Adult Psychological Assessment Cases

Case 2

Case Summary

The client was a 27 years old man educated up to MBA and working as an assistant officer in a a bank. He belonged to an upper middle class family. He came to the Centre for Clinical Psychology to seek treatment for his symptoms of increase heart rate, palpitations, dizziness, lightheadedness, fatigue, feeling of choking, bloated stomach, high blood pressure, fear of dying and a preoccupation of having future panic attacks since a period of 2 months. He was assessed through a clinical and diagnostic interview, panic diary, visual analogue and panic rating scale. After detailed assessment he was diagnosed with Panic disorder. His treatment plan included in-depth psycho-education, behavioral and verbal reattribution, cognitive restructuring, coping statements and relaxation exercises. The treatment was helpful in subsiding the client’s symptoms as evident by the discrepancy between pre and post assessment.

Bio data

Name: H.K.

Age: 27 years

Gender: Male

No. of siblings: 3

Birth Order: 2^nd

Education: MBA

Occupation: Assistant Officer in Bank

Marital Status: Unmarried

Religion: Islam

Informant: Client himself and his mother

Reason and Source for Referral

The client came to the Centre for Clinical Psychology upon the recommendation of his sister. He complained of increased heart rate, palpitations, dizziness, lightheadedness, fatigue, feeling of choking, bloated stomach, high blood pressure, fear of dying and a preoccupation of having future panic attacks. He was referred to a trainee clinical psychologist for the assessment and management of his symptoms

Presenting Complaints

Table 1: Presenting Complaints of the Client as Reported by Him.

Duration	Complaints
From 2 Months	Suddenly panic sets in
	The heart beats faster. Blood pressure rises
	Sweating and body trembling
	It is difficult to breathe. Looks like I’m not breathing
	Feels tired. Feeling dizzy
	Stomach upset
	Looks like I’m going to die
	There is a risk of recurrence

History of Present Illness

The client started to experience the above stated symptoms 2 months back when he experienced a major stressful event in his life. Before the event, the client rarely presented with any of the issues he reported. The client was living in Dubai and in March 2017, he went on a trip with his friends where he met with a deadly prank during night time. He was present in a car with three of his friends and they were going on an empty road. Two of the friends in the car knew about the prank while the client and one of his other friends did not know what was about to happen. The prank was initiated by acting out that the car had broken down and all the members had to leave the car. The client also did as said but after leaving the car they were suddenly chased by a guerilla. The guerilla was actually their friend dressed in a costume. The client and his other friend ran for their lives but could not find help or shelter. They were threatened by the guerilla for almost an hour while the prank took almost 3 hours to finish. It became a life-threatening event for the client while he tried to save his life for the most difficult 3 hours of his life. After considerable time had lapsed, the client and his friend were rescued by the other friends where they were told that they had been pranked. Initially the client was irritated by the whole event but eventually they all laughed it out. At the same night, the client experienced increased heart rate, sweating, palpitations, numbness and dizziness for the first time. He went to his uncle in whose house he was staying and asked him to check his blood pressure. The client’s blood pressure was high for which his uncle recommended him to drink plenty of water and try to sleep. The client was able to sleep after half an hour and woke up fresh in the next morning. After a few days the client visited the place again, where he was pranked for his satisfaction. He roamed around the whole place and felt content that nothing had happened. According to him, he wanted to pack-up the episode without getting affected from it anymore.

Besides the client’s efforts of forgetting the prank, he experienced the same symptoms after a week for which he consulted a cardiologist. He suspected a heart condition so got his ECG and blood tests done. The tests were clear but the doctor prescribed him with an anxiolytic (Indral 0.5 mg). The client started taking the medicine but read about its side effects on the Internet and thus decided to wear it off slowly.

The client started to experience his symptoms repeatedly (increased heartbeat and feeling bloated after eating, sweating while sitting in the office, dizziness while going to sleep) after one week and they increased to 3-4 times a week which made the client hypervigilant towards his problems. He feared that he would have a heart attack or would die due to his symptoms. Due to the constant concern he started to surf the Internet to know more about his problems. The websites provided him with loaded psychological words such panic attacks and depression and he diagnosed himself with Panic disorder. Since then he became more concerned about his symptoms, finding treatments on the Internet and also calling his family in Pakistan. He started to avoid the situations where he experienced the attacks which slowly started to disturb his occupational functioning. Leaving repeatedly and being constantly vigilant about his bodily symptoms made him less attentive towards his work. He started to keep a water bottle with him to use in the time of these attacks. He consulted a general physician 3 times and got his blood tests and EKG done. The reports were normal and doctors told him that there was nothing to be worried out. The symptoms were still evident which made him and his family tensed about the situation so they decided to consult a psychologist.

