCHOLOGY

EXTENSIVE MULTIAXIAL CASE STUDY

175.781 – CLINICAL PSYCHOPATHOLOGY

Student name: VM Westerberg

4 MAY 2012

175.781 CLINICAL PSYCHOPATHOLOGY V.M. WESTERBERG

ASSIGNMENT 1 2

TABLE OF CONTENTS

Page

1. - CASE DESCRIPTION 2

2.- MULTIAXIAL DIAGNOSTIC EVALUATION 4

2.1.- Fatima’s Multiaxial Diagnostic Evaluation 4

2.1.1.- AXIS I 4

2.1.1.a.- Criteria for panic disorder without agoraphobia 4

2.1.1.b.- Parent-child Relational Problems 6

2.1.1.c.- Sibling Relational Problems 6

2.1.2.- AXIS II 6

2.1.2.a.- Criteria for Avoidant Personality Disorder 6

2.1.3.- AXIS III 7

2.1.4.- AXIS IV 7

2.1.4.a.- Problems related to primary support group 7

2.1.4.b.- Occupational problems 7

2.1.5.- AXIS V 8

3.- ETIOLOGY OF PANIC DISORDER 9

3.1.- PSYCHOLOGICAL FACTORS 9

3.1.1.- Learning Theories 9

3.1.2.- Cognitive Theories 9

3.1.3.- Phylogenetic Theories 10

3.1.4.- Psychoanalitical Theories 10

3.1.5.- Attachment Theories 10

3.2.- GENETIC FACTORS 11

3.3.- BIOLOGICAL FACTORS 11

3.4.- SOCIO-ENVIRONMENTAL FACTORS 12

3.5.- MEDICAL FACTORS 12

4.- REFERENCE LIST 14


ASSIGNMENT 1 3

1. - CASE DESCRIPTION

Fatima is referred by Dr J.C. Smith for psychological consultation for the evaluation of a

probable mood disorder. On arrival, Fatima appears shy and reserved, speaking in a low tone

and a calm, pleasing manner. Her command of English is quite good although she says she

never had any formal English language instruction. Fatima is 34 and lost her mother when

she was 10. Her maternal grandmother took care of her when her father had to immigrate for

economic reasons.

Fatima came to New Zealand from Pakistan 8 years ago escaping the consequences of

refusing her long arranged marriage to a well-off business man 24 years her senior. She

decided to move in with her father´s new family who own a small but prosperous local

internet services business. She says that what she refers to as “the attacks” have somehow

been there for years, but noticed they became a real concern 7 years ago, shortly after she

started dating her boyfriend, a local boy and IT programmer who works in the family

business. She says, "I have fear of losing my boyfriend; every time I think he could leave me,

I just freak out. He is more sociable than me, and has more friends; one of these days he will

meet another girl and he will just go". About the attacks she says "I feel like I'm going to die,

I am short of air, my heart races, my hands sweat, and this scares me". She says that the

attacks are becoming longer lasting and more and more frequent.

One of her most recent and worst attacks was when she was about to have a job interview,

wanting to leave her current job, as she has many family and work problems, with constant

fighting and verbal and psychological abuse, especially by her father and youngest sister.

Fatima recalls being seated in the meeting room waiting to be called for her job interview,

when her heart started pounding in her chest, she says she felt lightheaded and faint, she

could not breathe properly, her fingers and face were tingling and she felt so bad and so

scared that she had to go. Since that time, the crises became more recurrent and in different,

unpredictable situations, and her fear of having an attack increased. Now the attacks occur

also at home. She says: "I’ve always considered myself less worthy than the rest, but now I

think I'm a complete waste, I’m the worst of all. Now I fear the attacks more than ever. They

even happen when I am alone in my bedroom".

She also says she was a rather fearful girl when she was little, but that she would always find

comfort in her mother, who was constantly concerned about her safety and made sure she

always knew where her daughter was and with whom. Fatima also says she tends to have a


ASSIGNMENT 1 4

hard time relating to people, especially when in a group. She says: "I never enjoyed going to

birthday parties. I watched the other children enjoying themselves and envied them. I have

always tried to go unnoticed. Social relations are difficult for me, I am sure I will say or do

something inconvenient, and I couldn’t take the shame and rejection".

She feels she may somehow be boycotting her own life. She says "It was so hard for me to

get that job interview, and I chose that day to have an attack, right then and there. The night

before the interview I was so nervous I could not sleep, I thought “why bother, I’m

underqualified, I will not make it and I will feel so ashamed of myself”.

