Differential Diagnosis
Single most likely diagnosis
- Anxiety Disorder: The patient's history of health anxiety, agoraphobia, and excessive reassurance seeking behavior are all consistent with an anxiety disorder. The patient's symptoms of emotional distress, torment, weepiness, and dark terrifying emotions are also typical of anxiety disorders.
Other Likely diagnoses
- Adjustment Disorder: The patient's symptoms of emotional distress and anxiety began after a series of stressful events, including contracting COVID-19, moving to a new apartment, and experiencing a traumatic event (living under barking dogs for six years). Adjustment disorder is a possible diagnosis, as the patient's symptoms may be a response to these stressors.
- Depressive Disorder: Although the psychiatrist ruled out depression, the patient's symptoms of emotional distress, weepiness, and dark thoughts could be consistent with a depressive disorder. However, the lack of other typical depressive symptoms, such as changes in appetite or sleep, makes this diagnosis less likely.
- Trauma- and Stressor-Related Disorder: The patient's history of living under barking dogs for six years and experiencing a traumatic event (contracting COVID-19) could contribute to the development of a trauma- and stressor-related disorder, such as post-traumatic stress disorder (PTSD).
Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Panic Disorder: The patient's symptoms of panic attacks, agoraphobia, and excessive reassurance seeking behavior could be consistent with panic disorder. Although the patient's symptoms are not typical of panic disorder, it is essential to consider this diagnosis due to the potential severity of the condition.
- Cardiovascular Disease: The patient's history of chest pain and breathlessness, although investigated and found to be non-cardiac, warrants consideration of cardiovascular disease as a potential diagnosis. The patient's excessive reassurance seeking behavior and health anxiety may be contributing to the persistence of these symptoms.
Rare diagnoses
- Mitochondrial Disease: The patient's symptoms of emotional distress, fatigue (although not reported), and impaired folate and BH4 cycles (MTHFR TT) could be consistent with a mitochondrial disease, such as mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS).
- Neurodegenerative Disease: The patient's symptoms of emotional distress, anxiety, and impaired neurotransmitter metabolism (high noradrenaline and low serotonin) could be consistent with a neurodegenerative disease, such as Parkinson's disease or multiple system atrophy. However, the lack of other typical symptoms, such as motor symptoms or cognitive decline, makes this diagnosis less likely.
The therapy session may have triggered the patient's symptoms by:
- Increasing the patient's awareness of their anxiety and health concerns
- Providing a sense of temporary relief or hope, followed by a crash or worsening of symptoms
- Triggering a sense of emotional distress or trauma, which may have contributed to the patient's symptoms
The patient's methylation report and genetic testing results (MTHFR TT, COMT CT, MAOA TT, MAOB GG) may be relevant to their symptoms, as impaired folate and BH4 cycles can contribute to anxiety, depression, and other psychiatric symptoms. The patient's response to 5-HTP, a supplement that increases serotonin levels, may also be relevant, as it provided temporary relief from symptoms. However, the patient's symptoms returned after a bad hangover and vomiting, suggesting that the underlying cause of their symptoms is more complex and multifactorial.