Paula Deen struggled with panic disorder with agoraphobia for twenty years. According to the case study, her problems began with her father’s death when she was only eighteen years. The death happened when Paula had just married her first husband who also turned out to be an alcoholic. The issue aggravated a few years later when Paula lost her mother after battling with cancer. According to the case study, Paula felt that she has lost all her security, sparking the fear that she would also die any time. Her worry increased rapidly over time, prompting her to avoid leaving her house. She struggled to maintain her troubled marriage to add to the financial issues she experienced at the time.
While Paula attempted to seek help, she could not manage an expert psychiatrist, resorting to the services of her church minister though she gave up after realizing that the minister was not as supportive as she had wished. However, Paula knew she needed the strength to cope with her challenges, which she found in her passion for cooking. The case study reports that cooking provided her security because it allowed her to rekindle her childhood, where she grew in the company of a loving, supportive family. Her family later relocated to another location, where Paula found supportive neighbors to whom she talked about her problem, prompting the onset of a treatment initiative that helped her cope effectively, especially after she eventually divorced her husband.
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Section 2: The Actual Assessment
Demographic Information
Paula Deen is a seventy-four-year old female living with her family. She is a divorced mother of two. At the time of the case study, Paula reported struggling financially and having a troubled relationship with her alcoholic husband whom she married when she was eighteen. The case study does not indicate her educational status, but it can be inferred that she did not have formal employment. Paula also reports having lost both of her parents, first her father through heart surgery complications then her mother through cancer.
Presenting Problem
The client presents with panic disorder and agoraphobia. According to the extant studies, people presenting with the conditions have the tendency to avoid some places, which can be summarized as the ‘fear of the marketplace’ ( Bandelow , 2013). Such individuals prefer shut-in lifestyles and social avoidance because they a chronically anxious about going out, causing intense panic and fear of doing so, especially when they perceive that they may not get help or escape from danger. Paula, as do other patients with her condition, is hesitant to leave her home, reluctant to go out alone, and unwilling to go to unfamiliar places.
Relevant History
Paula’s problems started early in her life, at the age of eighteen following the death of her father. The case study indicates that her father’s demise adversely affected her perspective of security since she considered him as the source of such comfort. She did not manage her grief, causing her to develop anxiety about death. The problem worsened with her mother’s death after suffering from cancer. The deaths changed Paula’s perspective of life, security, and death. She woke up each day thinking that she would also die, as the rest of the people she loved and to whom felt securely connected. Her marriage to an alcoholic, unsupportive husband may also have added to Paula’s problems. She did not have the right support to help diagnose her issues early and seek the right intervention, prolonging the problem for twenty years.
Symptoms
Paula’s symptoms include spontaneous, repeated panic attacks causing overwhelming fear and anxiety. She also reports feeling being out of control and the fear of impending death and doom when under the panic attacks. Much as the case study does not explicitly indicate, the relevant literature reports that individuals with the condition also experience physical symptoms at the onset of the attacks, including an impounding heat beat, trembling, chills, sweating, dizziness, weakness, breathing issues, numb or tingly hands, nausea, stomach pain, and chest pain ( Bandelow , 2013). Such persons, as the case study indicates, experience intense worry concerning when the next attack will occur. They also experience fear, causing them to avoid places where such attacks happened in the past.
Case Formulation
Macneil and colleagues proposed five factors (the five Ps) of an effective case formulation: (1) presenting problem, (2) predisposing factors, (3) precipitating factors, (4) perpetuating, and (5) protective factors (Macneil et al, 2012). Paula’s presenting problem is coping with the anxiety caused by her panic disorder and agoraphobia. Her predisposing factors are mostly environmental, including the troubled family relationships she has had, especially the loss of her parents when she was still young. The precipitating factors in the case study include the fact that Paula lacks the right support system that would enable her cope with her condition, especially because she does not have sufficient financial capability to seek an early intervention for her condition. Consequently, she resorted to seeking help from her church minister who has a degree in psychology, but quit later, after failing to find the right support. Accordingly, the perpetuating factors in Paula’s problem include the fact that she lives with an alcoholic and unsupportive partner, causing her to continue thinking about the loses she has already suffered in life. The protective factors in the case study include the need to find the right social support, the people Paula trusts may help her cope with the condition.