Fatima seems quite anxious and to every comment, question or intervention, she replies in an

overly pleasing way. She reports that she never had therapy before, but she believes she

should have consulted a psychologist a long time ago. She adds that she is not aware of

having any medical condition, excepting longstanding heartburn which is always worsened

by the attacks. She gathered courage and decided to visit a doctor about her attacks. He

suggested she should see a psychologist. Fatima says that the attacks are very limiting and

she is afraid that if she does not do something about them, she will never have a family of her

own. She blames her shyness for leaving college, where he was studying Literature, because

she could not stand the tests, particularly the oral tests, as she was very much afraid of them

and always felt intimidated by professors. She says she would like to get rid of the attacks.


ASSIGNMENT 1 5

2.- MULTIAXIAL DIAGNOSTIC EVALUATION

2.1.- Fatima’s Multiaxial Diagnostic Evaluation

Axis I: Panic disorder without agoraphobia (primary diagnosis). Parent-child relational

problems. Sibling relational problems.

Axis II: Avoidant Personality Disorder

Axis III: Heartburn

Axis IV: Problems related to primary support group. Occupational problems.

Axis V: 60 (current, approx.)

In Fatima’s case, a differential diagnosis should be made with social phobia, as she meets

criteria for this condition. However, panic disorder without agoraphobia was chosen as the

principal diagnosis because Fatima had attacks in various circumstances, not only in social

situations. Additionally, she meets the criteria for Avoidant Personality Disorder, a more

pervasive condition than social phobia, which also warrants a differential diagnosis.

Comorbidities are common in most psychopathology cases (Sadock & Sadock, 2007) as will

be shown later in this work focusing on panic disorder.

2.1.1.- AXIS I

2.1.1.a.- Criteria for panic disorder without agoraphobia (300.01)

A. The patient must meet both (1) and (2). Fatima meets criteria A1 and A2b.

(1) Recurrent unexpected panic attacks

(2) At least one of the attacks has been followed for 1 month (or more) of one (or more) of

the following symptoms:

(a) persistent concern about the possibility of having additional attacks.

(b) worry about the implications of the attack or its consequences (e.g.: losing control, having

a heart attack).

(c) significant change in behaviour related to the attacks.

B. Absence of agoraphobia. Fatima does not refer specific fear of having an attack in public

spaces, but further questioning is warranted in follow up visits.

C. The panic attacks are not better accounted for by the direct physiological effects of a

substance (e.g.: drugs, medication) or a medical condition (e.g.: hypothyroidism). Fatima

refers non-specific heartburn related to the attacks, which is not consistent with an organic


ASSIGNMENT 1 6

disorder. However, if symptoms persist, start happening in other circumstances, and cause

great discomfort, gastroesophagic reflux should be ruled out with a manometric study.

D. The panic attacks are not better accounted for by another mental disorder, such as social

phobia (e.g.: exposure to a specific phobic situation), obsessive-compulsive disorder (e.g.:

when exposed to dirt when the obsession is about contamination), posttraumatic stress

disorder (e.g.: in response to stimuli associated with a severe stressor), or separation anxiety

disorder (e.g.: being away from home or loved ones). Fatima’s behaviour is affected by

moderate social phobia that does not seem keep her from working or from having a stable

relationship with her boyfriend.

Panic attacks are not diagnosed separately per se, they are not codable as such, but are part of

broader disorders, as in the case of panic disorder without agoraphobia described above.

Having said that, the following criteria provide diagnostic guidelines in the current case:

A discrete period of intense fear or discomfort accompanied by four (or more) of the

following symptoms developed abruptly and reached a peak in 10 minutes:

(1) palpitations, pounding heart or accelerated heart rate

(2) sweating

(3) trembling or shaking

(4) feeling of shortness of breath or smothering

(5) feeling of choking

(6) chest pain or discomfort

(7) nausea or abdominal distress

(8) unsteadiness, dizziness or fainting

(9) derealization (feelings of unreality) or depersonalization (being detached from

oneself)

(10) fear of losing control or going crazy

(11) fear of dying

(12) paraesthesias (numbness or tingling)

(13) chills or hot flushes

Fatima meets more than four of the above symptoms, namely 1, 2, 4, 8, 11, and 12. However,

more questioning is needed to establish the approximate duration of the symptoms.


