Preface

Mr. W was a 22-year-old graduate student who presented to his family physician with acute episodes of chest pain and shortness of breath Mr. W had recently moved to a new city, where he had few friends or family, to begin graduate school. His physician performed a careful physical examination and electrocardiogram, which were both negative. Then he brought up the subject of stress and anxiety, and the patient readily agreed that both the recent relocation to a new city and graduate school were quite stressful. He was referred to psychotherapy in the student health service. Mr W’s symptoms continued, and over the next 2 years, he made about 20 visits to his primary care physician for various somatic symptoms. Labortory tests and physical examinations were all negative. In his second year of graduate school, he developed acute episodes of epigastiric distress that often awakened him from sleep and were relieved by antacids. During this time, the patient lost 20 pounds. An upper gastrointestinal series proved negative, and the patient refused endoscopy.

Finally, after 2 years of symptoms, the patient was referred for psychiatric consultation. He reported that his episodes of chest pain and shortness of breath were often accompanied by tachycardia, sweating, tremulousness, and a feeling that he was going to die. His epigastric distress frequently followed these acute episodes. Since the episodes began, he had become increasingly fearful of social situations, and he now avoided going to parties, to the theater, or to restaurants. The patient was diagnosed as meeting DSM-III criteria for panic disorder, and he was started on imipramine 25 mg at night, which was gradually increased to 100 mg over 2 weeks. His acute episodes of autonomic symptoms decreased over 3 to 4 weeks, and his avoidance of social situations gradually decreased over 3 months. Over the next 3 years, the patient only visited his family physician twice for yearly physical exams.