This document describes a case study involving a 25-year-old college student who experienced an episode of extreme fear when the electricity went out in her apartment alone three months ago. Since then, she has been having panic attacks, especially in dark places, with symptoms of sweating, increased heart rate, and feelings of danger and dying. Her provisional diagnosis is panic disorder based on the recurrent panic attacks. Differential diagnoses considered include anxiety disorder and nyctophobia. Recommended investigations and treatments include routine tests, non-biological assessments, psychoeducation, CBT, breathing exercises, and short-term anxiolytic medication to manage severe anxiety episodes.

1. CASE 1 (done)
Madam Kwong is a 45-year-old Chinese lady,who works as a manager in a product company.
She is married with 2 children.
She lives with her family in an apartment in Kuala Lumpur.
Madam Kwong first presented to the psychology clinic in June 2009.
She was referred by a general practitioner for ‘frequent phobic attacks’.
Madam Kwong suffered from a road traffic accident in March 2009 when she was knocked
down by a car from behind while she was walking on the pavement.
She sustained a soft tissue injury on her right foot. No fracture was found and she was
discharged home from the hospital on the same day.
She has persistent pain over her right foot and she needed a wheelchair while going out in
the first two months post injury.
She had visited various medical practitioners and was told her injury was largely healed.
Aside from the injury Madam Kwong was particularly enraged by the inaccurate depiction of
the incident by the media, describing her as careless.
She planned to file a lawsuit against the dr
Madam Kwong developed fear towards traffic afterwards, especially when she was crossing
roads or walking between cars.
She had hyperarousal responses towards sudden loud noises.
She suffered from frequent intrusions and nightmares related to the accident.
She developed various avoidant behaviours, for example going to work on foot instead of by
using transportations to avoid the crowd, noises and traffic.
If she had to use transportations, she will use it with a lot of fear and anxiety.
She took extra precaution in looking in all directions when walking, thus slowing down her
speed of walking considerably.
She had stopped driving as ever since the accident, she believes that she will end up in an
accident whenever she drives.

2. 1. Provisional diagnosis
a. PTSD
i. Life threatening event (accident)
ii. Frequent intrusion/nightmare
iii. Avoidance behaviour
iv. Hypervigilant (extra precaution)
2. Differential diagnosis
a. Illness anxiety disorder
b. Adjustment disorder
c. Substances induce anxiety
d. Somatoform disorder (interesting dr kata ><)
i. Visited various medical practitioner
ii. Still have pain even dah healed completely
e. Medical induce anxiety
f. Phobic disorder
3. Investigation
a. Full blood count- hb, esr, cbc, ufeme, rft, lft, tft
b. Urine drug screen
4. Treatment
a. Supportive psychotheraphy
b. Behavior modification
c. Relaxation therapy
d. Drug therapy: antidepressent/anxiolytic (BZD)

3. CASE 2 (done)
Pt, AAW is a 31 yo married Malay male,
presented with palpitations, sweating, heat sensations, trembling and depersonalization at
least once a day.
He also reported a sudden outburst of anger at times and is not aware of the trigger.
These problems have resulted in his inability to engage in social activities with others.
Pt also stated being forgetful and felt pressured at work as he could not remember simple
tasks (e.g. walking back and forth from home to the farm)
Pt has avoided attending social activities as he is afraid of being embarrassed in front of
others.
He believed that other people would look and talk bad about him.
Pt has difficulties falling asleep at night.
Pt started to feel anxious for the first time since 5 years ago at work (as dispatch officer).
It was triggered when his friends made remarks about him being too sensitive.
Eventually quit his job as his anxiety worsened at work and was afraid of sending parcels to
customers.
1. Provisional diagnosis:
a. Social phobia (must ada being embarrassed/people scrutinize/fear of being
evaluated@judge)
b. Generalized anxiety disorder
2. Differential diagnosis:
a. Depressive disorder
b. substance induced anxiety
c. Panic disorder
3. Investigations: Routine investigations(FBC, Thyroid Function Test, UFEME, LFT, RFT),
urine test, (same to case 5)
4. Treatments:
a. BZD (alprazolam)
b. CBT
i. Reinforcing therapy (allow them to hang out with small crowd 2-4 people)
ii. Increase social skill (social skill training)
iii. Being comfortable

4. CASE 3 (done)
Ruth Tan was 34 years old when she experienced her first full-blown panic attack.
It was not long after she had her second child, following a difficult pregnancy and birth.
She was in a crowded supermarket on a hot summer's day and could not stop the baby
screaming.
Suddenly, she felt herself getting hot and light-headed.
She could feel her chest getting tight, her heart beating faster and faster and she could
hardly breathe.
She suddenly thought that she might be having a heart attack or a stroke, because of the
physical difficulties she had during childbirth.
Her hands and feet started to tingle and she was convinced that she would faint and it would
be awful.
She left her shopping trolley and rushed out to her car with her screaming child.
She sat in the car in an acute state of anxiety.
Finally she was able to call her neighbour who worked nearby and who, fortunately, was able to
come and meet her and take them both home.
On several subsequent occasions, for no apparent reason, Ruth had suffered further panic
attacks.
By the time she came for therapy, it had reached the point where she was reluctant to leave
the house without a friend or her husband, in case she had an attack somewhere and
couldn't get home
1. Provisional dx:
a. Panic disorder (because of recurrent panic attacks)
2. Differential dx:
a. agoraphobia-(reluctant to leave house without friend / husband)
i. No help/escape will be available when outside
b. PTSD
i. Childbirth similar complain
ii. Ptsd symptom
1. Life threatening event
2. Avoidant of actual event that they have (anything that remind
them)