DSM-IV Multiaxial Assessment
According to The American Psychiatric Association (APA) (2013), the multiaxial assessment has often been the initial assessment that clinicians would conduct in diagnosing clients. Notably, the assessment provided mental health professionals a way of communicating with other experts and coordinate services for clients. While the fifth edition of the Diagnostic Criteria for Mental health issues (DSM-V) avoids this approach, it is useful in determining the right approach to handling Paula’s issues. The DSM-IV classification would categorize Paula’s condition in Axis I, which are described as any mental health issues apart from personality problems and mental retardation. Precisely, panic disorders and agoraphobia are broadly categorized as anxiety disorders, ranking squarely on the list of disorders in axis I (APA, 2013).
Treatment Plan
Literature, such as Simos and Hofmann (2013) and Bouchard et al. (2017), report several strategies for managing panic disorder and agoraphobia, but they consistently insist on the Cognitive Behavioral Therapy (CBT). According to the latter studies, the CBT method can help persons with symptoms like those exhibited by the client (Paula) develop coping methods. Notably, an individual may be unable to regulate the onset of the panic attacks, but they may gradually learn effective coping methods when such attacks happen. The CBT could enable clients achieve lasting change when applied properly.
The first step of the CBT process is to help the client identify and replace the negative thoughts that have been driving her symptoms. For example, it may be useful to direct Paula to contemplate how she perceives herself, understands the world around her, and her feelings during the panic episodes. As indicated in Bouchard et al. (2017), concentrating on the thought process could help Paula start realizing her typical thought pattern and its influence on her behavior. Second, it would be critical to apply different exercises and activities to build the client’s awareness of her negative thoughts and begin replacing them with a positive mindset. It would be fruitful to assign some homework activity between sessions to aid Paula to keep establishing and replacing negative thought with positive ideas. The extant studies also report that writing exercises could be an active way of conquering negative thought patterns, informing the third CBT step. For example, the therapist may decide to maintain a panic diary, a gratitude journal, or write any other journal to document their experiences ( Simos & Hofmann , 2013). Reflecting on such experiences, it is reported, may help Paula to begin understanding the challenges she has been facing likely to spur negative thought and what she has been doing to avoid such a mindset.
The fourth step of the CBT process involves skill-building and behavioral transformation. Accordingly, the therapist focuses on developing and sustaining healthy coping methods for transforming maladaptive behavior. Paula could learn to create stress-reducing strategies, manage anxiety, and deal with the panic attacks when they occur. Much as these skills could be rehearsed during the sessions, studies advise that the therapist may also ask the client to try new methods not conducted during the therapy to diversify the activity types used in the process. The fifth CBT step is desensitization, where the therapist concentrates on helping the client forget her avoidance behavior that have been central to the panic attacks. Here, it would be necessary to introduce Paula to anxiety-causing stimuli while teaching her the most effective coping methods for the resultant anxiety feelings. Lastly, the therapy should teach Paula the best relaxation techniques to help her remain composed during the anxiety-provoking circumstances. The skills thought during this step aid in managing Paula’s fears, managing tension, lowering the heart rate, and bolstering her problem-solving capabilities.
References
American Psychiatric Association (APA) . (2013). Diagnostic and statistical manual of mental disorders . Arlington, VA: American Psychiatric Publishing.
Bandelow, B. (2013). Panic disorder and agoraphobia . Oxford: Oxford University Press.
Bouchard, S., Payeur, R., Rivard, V., Allard, M., Paquin, B., Renaud, P., & Goyer, L. ( 2017 ). Cognitive behavior therapy for panic disorder with agoraphobia in videoconference: Preliminary results. CyberPsychology & Behavior , 3 (6), 999-1007.
Macneil, C. A., Hasty, M. K., Conus, P., & Berk, M. (2012). Is diagnosis enough to guide interventions in mental health? Using case formulation in clinical practice. BMC medicine , 10 (1), 1-3.
Simos, G., & Hofmann, S. G. (2013). CBT for anxiety disorders: A practitioner book . Chichester, West Sussex, UK: Wiley-Blackwell.