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2.1.1.b.- Parent-child Relational Problems (V61.20)

Fatima complains that her relationship with her father is characterized by verbal and

psychological abuse. This aspect requires further evaluation to help determine whether this is

supported by a focused interviewing and psychological theory (see below), or based on

misperceptions by a patient with criteria of avoidant personality disorder.

2.1.1.c.- Sibling Relational Problems (V61.8)

Fatima reports that her sister verbally and psychologically abuses her, which contributed to

the worsening of her panic attacks. In terms of attachment theory, siblings tend to fight for

the attention and favour of their parents. Research on sibling insecure attachment (Berk,

2010) is limited, possibly because of identification and accessibility to samples, and because

of ethical-legal issues.

2.1.2.- AXIS II

2.1.2.a.- Criteria for Avoidant Personality Disorder (301.82)

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to

negative evaluation, beginning by early adulthood and present in a variety of contexts, as

indicated by four (or more) of the following:

1. avoids activities that involve significant interpersonal contact, because of fears of

criticism, disapproval, or rejection

2. is unwilling to get involved with people unless certain of being liked

3. shows restraint within intimate relationships because of the fear of being shamed or

ridiculed

4. is preoccupied with being criticized or rejected in social settings

5. is inhibited in new interpersonal situations because of feelings of inadequacy

6. views self as socially inept, personally unappealing, or inferior to others

7. is unusually reluctant to take personal risks or to engage in any new activities because

they might prove embarrassing.


ASSIGNMENT 1 8

Fatima meets criteria 1,4,5,6, and 7.

2.1.3.- AXIS III

Fatima states that she is not aware of suffering from any medical condition, does not have

toxic habits, and based on her story, no medical condition appears to be relevant to her

current clinical picture. However, she complains of heartburn in the context of panic attacks.

Negative life events, like Fatima’s maternal death, family separation, verbal and

psychological abuse, and job problems, can modify the perception and/or interpretation of

some stimuli as painful (Drossman, 1997), which may explain Fatima’s gastrointestinal

symptoms.

2.1.4.- AXIS IV

2.1.4.a.- Problems related to primary support group

Fatima lost her mother when she was 10. This negative life event may have had pervasive

effects in her, aggravated by disruption of the family by separation as her father immigrated

to a foreign country and remarried. Fatima also complains of verbal and psychological abuse

by her father and her half-sister. The fact that she left her grandmother’s home to avoid an

unwanted marriage contributed to a further reduction in her support group. Fatima’s support

group appears to be integrated only by her boyfriend. Further questioning should be directed

towards the existence of any close friends or good relationship with other workmates or

customers as this may impact her diagnostic and prognosis.

2.1.4.b.- Occupational problems

Job dissatisfaction and difficulties or conflict at work due to problems with her boss (her

father) and co-worker (sister) both strongly contribute to Fatima’s inability to cope with her

panic disorder.

2.1.5.- AXIS V


ASSIGNMENT 1 9

Fatima has moderate symptoms of increasing panic attacks and moderate social and

occupational difficulties (conflict with family co-workers). However, she has managed to

maintain her relationship with her boyfriend for many years and she has been able to

overcome her social phobia to get and attend, although then leave, a job interview and to seek

for help about her symptoms. Although Fatima’s estimated GAF is quite low, evidence from

her case description suggests that a positive outcome could be expected following

psychological treatment: She is aware of her problem, she sought professional help by

herself, she has a stable relationship, and she wants to get rid of her attacks and be able to

socialize more.

3.- ETIOLOGY OF PANIC DISORDER


ASSIGNMENT 1 10

Psychological, biological, socio-environmental, and medical factors have been described to

be involved in the etiology, development and maintenance of panic disorder (Kring et al.,

2010). These will be explained as they apply to Fatima’s case in conjunction with the

corresponding theoretical framework, not separately.

3.1.- PSYCHOLOGICAL FACTORS

3.1.1.- Learning Theories

Based on Pavlov’s classical conditioning theory, Watson and Rayner (Berk, 2010) suggested

that any neutral stimulus can become conditioned or psychopathological when associated

with other stimuli that provoke fear. So, anxiety is an emotionally conditioned response.

