Symptoms, assessment and therapeutic intervention of individual with panic disorder

1. CASE STUDY OF PANIC DISORDER
SUBMITTED BY: HUMA PERVEZ, GULRUKH, KAINAT
FARZAND , MUNEEBA, MOMINA, MAHNOOR, FATIMA ASAD
SUBMITTED TO: MAAM SAIRA
Date: 8TH
APRIL, 2019
ABDUL WALI KHAN UNIVERSITY MARDAN

2. GENDER: Male
AGE: 34 years
SYMPTOMS:
SOMATIC SYMPTOMS:
● Increased heart rate.
● Shortness of breath.
● Sweating.
● Dizziness.
● Choking sensations.
COGNITIVE SYMPTOMS:
● Fear of dying.
● Fear of losing control.
● Recurrent unexpected panic attacks.
DIAGNOSIS:
Through assessment of standardized test and the symptoms presented by Joe meeting criteria
mentioned in DSM 5 for the diagnosis of panic disorder we made the diagnosis of panic disorder.

3. TARGET SYMPTOMS:
Target symptoms are traditional to the clinical interview and are the main reasons for seeking
treatment.
The target symptoms of Joe was that, he began to worry that he might have another panic attack
and started to feel anxious at the thought of going to supermarkets. He decided that there was no
need to go to supermarkets and instead went to his local shop when he needed something.
TREATMENT GOALS FOR TARGET SYMPTOMS:
● To help Joe develop ways to manage anxiety and panic attacks so that these symptoms are
no longer affecting his functioning, as measured by tracking her self-reports of panic
attacks and anxiety.
● Decreasing the intensity of panic attacks.
● Reducing the frequency of panic attacks.
● Reducing anticipatory anxiety and agoraphobia avoidance.
● Weaken the catastrophic misinterpretations.
● Treating co-occurring psychotic disorders.
● Achieving full symptomic remission.
● Returning to premorbid level of functioning.
TREATMENT APPROACH:
Cognitive behavior therapy was used for the treatment of panic disorder. CBT focuses on the
importance of both behavioral and thought processes in understanding and controlling anxiety and
panic attacks. The focus of treatment is on inadequate, obstructive, and damaging behaviors and
irrational thought processes that contribute to the continuation of symptoms. For example,
uncontrolled worrying (thoughts) about what may or may not happen if you have a panic attack
may lead to avoiding certain situations (behavior)

4. INITIAL PHASE:
RAPPORT BUILDING:
This phase start even before we initiate the actual therapy with Joe. This introductory phase may
often include someone inquiring about therapy. I used this first consultation, usually 20 minutes,to
explore the Joe's issue and to answer questions that he will ask. I already started rapport building
with Joe.
In this period I began to assess the Joe's problems to see whether it is an appropriate referral or
match depending on my expertise and specialization.
I also explain the expectations of therapy to Joe and provide him a better understanding of who
am I and what to expect.
The first appointment with Joe is an opportunity for me to build rapport, as rapport building is
paramount into a successful therapeutic relationship.
PRIVACY AND CONFIDENTIALITY PROTOCOLS:
During this first appointment I had explain the privacy and confidentiality protocols that have to
be followed throughout the therapy process. I also mentioned out the reasons that I may need to
break the confidentiality. I was also set the professional boundaries and explain the parameter of
my services.
PAYMENT SCHEDULE:
I setup the schedule to meet with Joe and addressed insurance benefits along with the payment
schedule. I secured a lot of psychosocial history, copying strategies and Joe's definition of his
problems throughout his first interview.
In this beginning phase I did more listening and less talking.
UNCONDITIONAL POSITIVE REGARD:

5. My duty is to accept what Joe is saying (unconditional positive regard) and understand his issues
through his perspective.
In this phase I start to formulate and develop treatment intervention.
MIDDLE PHASE:
in the middle phase we assess the Joe through standardized tests and then after assessment and
diagnosis we provide therapy appropriate for the panic attacks.
ASSESSMENT:
CRITERIA FOR DIAGNOSIS OF PANIC DISORDER
During the assessment client and the therapist discussed how his difficulties had progressed.
For a diagnosis of panic disorder, the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5), published by the American Psychiatric Association, lists these points:
● You have frequent, unexpected panic attacks.
● At least one of your attacks has been followed by one month or more of ongoing worry about
having another attack; continued fear of the consequences of an attack, such as losing control,
having a heart attack or "going crazy"; or significant changes in your behavior, such as
avoiding situations that you think may trigger a panic attack.
● Your panic attacks aren't caused by drugs or other substance use, a medical condition, or
another mental health condition, such as social phobia or obsessive-compulsive disorder.
Specifically designed tests for diagnosis of disorder were also used. The panic attack questionnaire
and panic disorder self-report scale.
The panic attack questionnaire is commonly used scale for assessing panic attacks including
features of panic symptoms, cognitions, triggers.