The client came to Pakistan in May 2017, where his sister recommended him to get guidance from a psychologist. Hence, he came to the Centre for Clinical Psychology to seek assessment and treatment. He reported no history of physical or sexual abuse or use of any illicit drugs.

Background History

Family History

Father. The client’s father was a 61 years old, retired WAPDA official. He was in good health and was a calm-natured person. He did not suffer from any psychological illness. He once experienced heart symptoms but recovered in a month after seeking treatment and taking medications. His relationship with his children was congenial. He was involved with them and took care of their needs. His relationship with the client as well was satisfactory where both of them loved each other and discussed matters cooperatively.

Mother. The client’s mother was in her fifties and was working as a principal in a well-reputed school. She did not have any medical or psychological illness. She was a composed lady who worked hard to raise her children. She dedicated her time for the appropriate upbringing of her children. Her relationship with the client was also congenial as the client discussed most of his issues with his mother. She was the first person to know about the client’s symptoms. She remained concerned about the client as he was far and contacted him occasionally to keep in touch with him. They talked to each other almost daily through calls.

First born Sister. The client’s sister was 29 years old who had done her MPhil in Environmental Sciences. She was currently employed and unmarried. She had a friendly nature and also was strongly attached to the client. She reported that her brother had grown a little distant after he moved abroad but they still talked frequently and had frankness between them. The client also readily discussed his matters with his sister. They cared for each other and provided themselves if the other needed help.

Second born was client himself

Third Born brother. The client’s brother was 23 years old and currently enrolled in the last year of BBA. He was a social and outgoing boy. He enjoyed with the client a lot and also missed him after the client shifted. The client felt attaches to his brother and also provided him with the relevant guidance in studies and other matters of life. They talked over video calls and through texts occasionally. The client’s brother took the client as a role model to follow.

Fourth born brother. The client’s younger brother was 19 years old and in the first year if BBA. He was also a cheerful and fun loving person. He was an obedient son who showed respect towards the client. Both of them had a strong bond between them and played cricket and indoor games with each other whenever they met. The client had a nourishing and fatherly attitude with his younger brother keeping them bonded with each other.

Personal History

Birth and Childhood History. The client was born after a complete gestation period of 9 months and through a normal delivery. He had normal birth weight and color. He achieved his developmental milestones at appropriate time but started to walk slightly earlier. He had a nourishing and playful childhood when he used to play with his sister, cousins and neighbors. He was a cheerful boy who adjusted easily with strangers. No neurotic trait was reported by the client.

Educational History. The client started his education at the age of 6 years. He was an average student throughout his educational life. His primary education was rich with knowledge and he was an eager child to go to school. His teachers never complained of him rather appreciated him in all parent- teacher meetings. No incidences of bullying were reported rather he was also good at sports. The client completed his matriculation with above average marks and got admission in the college of his own choice. His Intermediate also passed with average marks and a good image in the college. After Inter he decided to do BBA and got into a well-reputed university for graduation. He made many friends, was outgoing and also maintained his GPA in average lines. He completed his MBA from the same university and achieved above average marks due to his interest in the subject. The client and his sister both reported that the client was an easy going child especially in studies as he studied himself and consulted their mother for any kind of guidance.

Pubertal History. The client achieved puberty at approximately 15 years of age when he started to grow a beard, experienced changes in his genitals and his voice got heavier. He reported some instances of masturbation but told that he preferred to remain away from such acts. Homosexual or heterosexual experiences were not reported.

Occupational History. The client was working an assistant officer in a Bank situated in Dubai, UAE. He had been employed since one year and was content with his job. He reported that there were stressful times at work as well when the load of work increased and he had to work for more hours. He sometimes skipped his extracurricular activities due to work. He had satisfactory relationship with his employer and colleagues. He went out on trips and dinners with his friends and co-workers. He was social and did not face any major issues with his fellow employees. The client had been facing some problems due to his symptoms since the last 2 months at work as he avoided sitting in the office when his symptoms occurred or he would exit the room. He usually went to go for a walk or have a cool drink. He also took 3-4 half day leaves since his symptoms started to emerge. He did not discuss any of issues with his colleagues or boss as he decided to seek treatment on a personal level.

