6.115: Panic Disorder without Agoraphobia

Name: Tony Soprano

Source: The Sopranos (Television series, 1999-2005)

Background Information

Tony was born of Italian descent on August 24, 1960 and is male. At time of symptoms Tony was 39 years of age. Tony Soprano declares himself to be in the “waste management” business but is actually involved in criminal activity. The Tony is the capo in the Dilteo crime family. The duties included with this occupation are collecting “loans” and “persuading” people to pay back money that was “loaned” to them. These “persuasions” include physical attacks as well as other forms of violence. Tony has the added responsibility to attempt to keep peace between him and other members of the organization. Tony is in relatively good health for a man his age, but is noticeably overweight. Tony’s family mental health is very stressful. Tony has stressful relationships with his wife and work associates. An especially stressful and dysfunctional relationship with the mother is also present. Tony has a history of alcohol and tobacco use. Major life difficulties include stress from work and problems from aging mother. Tony displays poor coping skills, often resorting to anger and aggression. The use of alcohol and promiscuous relationships are used as escaping behaviors.

Description of the Problem

Tony has had several episodes of fainting. The first paint attack was described by Tony as a feeling of “ginger ale in the skull”. The symptoms Tony experiences during his panic attack episodes include “racing” heart, feeling faint and dizzy, chest pains, and breathing difficulties. Specific problems these symptoms are causing are increased difficulty dealing with demands from his occupation, increased stress with family responsibilities (especially issues involving the future of the Tony’s aging mother). Tony is hesitant to admit he is experiencing depression but ultimately does state that he is depressed. Tony became deeply saddened by the departure of ducks he had been caring for. He came to the realization the departure of the ducks symbolized his fear of losing control of his family, job, and life in general.

Diagnosis

Diagnosis for the Tony meets criteria for Panic disorder without Agoraphobia, DSM-4 TR code 300.01. Tony has recurrent, unexpected panic attacks and shows worry about the implications of the attack (e.g. losing control). The Tony does not display characteristics of agoraphobia. The panic attacks do not appear to be due to the Tony’s use of alcohol, tobacco, or any other pre-existing physical conditions.

Accuracy of Portrayal

The average person watching the portrayal of the Tony would think that panic disorder is only caused by extreme life stress and that the disorder has minimal impact on other aspects of life functioning. The main point for accuracy of portrayal included with this character is he also displays major depressive disorder. This lends to the accuracy of portrayal due to the high comorbidity between panic disorder and major depressive disorder, which is between ten to 65 percent. Also, accuracy of the portrayal comes from the recurrent and unexpected nature of the panic attacks. The inaccuracies from the portrayal include the presentation that panic attacks are only associated with highly stressful life events. Other inaccuracies are the lack of behavioral change and lack of impact on Tony’s relationships and social life.

Treatment

The primary source of treatment would be cognitive behavioral therapy. CBT would focus on having Tony face behaviors and thinking patterns that sustain or trigger the panic attacks. This treatment would have Tony realistically ask themselves such questions as, “what is the worst thing that could happen?” For Tony, questions might include, “what is the worst that could happen to my business or family if something were to happen to me?” When Tony is forced to look at the worst outcome and realize that everything would go on if this outcome happened, he learns the source of his panic is less terrifying. Cognitive behavioral therapy might also be supplemented with anti-depressant medicationdue to his co-occuring depressive symptoms. The treatment that is displayed on the show for Tony is a psychoanalytic approach. The American Psychiatric Association does not acknowledge the role of intensive psychoanalytic therapies, including psychoanalysis, in the treatment of panic disorders. However, studies have shown significantly reduced panic symptoms from panic-focused psychodynamic psychotherapy (Barbara et al., 2007). More evidence must be gathered before the treatment presented in the show is recognized as a significant treatment for panic disorder.