Reference no: EM132393154

Kamal and a group of friends from business school stood in line for an amusement park ride. The line snaked its way through a wooded area and was enclosed to keep people from cutting in front of others. Kamal felt a little uneasy in the line; it was hot and humid, and the line was not moving quickly. He sometimes felt uncomfortable in places where he could not escape a crowd. Still, he was with friends, and it was good to get away from his studies for the day. After an hour of waiting in line, Kamal felt poorly. In addition to the heat, he had been eating junk food all day. The wait grew to an hour and fifteen minutes, and a terrible feeling came over Kamal. He needed a restroom. Badly.

People were packed into the queue. If he tried moving forward, people would think he was cutting in front of them. He could walk back towards the ride's entrance, but there were hundreds of people behind him. Kamal played on his phone, distracted by the pressure in his lower abdomen. "I have to find a bathroom," Kamal told his friends and abruptly started walking back through the line. As he apologized to those he pushed past, he realized that he was not going to make it. He looked for a place to step into the trees, but there was no way to do that without scaling a fence. About 200 feet from escaping the line, Kamal lost control of his bowels and soiled himself. He hobbled out of the line and lay down on the ground, hoping to control the mess in his shorts. 

"It was the worst thing that had ever happened to me," Kamal said. "I was ill; I crapped my pants like a baby, and it was humiliating." Amusement park personnel assured him that this was a regular occurrence and gave him a ride to their infirmary where Kamal threw away his clothes, took a shower, and was given sweatpants and a t-shirt. Kamal met up with his friends later and told them what had happened. "Some of them could have been a little more understanding," he said. Kamal rode home in silence; at least his stomach felt better. 

Several weeks later, Kamal was at a concert. Although he and his girlfriend arrived early so they could find seats near the exit, it was very crowded. The couple kept getting pushed further and further into a corner. Then it dawned on Kamal that if he needed to use the restroom, there were hundreds of people in his way. In addition, if he had another attack like the one at the amusement park, the restrooms at a concert venue were likely to be dirty. "My stomach churned when I realized this, and I wondered if I was going to have another bout of diarrhea," said Kamal. "I started replaying the events at the amusement park, and my head started spinning." Kamal trembled and broke into a sweat. His heard pounded, and he began hyperventilating. Kamal's hands contracted and his face went numb. "It was terrible, he said about the episode. "I couldn't breathe, and I was certain I was dying." Kamal's girlfriend went for help and for the second time in a month, security and medical people came to his aid.  An ambulance was called. 

"Most of my symptoms were over by the time the paramedics arrived," said Kamal. "My breathing was under control, and I could use my hands again. I no longer thought I was dying." The paramedics noted that Kamal's heart rate and blood pressure were a little elevated, but nothing too worrisome. When Kamal refused to be transported by ambulances, his girlfriend took him home. "Second worst thing that ever happened to me, but at least this time I didn't take a dump in front of anyone," he said. Kamal spent the rest of the weekend hunkered down in his apartment trying to make sense of what was happening to him.

Monday morning arrived, and Kamal gathered his belongings and headed out to the subway to go to school. At the top of the stairs to the subway platform, Kamal again felt his stomach churn. What would happen if he got down to the crowded subway platform and couldn't breathe? Was his stomach trouble coming back? What if he got on the subway and couldn't escape? "Then it happened again," Kamal said. His head spun, and he sat down so he would not fall. His heart pounded, and he felt that he couldn't breathe. His hands and face went numb as he hyperventilated. He trembled as sweat ran down his face. "The sensation of losing your mind is awful," said Kamal. "But at least this time I knew that it would be soon over, and I could just go home." He would miss an exam that day, but he was generally a good student so he felt that his professor would understand. Kamal went back to his apartment. "I decided to take a day off and just blow off some steam," he said. He spent the day playing video games and then canceled on his girlfriend; they had had plans to go to an event. The next day, Kamal couldn't bring himself to go to school. Another day, he told himself, and he would tackle the subway after being sure to take an anti-diarrhea drug and using the toilet before leaving his apartment. 

A day later, Kamal stared down the stairs at the subway station he willed himself down the stairs, although his legs were shaking. The short journey down the stairs took twenty minutes. His train arrived, but Kamal could not get on it. He took deep breaths and silently recited prayers until he eventually found the strength to get on the subway train. "I sat for the whole trip gripped in fear that a freak out was going to happen," he said. "It didn't but the trip was horrible enough that I decided that was going to be the last time I used the subway." it took Kamal an hour and a half to walk home. 

Several weeks went by, and Kamal's grades started to slide. "I didn't have the money for cabs, and with the subway out of the question, I was walking three hours a day. He was often late to class and when he did arrive, most of the seats near the exits were taken. "I started to figure out that if the room held more than 50 people, I couldn't enter it," Kamal explained. "I figured the odds were too high that I could get in and either freak out or worry that I couldn't get to the restroom if I needed to." His social life was also faltering. Most of his friends wanted to do things that entailed riding the subway or involved crowds or venues where it might be hard to leave if Kamal need to: concerts, parties, and movies. His girlfriend could not understand what had come over him. He went from being a social guy to not wanting to leave his room. When they attended a wedding, Kamal was miserable. "By that time, I had been having freak outs about once a week, and I was no longer able to able to  predict when they would happen, so I pretty much spent the whole time worrying about it."

Six months after the trip to the amusement park, Kamal's girlfriend had left him and he had flunked out of business school. His parent's helped him move back home, they took him to a doctor who ran a variety of lab test. Kamal had nothing wrong with his heart of lungs, and there were no other signs of medical problems. He did not use recreational drugs or alcohol.

List alternative diagnosis considered and provide detailed information as to how client did or did not meet the diagnostic criteria for each diagnosis considered