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Samantha is a 23-year-old single female referred by her cardiologist for an evaluation. In the prior 2 months she has presented to the emergency department

Samantha is a 23-year-old single female referred by her cardiologist for an evaluation. In the prior 2 months she has presented to the emergency department four times for complaints of chest tightness, palpitations, shortness of breath, trembling, and surety that she is about to die. Each time the symptoms came on rapidly, peaked within minutes, and leave Samantha scared, exhausted, and fully convinced that she just experienced a heart attack. But each emergency department visit yielded normal exam findings, vital signs, no increase in cardiac enzymes, normal EKGs, and negative toxicology screens.

The patient reports five similar attacks in the previous three months. One attack occurred at home, one while driving a car, one at the mall, and the rest occurred at work. She now has a persistent fear of these attacks, and she has had to avoid many days of work, has stopped exercising, and has limited her social events to extremely few. She will not accept the assurance of friends that she is all-right, and she finally agrees to see you.

Samantha denies any history of psychiatric disorders, except for some anxiety when in grade school that was diagnosed as "school phobia." Samantha's mother committed suicide last year by overdose in the context of recurring major depression. At this time Samantha is living with her father and two younger sisters. She has graduated from high school and college, and is currently working as an accountant at a local shipping firm.

On examinations, the patient appears anxious, but is cooperative and coherent. She denies any symptoms of depression, but does seem preoccupied with her "heart disease." She denies any psychotic symptoms and reports no feelings of mania or difficulty sleeping.

  1. What is the likely diagnosis for this patient?
  2. What are some of the predisposing factors that may be contributing to this disorder?
  3. What are some of the maintaining factors that keep this disorder present?
  4. What are some of the treatment options for this patient?

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