This is a report about Paula a client who was referred to therapy by the general practitioner of the hospital.Following a thorough physical checkup performed on Paula the GP feels that Paula’s heart is sound enough and her condition is psychological.(Getzfeld, 2004).
Paula’s case is not an isolated case of psychological dysfunction and in fact a sizeable number of people suffer these attacks in silence. (Beck, Rush, Shaw, & Emery, 1979). This is perhaps due to the feelings of embarrassment and stupidity that they feel they might be accused of.
Additionally, panic attacks are not well known to many and hence the stigma. Nonetheless, panic attacks are not insignificant and can have a crippling effect in someone’s life. They are a symptom of underlying stressing and traumatic events in the patient’s life. (Feather & Ronan, 2006). This report gives a diagnosis of Paula’s case. It gives a comprehensive analysis of what is the onset of Paula’s condition, the triggers and the effects of her attack. At the end of the report it will give the findings and recommendations on the way forward for Paula in getting treatment for her condition.
Diagnosis Paula has been experiencing an array of symptoms that occur frequently at the workplace and outside home. These symptoms include dizzy spells, shortness of breath, dizziness and lightheadedness as well as chest pains and fast heartbeats. Paula feels that there is cause for alarm because these symptoms may be an indication of a heart attack. For this reason she has sought medical help from her general practitioners, and she has even visited a cardiologist for a sonogram and echocardiogram. Both these tests showed no defects or indication of heart attack.
Nothing is wrong with Paula’s heart and apparently the symptoms may be a psychological related. The doctors at the company clinic where Paula works suggested that she try to relax more and steer away from caffeine, nonetheless the attacks still persevere despite Paula’s attempts to relax. She sought a second opinion from another physician who also gave similar diagnosis i. e. her attacks are a psychological problem hence she needs to sign up for therapy. With that Paula came to the clinic. Brief history of Paula
In order to clearly diagnose Paula’s condition information from her life experiences both in the present and from the past had to be sought. Paula is 27 years old, single and lives at home with her parents. She has a good job at a securities and bond trading company which she has worked for loyally since she graduated from university with a BA in economics seemingly her life was be smooth and no developmental milestones have been experienced on her part. Prior to her recently persistent attacks she was ready to enroll for MBA.
Her father died soon after she graduated from University after a brave fight with cancer, emphysema and the killer heart attack. Her mother has some health problems although nothing too serious. Her grandparents died of cancer; her grandma of breast cancer and her grandpa of colon cancer, she feels that cancer runs in the family and is afraid of it too. This is the reason why she stopped smoking and does not drink alcohol. She says matter of factly “I have enough bad seeds in me”. Paula is the only child not by plan but out of natural misfortune.
She had a little brother who died at the age of three out of heart defects that developed with age. He also had other birth defects that Paula was unwilling to disclose. This memory made her teary. Obviously, the death of the little boy had deep-seated effects in all the family members. (Feather & Ronan, 2006). According to Paula, her parents did not try to get pregnant again and the option of adoption was too devastating to consider. Paula’s mother and friend at work feel greatly concerned over her condition and Paula feels that as well. Paula feels that it is time she had greater control over her problem.
The medication she has been taking i. e. Xanax and Contac zonk her out and she refers to herself as a ‘walking dead’ when she is on this medications. The persistent attacks seem to be triggered by anything major to Paula and given the nature of her job she reports frequent dizzy spells, faints and attacks at work. She remembers a case whereby a client fell through and all the blame was pinned on her. At the same time a coworker at the workplace had shown particular interest on Paula as a woman. All these major events occurring concurrently in her somewhat laid back lifestyle triggered an attack.
In the moment of it all, the other workers got wind of her weak point and she is afraid that they might think of her as ‘chicken’ or incompetent of handling such a demanding job. Frequency of attacks Paula’s attacks have been with her for a long while. She points out that ever since she entered university she started experiencing them. The stress levels were high what with the huge load of work, pressure from men in campus and the need to fit in since the university was small and everyone knew everyone else. In her high school it was easy to be an invisible wall paper and stay unnoticed when necessary.