5. 3. But in this case she's scared of stroke/heart attack (fear of dying)
4. No nightmare
5. No flashback
6. No hyperarousal
c. Adjustment disorder
d. Generalized anxiety disorder
e. Medical induced anxiety
f. Substance induced anxiety
3. Investigation:
a. GRBS
b. FBC- tro anaemia
c. Thyroid function test
d. RFT-BUSE
e. Urine toxicology - to rule out drugs usage
f. ECG
g. Non biological investigations-
Collaborative hx w family/ parents/ colleagues
Anxiety screening test: Gad 7, Dass 21
h. Premorbid functioning
4. Management:
a. Non-pharmacological
i. Relaxation therapy, deep breathing
ii. Behavior modification- CBT, psychoeducation, desensitization
1. Look at negative/ unhelpful thoughts and how its affecting their
behavior
2. Replacing unhelpful thoughts with helpful thoughts
iii. Systematic desensitization (used in specific phobia)
1. Melawat la small supermarket at time yang tak ramai orang
2. Increase in anxiety provoking therapy
b. Pharmacological therapy:
i. anxiolytic (BZD) - duration not more than 14 days (watch out for
dependency and addiction)
ii. SSRIs for long term

6. CASE 4
Puan JM is a 38-year-old divorcee, mother of two teenagers.
She has had a successful, well-paying career for the past several years in upper-level
management.
Even though she has worked for the same, thriving company for over 6 years, she has found
herself worrying constantly about not performing well at work, losing her job and being
unable to provide for her children, followed by severe palpitations.
This worry has been troubling her for the past 8 months.
Despite her best efforts, she has not been able to shake the negative thoughts.
Ever since the worry started, Puan JM has found herself feeling restless, tired, and tense.
She often paces in her office when she is there alone.
She has had several embarrassing moments in meetings where she has lost track of what
she was trying to say.
When she goes to bed at night, it is as if her brain would not shut off.
She finds herself mentally rehearsing all the worse-case scenarios regarding losing her
job, including ending up homeless.
She also reported constant low feelings that at times she feels life is not worth living
anymore.
She has stopped doing things that have been of interest to her before.
There were times that she contemplated ending her life, but she was not very forthcoming
talking about it.
a) provisional diagnosis
i) GAD (dsm5- 3/6 symptoms for >6 month)
1) Worry constantly (of daily activities level of worry is not same like normal
people)
b) Differential diagnosis
i) OCPD
ii) Major depression disorder, MDD
iii) Phobic disorder
iv) OCD with pure obsession
c) Investigation
i) Routine investigations (FBC-anemia, Thyroid Function Test, UFEME, LFT, RFT)
ii) Serum/urine cortisol- pheochromocytoma

7. iii) RBS- hypoglycemia
iv) urine test-drug
v) ECG-palpitation
d) Treatment
i)

8. CASE 5 (done)
25 yo college student, was alone in her apartment when suddenly the electrical supply to her
apartment were shut down,
This happened 3 months ago
When she was left alone in the dark, she felt a sense of extreme fear thinking that she will
be harmed.
Ever since the incident, she started having episodes of extreme fear occurring at different
times of a day, but it worse when she is in dark places.
Each episode will result in her sweating a lot and her heart beating very fast and feeling like
she is in danger and sense of dying.
She denied any psychotic symptoms like hallucinations, or delusions. She denies ever having
major mood swings. She claims that her personality is always being someone who tends to
worry a lot.
A) provisional diagnosis
a) Panic disorder (panic attack not dx)
i) 3 month
ii) Sweating
iii) Heart beat
iv) Feel danger
v) Sense dying
B) Differential diagnosis
a) Anxiety disorder (not ayat dx, it umbrella term TT)
b) Nyctophobia
i) Not specific (specific phobia kena ada for >6m for dx)
c) Not ptsd (sbb not life threatening - war, mva, natural disaster)
i) Criteria dsm (triad)
C) Investigation
a) Routine investigations(FBC, Thyroid Function Test, UFEME, LFT, RFT), urine
test
b) Non biological investigation: collaborative hx with family member/collegue/anxiety
screening test (das 21/gad 29...etc)
c) Personality test: can be accepted (act as collateral information)
d) Premorbid functioning
D) Treatment
a) long term management
i) SSRI
b) Non pharmacological approach

9. i) Psychoeducation about anxiety/panic disorder
ii) CBT
(1) Type of therapy looking at unhelpful thought
(2) That affect pt feeling and behaviour
c) Teach patient about breathing therapy
d) Anxiolytic
i) diazepam/alprazolam
ii) Not more then 14 day
(1) Worried about dependence
(2) Addiction
iii) Indication
(1) Severe anxiety