Hobbies/Interest. The client was athletic and enjoyed sports from his childhood. He played cricket while he was in Pakistan. After moving to Dubai, he was unable to continue playing cricket but indulged himself in swimming and gym activities. He regularly dedicated time to physical activities but reduced them after the symptoms started emerging.

Pre-morbid Personality. The client was social and outgoing before his symptoms started to show. He was eager to go on trips, have fun and feel energetic. He was confident and never felt more focused or attentive towards his health or body. He used to go for exercise, extracurricular activities (gym, swimming, outdoor games) and did not hesitate in physical exercises. Even at times of stress, the client used to act cool and calm because he took life problems as a challenge but nothing to stress about. He had a high frustration tolerance and less impulsivity. He took decisions steadfastly rather than remaining confused.

Psychological Assessment

The client was psychologically assessed on informal and formal basis. Informal assessment included:

Clinical Interview
Mental Status Examination
Visual Analogue
Panic Diary

Formal assessment comprised of:

Panic Rating Scale

Clinical and Diagnostic Interview

Informed consent was obtained from the client and his mother to report all information willingly and to ensure that the client was taken therapy according to his consent. The interview was conducted with the client and his mother. The interview gave detailed information about identifying data, personal life, education, sexual history, pre-morbid personality and history of present illness. The interview was beneficial in obtaining information of client’s symptoms, duration and frequency of symptoms, etiological factors as well as the maintaining factors. History was elicited to gain knowledge about the client’s daily life functioning before and after the emergence of symptoms. Family history was elicited to identify the support system for the client. History was also validated from his mother who provided with more information about the client’s behavior. The interview as a whole provided information about the client’s current health and to devise a case formulation and a management plan.

Mental Status Examination

The client was an average heighted young man appearing to be in his late twenties. He was well-groomed and wore clothing which was adequate according to the weather. The client kept on fidgeting with his hands and shaking his legs. He appeared to be anxious as he spoke in a loud tone and his rate of speech was fast. He maintained adequate eye contact and appeared to be attentive towards the therapist. His orientation of time, place and person was intact. He had adequate short-term and long-term memory. He had insight about the psychological nature of illness.

Visual Analogue (Subjective ratings)

The client was asked to rate each of his symptoms on a scale of 0 to 10 to get information about the level of disturbance each symptom was causing and what intensity it had for him. In the scale 0 meant that the symptom was least intrusive in his life while 10 meant that it was the most.

Table 2: Ratings of the Symptoms According to the Client

Symptoms	Pre-treatment Ratings (0-10)
Physical and physiological symptoms (Increased Heart rate, sweating, dizziness, breathlessness, numbness, choking)	10
Fear of having a heart attack	9
Fear of dying	9
Fear of having a panic attack in the future.	9

Panic Diary

The panic diary was given to the client in order to analyze frequency and intensity of panic attacks, as well as triggering factors, bodily sensations, emotions and his misinterpretation of negative thoughts as well as coping strategies used. He was explained the whole chart and was asked to fill it after every attack he had. The client filled the chart cooperatively which clarified more aspects of the panic attack (see Appendix B).

Quantitative Analysis

Table 3: Areas of the Panic Diary and the Client’s Responses

Areas of Panic Diary	Pre-treatment Rating
Frequency of panic attacks	3-4 per week
Duration of panic attacks	5-10 minutes
Intensity of belief in misinterpretation of symptoms	9/10 on average

Qualitative Analysis

Table 4: Areas of the Panic Diary and the Corresponding Client’s responses

Areas of Panic Diary	Functional Analysis
Precipitating factors	Sitting in the office, Lying on bed at night
Bodily symptoms during panic attack	Increased heart rate, dizziness, breathlessness, sweating.
NATs or misinterpretation of symptoms	I will die, I’m having a heart attack
Feeling/Emotions	Fear, anxiety
Coping Strategies	Checking blood pressure, drinking water, getting reassurance from uncle

Formal Assessment

Panic Rating Scale

The panic rating scale was administered to ensure the presence of panic attacks and related behaviors and physiological arousal of the client (Wells, 1997). It is a self-administered test consisting of 4 items which assess panic attacks from various dimensions.

