Management of panic anxiety with agoraphobia by using cognitive behavior therapy.

Panic disorder with agoraphobia is a psychological disorder. We are presenting a case report of male client, visted as out door patient in the counseling centre of National Institute of psychology. Client reported the symptoms such as palpitations, pounding heart, accelerated heart rate, sweating, trembling/shaking, feeling of choking, chest pain, discomfort, nausea, abdominal distress, feeling dizzy, lightheadedness, and fear of losing control when he is in the crowd. The signs and symptoms of a panic attack develop abruptly and usually reach their peak within 10 min. Most panic attacks end within 20 to 30 min, and they rarely last more than an hour. The client was diagnosed, Panic Anxiety with Agoraphobia. Cognitive behaviour therapy was used for the treatment. After seven sessions, client's symptoms were diminished.

INTRODUCTION

Panic attack is a discrete period of intense fear or discomfort, accompanied by cognitive and physical symptoms of arousal. These include tachycardia, sweating, shortness of breath, chest pressure, choking sensations, dizziness or lightheadedness, depersonalization or derealization, stomach discomfort, and fears of dying or going crazy.[1] It is anxiety about being in places or situations from which escape might be difficult or embarrassing. Cognitive behavioral therapy (CBT) is effective in the treatment of these anxiety-related conditions, like social phobia,[2] nocturnal panic,[3] and depression and may provide a viable alternative to medication.[4] However, such treatments comprise a complex set of procedures.[5] CBT is an effective treatment for many but not all patients with panic disorder and can be confidently used with panic disorder without agoraphobia (PD).[6] The etiology of panic disorder, cognitively based research to date, has largely focused on catastrophic misinterpretation of bodily sensations.[7]

CASE REPORT

The client, 24 years of age, student of M.Sc Anthropology, visited with symptoms that when he is in any social situation he feels headache, palpitations, pounding heart, jelly like legs, feelings of choking, shortness of breath, nervousness, dizziness, losing control on himself, feels detached from the surroundings for few minutes. The client reported that he had lost his control and feel like faintness. As a result he feels low, started to stay in isolation, and lost attention and concentration in his studies. The client blamed his father for his bad mental health. The client was treated with CBT. He was educated about the nature of the disease and the role of fearful thoughts in production of the symptoms and how adrenaline is secreted because of the activation of the sympathetic nervous system. This system commonly activated in the fight or flight reaction no matter the fear is real or imagined. In the case of panic anxiety, a person had the fearful thought that is mostly imagined fear. The client was educated that there is no safe place or safe person, “You are the safe place and the safe person. The reason is that you are terrifying yourself with your thoughts.” He was counseled that instead of terrifying from the symptoms because of the secretion of adrenaline that “what is happening.” “Accept” the feeling and recognize the situation that because you have the scary and the fearful thoughts in your mind, adrenaline is secreted, and due to that secretion symptoms like pounding of heart, sweating etc are the results. He was educated “When you accept and understand the real cause of the symptoms you will have no more these aggravated symptoms. Initially they may be produced, but when you will not scare from these symptoms they will be subsidized.” Treatment consisted of seven sessions over 9 weeks. Client has controlled over his worsen symptoms of panic anxiety in social gatherings.

DISCUSSION

Panic anxiety is categorized in the group of anxiety disorders. Anxiety disorders affect 14% to 25% of the general population.[89] Anxiety disorders are associated with mild to severe levels of social, occupational, and physical impairment,[10] and can be as painful as chronic physical disease.[11] Most clients with anxiety disorders seek help in primary care settings,[1213] that predominantly present with generalized anxiety disorder, panic disorder, and posttraumatic stress disorder.[14] In the case of panic anxiety, on the secretion of the adrenaline, bodily changes happens, like palpitations, sweating, trembling and headache, etc. A patient with social anxiety or panic anxiety gets alert from the symptoms and started frightened from the symptoms. As a result, this increases the severity of the problem. CBT involves enhancing the development of skills in cognitive restructuring and behavioral exposure to reduce panic anxiety and confront underlying fears. It typically involves 10–15 individual or group sessions that may include psychoeducation, self-monitoring, relaxation training, cognitive restructuring. Treatment duration and outcome depend on symptom severity; psychological or biological comorbidities; patient resistance to treatment, ability to master CBT concepts and skill maintenance following treatment; and the treatment provider's competence.[15] Cognitive restructuring helps in identifying and modifying catastrophic interpretations of events that contribute to anxiety and maladaptive behaviors.[16] CBT focuses on the thinking patterns and behaviors that are sustaining or triggering the panic attacks. It helps to look at fears in a more realistic way. CBT views anxiety as the result of maladaptive habits of thinking and behavior, usually including the tendency to overestimate the possibility of something negative occurring and to avoid that which produces anxiety. Studies have found that avoidance temporarily eases fear, but tends also to reinforce it so that it continues over time. To manage panic anxiety, there are ample of evidencs that CBT may be better tolerated and more cost-effective than pharmacologic interventions. Medication is associated with high relapse rates,[17] CBT is better used for the patients who do not respond to medication.[18] Thus, the early the patient will be diagnosed the better it will be for the treatment outcome. Psychoeducation is highly recommended to encounter the panic attacks and fearful thoughts.[19]