Other stimuli that are similar to the conditioned stimulus may in turn elicit the conditioned

response; this is known as generalization, which perpetuates the condition. Skinner’s operant

conditioning explains avoidance of phobias in terms of negative reinforcement or relief

brought about by the elimination of a negative experience. This avoidant behaviour

maintains the disorder (Berk, 2010). Mowrer’s two-factor theory of avoidance-escape

explains panic attacks as a combination of classical and operant conditioning. The individual

tends to escape the stimulus that causes fear and avoid situations that cause it (Berk, 2010).

Avoidance of noxious stimuli reduces anxiety and avoidance is, therefore, negatively

reinforced. Fatima may have learned to avoid social situations as this provides relief from her

symptoms. According to Bandura's (1997) self-efficacy theory, threat perception depends on

the individual’s risk assessment of the situation, self-confidence and coping ability. Fatima’s

treatment should address these skills, as she appears to lack them.

3.1.2.- Cognitive Theories

From a cognitive-attributional approach, Clark (1986) argues that the "catastrophic

interpretation" of bodily sensations is what causes panic attacks. The concept of

misinterpretation of bodily sensations actually derives from Beck’s cognitive theory (1976).

However, there is a significant difference: In Beck's theory, what contributes to anxiety is the

interaction between negative cognitions of danger, control and coping, while Clark only

considers negative cognitions as catastrophic misinterpretations of bodily sensations. Fatima

may interpret tachycardia as ominous, which may trigger her panic attacks.

Piaget’s cognitive theory about schemas (Berk, 2010) states that mental classifications are

established at an early age, but keep being remodeled throughout life. So, individuals who are

consistently abused or criticized end up thinking they are incompetent and that they deserve


ASSIGNMENT 1 11

being mistreated. This theory may play a relevant part in Fatima’s cognitions about her

worthlessness.

3.1.3.- Phylogenetic Theories

Psychologists like Seligman and Eysenk theorised that individuals are phylogenetically

prepared to respond to certain stimuli with ease and to others with difficulty, rejecting

classical and operant conditioning in the etiology of panic attacks and proposing the

principles of selectivity, easy acquisition, and resistance to extinction in them (Berk, 2010).

Eysenk added that intelligence and personality modified phylogenesis. OPA and WASI tests

on Fatima would inform her psychotherapy. Moreover, Ohman (Berk, 2010) says there are

late onset (adolescence) intraspecies disorders, like social phobias in humans, relate to the

system of dominance-submission of the human species. The more submissive individual, like

Fatima, acts in an overly pleasing way hoping to elicit better socio-affective outcomes.

3.1.4.- Psychoanalitical Theories

Freud claimed that anxiety neurosis is a reaction of the EGO against the drives of the ID or

instincts (Berk, 2010). The warning signs come from a struggle and failure to repress basic

impulses, leading to recurrence and to psychopathology. Fatima’s maternal death may have

affected the consolidation phase of her superego which takes place between ages 6 to 12

(latent phase) with a possible permanent effect on her ability to socialize. Erikson’s

psychosocial theory states that between ages 6 to 12, the stage he called industry vs.

inferiority, the individual develops feelings about his/her social competence (Berk, 2010).

This is in keeping with Fatima’s social incompetence which may have led to her social

phobia.

3.1.5.- Attachment Theories

Bowlby's attachment theory (Berk, 2010) suggests that early attachment relationships of the

child with his/her primary caregiver, if based on an anxious attachment style, predispose the

child to become an adult who may generate intense anxiety to signs of separation from the

person with whom s/he has established a secure attachment style. However, Fatima appears

to have had a secure attachment style with her mother from her comment “[I was a] fearful

girl when I was little, but I would always find comfort in my mother”. This is a positive

finding as according to Bowlby (Berk, 2010) the first attachment style acts as a prototype for

all future social relationships. In order to assess Fatima’s attachment problems, the Adult

Attachment Interview (AAI) (George, Kaplan, & Main, 1984) would be of help to evaluate

her general experiences with her caregivers.


ASSIGNMENT 1 12

3.2.- GENETIC FACTORS

The etiology of panic disorder is multifactorial, strongly influenced by genetic factors (Kring

et al., 2010). Genes associated with panic disorder include those that encode the synthesis of

catechol-O-methyltransferase (COMT), cholecystokinine (CCK) and monoaminooxidase A

(MAO-A). The review of studies about the genetic etiology of panic disorder also supports

the environmental nature of the disease, as it can also be seen in higher rates than in control

samples among adoptees whose parent/s have a panic disorder (Na et al., 2011). First-degree

relatives with panic disorder have a 7 times higher risk of having the condition compared

with relatives of unaffected controls (Na et al., 2011). The Virginia Adult Twin Study of

Psychiatric and Substance Use Disorders meta-analysis with more than 5000 twins (Hettema

et al., 2001) reported a heritability of 0.28 for panic disorder. Fatima recalls that her mother

was “constantly concerned about her safety and made sure she always knew where her

daughter was and with whom” which supports the heritability of anxiety disorders. Further

questioning could help shed more light on this issue.

