Case Study – Panic Disorder

By /

Background

Patient name: Sam
The first occurrence of Sam’s symptoms occurred 6 years ago when he was sitting at home, and he started to feel panic attack symptoms. There was no obvious trigger. He began to feel his heart beat getting very fast along with heavy breathing, sweating and fear. The thought of these symptoms made him feel like he was going to die. These symptoms started happening more and more frequently to the point where Sam had a panic attack daily. As a response, Sam started to avoid going out and gatherings and stayed home more often. He also started visiting the doctor frequently, but could not find an explanation for his symptoms.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the American Psychiatric Association (APA) classifies panic disorder as an anxiety disorder. According to DMS-5, a panic attack can be expected or unexpected. Expected panic attacks are associated with a specific trigger or fear, while unexpected panic attacks have no apparent trigger. According to DMS-5, a panic attack is classified if four or more of the following symptoms are present in an acute episode:

  • Palpitations
  • Sweating
  • Tremors
  • A feeling of smothering or shortness of breath (difficulty breathing)
  • Chocking
  • Chest discomfort or pain
  • Nausea
  • Dizziness, lightheadedness or fainting
  • Derealization (detachment from reality) or depersonalization (detachment from self)
  • Fear of going crazy or losing control
  • Fear of imminent death
  • Paresthesia (numbness and tingling)
  • Hot flushes or chills

The lifetime prevalence of panic attacks without agoraphobia is 22.7% while the occurrence of panic disorder is 1-2% of the general population [Kessler, 2007]
According to DMS-5, the symptoms that led to Sam’s diagnosis are as follows:

  • Palpitations – heartbeat going very fast
  • Difficulty breathing is defined as heavy breathing
  • Sweating
  • Fear of death

After the first attack, the thought of having another panic attack served as a trigger for further attacks in Sam. The frequency of symptoms increased up to one panic attack every day. However, the current situation of the patient seems quite better. The spectrum of symptoms in panic disorder follows the following pattern:

  • Trigger: the fear of having a panic attack
  • Perceived threat: I might have another panic attack!
  • Anxiety
  • Physical/cognitive symptoms: breathlessness, palpitations, sweating
  • Catastrophic misinterpretation: I am going to die!
  • Avoidance and safety seeking: Not going out. Seeing a doctor. Seeking an explanation for the symptoms and getting upset when an explanation could not be provided, leading to further symptoms.

Treatment Plan

Cognitive behavioural therapy (CBT) is a therapeutic approach to panic disorder and has proved to be beneficial as both short- and long-term therapy. CBD helps change the course of the disorder and increases the interval between the episodes. Studies have shown that the outcomes of CBD in panic disorder are better than pharmacological interventions [Manfro, 2008].
In the case being discussed, the main goals for CBD to improve Sam’s condition can be summarized as follows:

  • Understand the nature of the condition and identify the potential triggers for Sam.
  • Identify that the set of physical symptoms of anxiety is a source of fear, which creates a vicious cycle.
  • Use exposure and graded therapy to provide insight into the problems to decrease the frequency of attacks.
  • Improve social interaction and reincorporate presence in gatherings and social events.

As a therapist, the main techniques that could be used for Sam are psychoeducation and cognitive techniques, including graded exposure. I would like to start the therapy with psychoeducation. The main goal of psychoeducation is to provide the patient an insight into his disorder and to focus on techniques to identify and define sources of anxiety and triggers that result in the symptoms of panic attacks. This can be used to introduce behaviours to avoid the triggers and introduce an avoidance pattern in the behaviour of the patient.
The main goal of cognitive techniques in Sam is to identify the catastrophic thoughts in response to the panic symptoms and use graded exposure therapy to create a new set of thoughts in response to the symptoms. Some of the techniques I can use in the sessions are as follows;

  • Encourage Sam to identify the triggers and other factors that contribute to the initiation of a panic attack. Ask him to document his thoughts in each episode of panic attacks and then compare the notes to identify similar patterns throughout the episode. The goal of this exercise is to introduce a pattern that would help Sam predict the upcoming episode of panic attack and act accordingly in time.
  • Provide a set of exercises or techniques that would help during an acute episode. For example, breathing into a paper bag, distraction through music or TV or reverse counting from 100 to help reduce the physical symptoms.
  • Introduce graded exposure to the physical symptoms of panic attacks and help incorporate the set of symptoms into the daily routine. For example, exercising every day to introduce exercise-induced palpitations, breathlessness and sweating into the daily routine of the patient.

Referencs

  • Kaczkurkin, A. N., & Foa, E. B. (2015). Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. Dialogues in clinical neuroscience, 17(3), 337–346. https://doi.org/10.31887/DCNS.2015.17.3/akaczkurkin
  • Manfro, G. G., Heldt, E., Cordioli, A. V., & Otto, M. W. (2008, October 1). Cognitive-behavioral therapy in panic disorder. Brazilian Journal of Psychiatry. Retrieved November 7, 2021, from https://www.scielo.br/j/rbp/a/KtnLKCSvtGS95dsLytgTSNz/?lang=en.
  • Kessler, R. C., Chiu, W. T., Jin, R., Ruscio, A. M., Shear, K., & Walters, E. E. (2006). The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Archives of general psychiatry, 63(4), 415–424. https://doi.org/10.1001/archpsyc.63.4.415
  • Sheryl Ankrom, M. S. (2020, July 7). DSM-5 criteria for diagnosing panic disorder. Verywell Mind. Retrieved November 7, 2021, from https://www.verywellmind.com/diagnosing-panic-disorder-2583930.

 

Scroll to Top