Quantitative Analysis

Table 5: Item Analysis of the Panic Rating Scale

Item #	Statement	Pre-Treatment Rating
1	Number of panic attacks in the last week	5
2	Frequency of avoidance behaviors	7-8 times
3	Average rating of coping strategies	60% on average
4	Average rating of beliefs on anxious thoughts	45% on average

Qualitative Analysis

The scale shows that the client had five panic attacks in a week and was also inclined towards avoiding such situations. His coping strategies were mostly, controlling his breathing, using medications, repeatedly checking his pulse, and trying to be with someone for reassurance or immediate help. The thoughts accompanying and maintaining the client’s attacks were mostly that he may have a heart attack or a stroke and fear of suffocation.

Diagnosis

300.01 (F41.0): Panic Disorder, unexpected panic attacks.

Case Formulation

The client was a 27 years old young man complaining of increased heart beat, sweating, dizziness, lightheadedness, choking, bloated stomach, fear of dying or going crazy and remaining preoccupied of having another panic attack in the future. He was diagnosed with Panic Disorder because of the symptoms and etiological factors. The risk of developing a panic disorder also includes environmental disorders (American Psychiatric Association, 2013). These can be identifiable stressors in months before the first panic attack such as interpersonal difficulties, physical well-being and negative experiences. In the client’s case as well, he experienced a grave incidence which risked his life. The prank caused him to think that he was going to die due to a constant threat. This may have triggered his panic attacks and the symptoms that started to appear just after the incident.

Goldstein and Chambless (1978) proposed a learning theory that a fear of impending panic or other feared bodily sensations, labeled “fear of fear.” From this perspective, innocuous bodily sensations become classically conditioned to the aversive physiological arousal associated with panic attacks. Because these classically conditioned sensations could trigger an unwanted panic attack across situations, individuals avoid various situations out of fear that they would be unable to cope with their panic if it were to occur in that situation. In the client’s case, his heightened physiological sensations had become associated with exacerbated bodily symptoms which resulted in a panic attack.

In addition to the above theory, Goldstein and Chambless (1978) also give more cognitive elements as a part of their theory as they propose that individuals who experience a panic attack are hyper alert towards their bodily sensations and interpret them as a sign of upcoming panic attack. The client under therapy also presented with the same cognitions and behavior. He became excessively concerned about his heartbeat and breathing and attempted to check them after every 20-30 minutes. He would usually check his blood pressure by a sphygmomanometer or ask his uncle to check his pulse. The act of being hyper alert caused him to experience and notice his symptoms more as compared to if he ignored them.

Bouton, Mineka, & Barlow (2001) propose that Panic Disorder develops because exposures to panic attacks causes the conditioning of anxiety (and sometimes panic) to exteroceptive and interoceptive cues. This process is reflected in a variety of cognitive and behavioral phenomena but fundamentally involves emotional learning that is best accounted for by conditioning principles. Anxiety, an anticipatory emotional state that functions to prepare the individual for the next panic, is different from panic, an emotional state designed to deal with a traumatic event that is already in progress. However, the presence of conditioned anxiety potentiates the next panic, which begins the individual’s spiral into Panic Disorder. In the client’s case as well, his exposure to situations in which he experienced the heightened bodily symptoms became associated with the thinking pattern that he was going to have a panic attack. In future instances, the conditioned bodily symptoms, thus lead to the triggering effect of thoughts and misinterpretations, eventually leading to a panic attack.

According to the vicious cycle model of David Clark (1986) panic attacks result from catastrophic misinterpretations of bodily or mental events. The events are misinterpreted as a sign of immediate impending disaster such as a sign of having a heart attack or collapsing or going crazy. The vicious cycle contains three elements; emotional reactions, bodily sensations and thoughts about sensations (misinterpretation). These elements are linked in a sequence which follows a particular pattern which can begin with anyone of the elements. Misinterpretation of bodily sensations is associated with anxiety and anxiety becomes a precipitating factor for another panic attack. This could be correlated with the present case as palpitations were seen as a sign of heart attack. The misinterpretation caused anxiety and maintained the vicious cycle.

Idiosyncratic Case Conceptualization (Clark, 1986)

Management Plan

The client’s symptoms were managed and treated under the lines of Cognitive Behavior Therapy.