Unfortunately in university this was not the case and she lacked the necessary support systems or good outlets to channel the stress she was feeling. She also recalls her father’s death which affected her greatly. It was overwhelming for her although she had suspected it would happen soon. This reminded her of her brother’s death. For this reason Paula feels ‘life is very unfair’. The death of loved ones caused her to withdraw from life completely. At school she would get sweaty and the dizzy spells prior to presentation and even before she lost her virginity she had a panic attack.
Paula’s case now involves her mothers, her co-workers the doctors and now psychiatrist. Before, it was her personal problem and she felt she could deal with it. Now her life is significantly affected and people around her are worried. Doctors feel that it is time she saw a therapist to uncover the real cause of the problem. Her mother feels strongly about the same as also the people at work. Assessment and investigation plan It seems that Paula is suffering from severe depression which manifests itself in panic attacks.
(Alpert & Fava, 2004) She has not developed the expression skills and seems to bottle up feelings of anxiety, frustration, hurt and stress. She has managed to deactivate her social life and is highly dependant on her mother for comfort although she does not disclose her inner feelings to her mother as well. Notably, at 27 and with a good job she is still unattached to anyone and does not go out with friends. Throughout the sessions she makes no mention of significant persons other than her mother. Even at university she frequently went home to be babied.
Her family background is a troubled one with a history of heart diseases and cancers. Her loved ones seem to be consumed by these diseases and she feels afraid of being the next. Panic attacks manifest either as ‘a way of getting through tough situations’ as she puts it or as a reaction to overpowering feelings of loss, excitement or expectations. After reviewing Paula’s case in detail it is recommended she have behavioral therapy as a start treatment program since it is the best therapy linked to activating the client from depression, a condition that is the underlying cause of Paula’s panic attacks.
BATD (Behavioral Activation treatment for Depression) overview, foundation and Assumptions. This treatment option bases its foundations from cognitive therapy. It basically involves activating the client from depression by encouraging them to make connection between powerful experiences both in the present and in the past with the symptoms that they may be having. In Paula’s case it is panic attacks. The basic assumption of this therapy is that depression and subsequent symptoms of depression arise from life expenses of the patient and not the genetic predisposition. (Cooper, Smith & Upton, 1994).
Vulnerability is severed by traumatic life events. This therapy encompasses assessment and treatment of cognitive, emotional and behavioral aspects of the clients. This means that its efforts are channeled toward sharpening social skills of the client through training and reinforcements, imparting relaxation techniques as well as therapy to help relax the client, increasing pleasurable activities in the clients life say situations with more laughter and easiness, training clients on assertness and emotional expressions and restructurings the clients patterns of thoughts and cognitive perceptions.
(Gortner & Jacobson, 2000, Martell, Addis & Jacobson, 2001) These areas are greatly emphasized because they alter the client’s beliefs of the world around them and eventually how they choose to resolve their inner problems or conflicts which are evident in behaviour. According to Beck, Rush, Shaw and Emery (1979 p. 118) mentioned in Jacobson, Mortell and Dimidjian 2007, p. 257 ‘the aim of this therapy to bring about change in the clients negative outlook in life’. The beliefs and expectations of a person indecent in his cognitive make up ultimately affect behaviour.
The behavioral activation therapy recognizes that some depressions and subsequently panic attack may be or a result of genetic predisposition, it greatly emphases environmental factors as a great a preventative measure for depression maintenance. Course of treatment Paula’s treatment will commence with the establishment of therapeutic rapport with the therapist while they discuss the objectives and goals for the therapy and the sessions. This will be achieved by encouraging Paula to ask questions and be as comfortable as possible during the sessions.
Paula and the therapist will explore the implications that her depression has had on Paula’s life for instance she lacks a social life, she cannot do her daily tasks any more, she will lose her job and so on. Under this treatment the therapist will be performing some functional analysis on Paula to gauge how well Paula is responding to treatment. For example, she should be able to start driving her car to work and performing her duties at work. The use of home works will be helpful to both Paula and the therapist in finding areas that the therapy should concentrate on.
The therapy sessions will also explore the strategies that Paula should use to avoid a relapse. Paula intervention plan The first step in her treatment plan is to get her to talk more about her unpleasant life experiences. So far she has registered commendable progress into talking about her father and her young brother. When she first came in she was fidgety and kept checking her pulse over her neck. She had a panic stricken look but now she has relaxed a little.
