Case Study Report: Panic Disorder with Agoraphobia
In the case of Dennis Holt, a thirty one year old man presenting with occasional occurrences of panic attacks, the eventual diagnosis was Panic Disorder with Agoraphobia. The etiology of the disorder can be considered to result from a problem with cognition. Holt viewed the world with extreme negativity. He expected people not to like him, and expected the worst to happen in every situation. He feared that he was terrible at his insurance sales job, but there was no real evidence to support that feeling. After his first panic attack, he also became very fearful of when the next one might occur, and this sent him into situations that he already found uncomfortable with the idea that he would have a panic attack, and perhaps people would think less of him.
He became hyper vigilant about signs that he received from his body, such as nervousness or a quickened heart beat, and worked himself into a panic while trying to avoid a panic attack. In addition, he was a very anxious, high strung person, as well as being self conscious. These factors can be traced back to his negative relationship with his father, whom he could never seem to please. Holt also suffered from gastrointestinal problems, some of which could be attributed to his anxiety. These problems made him even more self conscious and nervous. He eventually developed a fear of driving on the left side of the road due to a panic attack while driving. A panic attack during a dinner made him fearful to eat with large groups. Finally, a panic attack during a shopping trip made him unable to face being in the tight confines of a mall. However, he could participate in activities that allowed him to be in open spaces or involved just a few people. His divorce from his first wife apparently contributed to his feelings of low self worth, and his hesitance to “rush into anything” with his new fiancée further displayed his negative cognitive outlook on the world.
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Looking at the DSM-IV criteria for panic attacks, Holt fit the criteria in several ways. He experienced palpitations, sweating, trembling, shortness of breath and a smothering sensation, a choking sensation, chest pain and discomfort, abdominal distress, dizziness, numbness, and tingling, accompanied by a feeling of intense panic, and all these symptoms had lasted at least ten minutes. For a diagnosis of Panic Disorder, one must have had a panic attack that caused the person to change his or her behavior for at least one month, as well as recurrent, unexpected panic attacks, and Holt also fit this criteria. Holt had fears of being trapped in uncomfortable places and situations, and the fear that being in those situations would bring on a panic attack. His gastrointestinal problems also made him fearful of being in a situation that he could not remove himself from. These symptoms qualified him for a diagnosis of Agoraphobia. Finally, Holt’s constant anxiety, muscle tension, inability to relax, tension headaches, constant fatigue, inability to sleep well, and gastrointestinal problems also qualified him for a diagnosis of Generalized Anxiety Disorder. While Holt did not experience many panic attacks, and he did not have the symptoms of derealization, depersonalization, fear of losing control or dying, or chills and hot flushes, he had well more than four of the thirteen symptoms needed to diagnose a panic attack. Also, while his fears had not rendered him housebound, he avoided enough social situations to be considered agoraphobic. Overall, Holt’s diagnoses appeared to be unquestionably correct, and he was a near perfect fit for the overall diagnosis.
The diathesis-stress perspective, as applied to Holt, seemed to play a reasonably significant role in his psychological disorders. The two diathesis that could possibly be applied to Holt’s condition were the fact that he had minor stomach problems and was rather shy as a child and an adolescent. This last fact could come into play considering the stress put upon him by his father from an early age onward. The father wanted Holt to excel and be the best in everything he encountered, including school work and sports, but Holt was only average in these areas. His job as an insurance salesman was not acceptable to his father, who had wanted Holt to be an aeronautical engineer, and Holt’s first failed marriage was a constant disappointment to his father. The father always brought up these perceived shortcomings, and this action led to arguments at almost every visit. Holt was able to participate in school functions and activities despite his shyness, and he did not take his father’s criticism quietly. However, Holt’s performance in college may indicate that his shyness and the constant stress of his father’s nagging did, in fact, have an impact on his mental state. He became consumed with “test anxiety” in college, and panicked over tests to the point that he was nearly unable to take them. While some of his professors allowed him extra credit work because of his growing problem, his grades still fell. Around the time that he developed worsening gastrointestinal problems, he disclosed to the therapist that he had faced constant pressure from both of his parents to make better grades and rise out of academic probation. The gastrointestinal problems had been a small part of his life before, but the stress he was under sent them out of control. Holt was diagnosed with Irritable Bowel Syndrome, but still suffered from problems despite the medicine he was given. One could argue that the parental stress applied to the diathesis of shyness and stomach issues pushed Holt into the psychological problems he suffered later in life. Self consciousness and fear of entrapment and embarrassment could have arisen from his predisposition for shyness and stomach problems.
Holt’s case was obviously handled from a cognitive viewpoint. He was taught positive thinking techniques in order to overcome, or at least control, his fears and improve his self esteem. He was also taught appropriate self talk, and learned to not put himself down as much. Behavioral treatment was also used. For example, Holt was taught relaxation techniques and was forced to confront some of his fears, such as shopping at the mall, head on. Holt was not exposed to breathing restructuring or exposure to bodily sensations, however. This is rather surprising seeing as how these are two important parts of cognitive behavioral therapy. Perhaps the therapist felt that retraining Holt’s thinking and behavior were the most necessary components to his well being. Holt was also not given medication to still his nerves. He did not want it, so his therapist worked around that request. However, with medication Holt may have improved much more quickly than with cognitive behavioral therapy alone. One is told that Holt was in therapy for six months. With medication, that time could have been shortened, and he could have felt much better sooner.
Axis I - Panic Disorder with Agoraphobia
Axis II - Generalized Anxiety Disorder
Axis III - Gastrointestinal Disease
Axis IV - Problems with primary support group: father
Axis V - 45
The GAF chosen was based on the fact that Holt suffers from serious panic symptoms, along with the fact that he is turning down invitations from friends and limiting his actions due to the fear of having a panic attack while driving or while in a large group. His relationships may be suffering due to his irrational fears.
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