3.3.- BIOLOGICAL FACTORS

The polymorphic symptoms of panic attacks suggest that no brain structure alone can

generate them by itself. The integrated activity of various cerebral areas would be involved in

the clinical presentation of the syndrome (Kring et al., 2010). Laboratory and neuroimaging

studies in animals indicate that anxiety is mediated by structures such as the prefrontal cortex,

the amygdala, the hippocampus, the locus coeruleus and the perisylvian gray matter (Kring et

al., 2010). The prefrontal cortex is considered the neuroanatomical substrate of phobic

avoidant behaviour in the context of panic disorder (Kring et al., 2010). The limbic system is

where anticipatory anxiety lies, while the locus coeruleus is the main brain source of

norepinephrine, the neurotransmitter responsible for triggering panic attacks.

Neuroimaging techniques (CT, MRI, fMRI, SPECT) show neuroanatomical alterations in the

right temporal lobe of patients with panic disorder (Dantendorfer et al., 1996), and a

correlation has been shown to exist between the degree of brain structural abnormalities, the

severity of symptoms, disease duration, and prognosis. (Thomas et al., 2001). Biological

measures for panic disorder are expensive, not diagnostic, and not practical for Fatima’s

assessment.


ASSIGNMENT 1 13

3.4.- SOCIO-ENVIRONMENTAL FACTORS

Panic disorder is found in all cultures, races and socioeconomic levels and usually begins in

adolescence or in early adulthood, a time of transition to independence (Goodwin et al.,

2005). Research shows that non-modifiable variables such as sex are associated with the

development of panic disorder (Bruce et al., 2005), with women being at higher risk. A recent

study also applicable to Fatima shows that the deterioration of social functioning perpetuates

panic disorder (Rodriguez et al, 2005) increasing the number of attacks.

Studies of patients with panic disorder have shown that the type of relationship with their

parents during childhood may influence the development of the condition (Alnaes &

Torgersen, 1989). The mother seems to be the most important caregiver for the development

of comorbid depression and the father for the development of avoidant behaviours.

Additionally, patients with panic disorder tend to have a greater avoidance tendency and be

less in control of their emotions (Alnaes & Torgersen, 1989), all of which can be found in

Fatima’s story. In another relevant study, Servant and Parquet (1994) found that 33.7% of

patients diagnosed with panic disorder had experienced a major loss or separation before the

age of 15, as is the case of Fatima’s.

3.5.- MEDICAL FACTORS

Both panic and phobic anxiety have been linked to increased cardiovascular morbidity and

mortality (Smoller et al., 2007). Panic disorder is found more often in individuals with

medical problems (3-8%) than in those who do not have it (1-3%) (Kroenke et al., 2007).

Literature research shows that about 45% of the patients with heartburn claim that stress and

anxiety induce or worsen their symptoms (Drossman, 1997). However, research also

consistently shows that acid production is neither increased by stress nor elevated in patients

with anxiety disorders. An extensive meta-analysis by Maunder (1998) stated that although

almost every single related study showed a link between panic disorder and gastrointestinal

diseases, nothing is known about the possible pathogenic mechanisms for this. Moreover,

Maunder (1998) concluded that there is no evidence to support such an association, just a

correlation.


ASSIGNMENT 1 14

Finally, at least two potential protective factors have been identified against the occurrence of

panic attacks: A good level of social support and good physical health (Kring et al., 2010).

Fatima does not complain of any medical condition and has, if not social at least affective,

support from her boyfriend, which speak in favour of her prognosis following treatment.

In summary, current data support the hypothesis that the etiology of panic disorder is

multifactorial (Bandelow et al., 2002; Kring et al., 2010) but that due to the retrospective

nature of the studies, the data should be interpreted with caution.

4.- REFERENCE LIST


ASSIGNMENT 1 15

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clinical psychopathology:extensive multiaxial case study

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