It is impossible to accurately state the duration that Paula might take to show full recovery since depression can be hard to overcome with the lack of proper support systems and the troubling environment at her workplace. Nonetheless, Paula sounds really determined to get over this problem and regain full control of her life. A two hour session with the psychiatrist thrice a week for a month and once a week for the following two months is recommended. This will be flexible enough for Paula to manage work and treatment. The significant people in Paula life i. e.
family and coworkers need to give Paula all the support she needs to overcome this milestone. This is because her depression is not just an inner problem but the environment also triggers her attacks. The boss could encourage Paula to take some early days off and maybe some days be allowed to work from home until she is ready to work full time. The mother needs to continue being there for her daughter but on the other hand encourage her to be more independent. This will ensure that she is strong enough to handle life situations on her own and avoid a relapse in case she dies.
The coworkers may be a bit more supportive when she experiences panic attacks and let her know it is nothing to be ashamed of. Again, Paula should expand her social networks and support system and this will a particular area where she will be trained during therapy sessions. Paula seems to over think her situations and the events in her life. A case in point is where she is quick to say that her coworkers will recommend she be transferred to the mail room because of the panic attacks. She feels that she should ‘never’ have an attack at the office again.
She says ‘everyone will laugh and say look at the retard at it again. ’ She also seems to have planned out her suicide and thought of the consequences i. e. she would go to hell, it would be painless if she overdosed on Aspirin, she would play some sad music, the suicide letter and other details fully planned. This seems to be Paula’s pattern of thinking and it is detrimental. In therapy, I will be interested in activating Paula’s spontaneity and her ability to accept her vulnerabilities and limitations towards having a fuller life. Measuring progress
In order to gauge progress on Paula’s treatment the therapist should be able to find improvements in Paula’s frequency of panic attacks. Ideally, they should reduce in the first month of treatment significantly. Additionally, her patterns of avoidance will be evaluated to see how well she is able to confront her fears. (Carr, 2001). For example, she avoids getting close to any man who might show interest in her hence stays away from social scenes like movies theatres and social gatherings. She also marks all the exit points to a place just incase she suffers another panic attack.
Driving is also a problem to her and she has to be driven by her mother. She also avoids going out doors and stays in mostly where treatment will be effective, Paula should be able to take on her daily activities and develop healthy relationships with new people. The therapist will also make use of homework whereby Paula can try to engage in a task she feels prohibitive or unable to handle and see how well or not she manages the situation. This homework will allow her to self monitor her own progress and in therapy session discuss the feelings of accomplishment and pleasure derived from engaging in that activity.
Results of the actions So far Paula has impressively shed light on her life. She has made the first big step towards treatment and that is the resolution to seek professional help. The diagnosis is that Paula is suffering from panic disorder which overlaps severe depression. She has had traumatic life experiences and suppressed them sufficiently. However she has reached a point where the emotions and negative psychological beliefs can no longer be bottled up hence the frequent panic attacks.
The panic attacks have greatly eroded her self-esteem to a point that she planned a suicide although did not execute it. After evaluating her case I recommend psychiatric assessment just to ascertain this diagnosis so that the next level of therapy i. e. relaxation therapy and psychoanalysis can commerce. Although Paula is not actively keen on attempting another suicide, the risk is inherent and she needs close monitoring by her family and friends before and during therapy until she is strong enough to stand on her own.
Paula should enroll in an activity that will enable her to think outside herself and her problems as well as boost her self-esteem. Yoga and social gatherings will particularly do her a lot of good. (Gortner & Jacobson, 2000). Lastly but importantly, Paula’s GP and cardiologist input would also be necessary in affirming this diagnosis so that Paula is well convinced that her panic attacks are purely psychological and not heart attack related. This will encourage her to continue the treatment. Conclusion
Panic attacks are surmountable behavior activation therapy is a good way of assisting clients who suffer these attacks. The collaborative relationship between the client and the therapist should be useful in uncovering the depression in clients who suffer depression. The patterns of avoidance that Paula has developed such as avoiding relationships and friendships with others, avoiding social places staying away from work among others are crippling to Paula’s life and need to be confronted. Paula has to find a way of dealing with her problems in healthy ways.