6. During assessment it was revealed that client avoids many places and situations like shopping
malls, driving car and experienced symptoms of palpitations. Sweating, fear of going crazy and
dying.
So from the assessment we made the diagnosis of panic disorder.
COGNITIVE BEHAVIOUR THERAPY:
IDENTIFICATION OF THE PROBLEM:
More specifically, the first time Joe had a panic attack, while queue in a supermarket. He was
feeling stressed at the time because he had left work late and was worried he was going to be late
home again, possibly resulting in an argument with his wife.
He was thinking about how he needed to get out there as quickly as possible and began
experiencing a number of physical symptoms, associated stress and anxiety such as increased heart
rate, sweating and dizziness. When this happened Joe started to think about how faint he feel and
how embarrassing it would be if he did so in front of other people in the supermarket.
These thoughts resulted in increased anxiety, further physical symptoms and further catastrophic
thinking.
We went through Joe’s experiences of panic in detail and learned that his panic attacks consisted
of
a. Physical sensations.
b. Misinterpretation of those sensations as dangerous (catastrophic thinking).
Therefore the areas we identified as important for intervention were catastrophic thinking and
avoidance.
MANAGING CATASTROPHIC THINKING:

7. We began by getting Joe to identify his thought processes when he was stressed and anxious. By
doing so Joe was able to recognize that when he noticed symptoms of anxiety, he started having a
lot of catastrophic thoughts.
Catastrophic thoughts:
1. Fear of death
● Am I having a heart attack?
● I am having a stroke.
2. Fear of losing control
● I am having a nervous breakdown
● If I don’t escape, I will go crazy.
3. Fear of humiliation or embarrassment:
● I will faint and be embarrassed.
● They will think I am lunatic.
Next we looked at these thoughts in detail and considered how accurate these were.
For example, Joe was worried he was going a faint because his heart rate had increased and he felt
dizzy. We investigated fainting and learned that people faint when their heart rate decreases and
therefore it is also impossible to faint when person is anxious and his heart rate is elevated.
As well as information about anxiety and panic, joe was provided with techniques to help him
elevate his thinking and comes up with more balanced alternatives and test these alternatives out.
Joe said that he felt more in control as he realized that anxiety is a normal part of life and panic
only occurs when thinking about sensations becomes distorted.
INTERVENTIONS AND STRATIGIES:
The following strategies of Cognitive behavioral therapy was used for treatment of panic attacks
and panic disorder:
RELAXATION TRAINING:

8. Relaxation training can be helpful in treatment for panic. Relaxation training included muscle
flexion and extension exercises to help Joe relax the muscle tension that develops as a result of
anxiety or his worry for future panic attacks as well as deep breathing is used to help Joe decrease
the physiological anxious response or improve stress reaction to a panic situation and feel more
relaxed.
COGNITIVE RESTRUCTURING:
Joe was obsessed with negetive thoughts about panic symptoms and feared situations which made
him more anxious and stressed so cognitive reconstructuring was use to change his negative
thoughts to healthier ones and make him feel less anxious or stressed.
MINDFULNESS:
Mindfulness as a tool for overcoming anxiety is increasingly becoming the focus of a great deal
of scientific research. In order to help Joe develop a new response to anxiety provoking thoughts
or situations, mindfulness is used. With the help of this technique Joe can learn to detach himself
from negative thinking by facing thoughts without reaction.
EXPOSURE TREATMENT:
Once people feel less anxious about future panic attacks due to using relaxation training,
mindfulness, and cognitive restructuring, they are more able to confront anxiety-provoking
situations. Systematic exposure is an intervention that helps people face what they normally avoid.
So by purposely putting Joe in challenging situations,he would be able to defuse the fear
associated with them, and no longer fear the situations in the future.
Goal achievement:
By repeatedly doing the tasks, he become more confident in his ability to manage anxiety regarding
panic attacks, catastrophic thoughts weaken, the sensation gradually reduced and returned to
premorbid level of functioning.
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