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The patient is a 23-year-old woman who comes to her primary care physician's office concerned about periodic difficulty in breathing. She thinks she may have asthma.

She first experienced an attack of dyspnea while she was attending a special 2-week educational program for the state's top high school students; it was held about 2 hours from her home. During her stay, she experienced an episode in which she suddenly felt she was unable to breathe. School health officials thought she was having an asthma attack and sent her home. She was subsequently evaluated by her pediatrician. He detected minor wheezing on deep inspiration but ruled out asthma and attributed the attack to a possible allergy.

The patient experienced no further attacks for several years, until she left her parents' home for the first time to attend law school. She began to have repeated attacks of dyspnea and sought the advice of her primary physician.

During an attack, the patient feels as though she cannot breathe and that she is about to faint or die. Her heart races and she trembles. She worries that the episodes are a manifestation of an undiagnosed and perhaps life-threatening illness. The patient is embarrassed by these attacks and has not told anyone about them. However, dread of the next episode is now dominating her life and she fears she is "going crazy."


At his parent's insistence, a 22-year-old man seeks medical attention from his primary physician. He has just flunked out of college a second time. The parents want to understand the reasons behind their son's academic failure, and they fear that he may be abusing drugs. This fear was fueled, in part, by another physician who had previously evaluated the patient: the clinician had told the parents that their son was probably a "doper" and a "bad kid."

The patient had been popular and a good student in high school. He was an outstanding athlete. His parents reported that they had enjoyed living with him and that he had always been helpful around the house.

The patient reports that although he loves to coach sports, he is unable to get up in front of a group and teach. He finds it similarly difficult to speak in the classroom. He describes himself as "very shy" and reports that he is afraid people are laughing at him. Friends seek out his company, but he never pursues these relationships.

He reports that drinking was a "regular" part of daily campus life and that he had been using alcohol almost every day to the point of intoxication to cover up his shyness. His alcohol dependence led to his expulsion from school.

Case 3

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