Short-Term Goals

Short-term goals	Therapeutically Applied Techniques
To build trust and understanding between the therapist and client	Therapeutic Alliance Supportive work
To provide information to the client and his mother about his symptoms, their etiology, prevalence, treatment options, prognosis and client’s role	Collaborative Empiricism Psycho-education
To make the client understand the precipitating and maintaining factors of his symptoms	Socialization with the CBT model Paired association task Body focus task
To disconfirm the client’s misinterpretations of his symptoms and break the feedback cycle which blocks disconfirmation	Behavioral reattribution strategies (Hyperventilation provocation task, Physical exercise tasks)
To modify client’s beliefs and misinterpretations	Verbal reattribution strategies (Questioning the evidence, education and exploring Counter-evidence)
Normalize the client’s experience of physical symptoms	Survey technique
Reduce the likelihood of relapse	Relapse Prevention Therapy Blueprint

Session Reports/ Management Plan

Session No.1 Time of session: 45 minutes

Session Agenda

Develop therapeutic alliance, History taking, Mental Status Examination, Symptom elicitation and subjective ratings

Techniques

History taking

Rationale: To take the client’s consent for therapy and gather information about the client’s past life, and development of symptoms. Procedure: The interview was held with the client and his mother. They were told to report the details. More relevant and in-depth information was probed by the therapist herself. An informed consent was also signed by the client to ensure he was willingly taking the therapy. Outcome: The interview gave detailed information about identifying data, personal life, education, sexual history, pre-morbid personality and history of present illness. The interview was beneficial in obtaining information of client’s symptoms, duration and frequency of symptoms, etiological factors as well as the maintaining factors. History was elicited to gain knowledge about the client’s daily life functioning before and after the emergence of symptoms. Family history was elicited to identify the support system for the client. History was also validated from his mother who provided with more information about the client’s behavior. The interview as a whole provided information about the client’s current health.

Mental Status Examination

Rationale: To assess the client’s functioning in multiple areas.. Procedure: Some of the information was gathered by observing the client’s behavior, actions and speech while others were directly asked from the client. Outcome: The client had appropriate behavioral functioning except the presence of a pre-occupation with his bodily symptoms and reactions.

Symptoms Elicitation and Subjective Rating

Rationale: To get a clearer picture of the client’s symptoms and his own rating about each symptom. Procedure: The client was asked to rate his symptom on a scale of 0-10 where 0 was least problematic and 10 was the most. Outcome: The client prioritized his symptoms according to their severity which helped in determining which symptoms were to be dealt first.

Therapeutic Alliance

Rationale: To bring both the therapist and client at ease and on good terms, trust each other, be open towards one another and show respect. The alliance is necessary to create a sense of understanding, confidentiality and regard between both individuals so that blocks and hesitance can be avoided. Procedure: The therapist, at first, introduced herself to the client and his care-giver after which they were allowed to explain their problems. The client was shown unconditional positive regard while he was telling about his beliefs and symptoms. Empathy was practiced to ensure that the therapist understood and cared for what problems the client was going through. Reassurance was also provided in the initial session to develop a sense of concern toward the client. During the process, the client’s mother also discussed the problems openly providing with maximum information about the client. Interruptions were kept at minimum to ensure adequate flow of information towards the therapist. Outcome: The client trusted the therapist and problems were discussed freely.

Homework given: Panic diary was given to assess the frequency, duration, intensity, antecedents of panic attacks.

Session No.2 Time of session: 45 minutes

Session Agenda

Continuation and completion of history, Differential diagnoses, formal assessment (Panic rating scale)

Homework review: The client’s panic diary was reviewed.

Techniques

Continuation and Completion of history

Rationale: To obtain more detailed information about specific areas of client’s life. Procedure: The client was asked to report more information which he may have missed in the last session. Moreover, the therapist also inquired more information which she previously could not ask. Outcome: Revisiting the history helped in filling the gaps and getting a more detailed analysis of the problems

Differential Diagnoses (American Psychological Association, 2013)

Rationale: To get a clearer picture of the client’s symptoms and rule out irrelevant diagnosis. Procedure: Symptoms specific to the disorder were asked. The cluster of anxiety disorders were thoroughly investigated to reach to a final diagnosis. Outcome: PTSD and specific phobia were ruled out while Panic disorder was the most justified.

Formal assessment (Panic rating scale) (Wells, 1997)

Rationale: To confirm the presence of panic attacks and consequent coping strategies. Procedure: Panic rating scale was self-administered by the client in duration of 10 minutes. Outcome: There was a high frequency of panic attacks experienced by the client and multiple coping strategies were employed by him to cope with the symptoms

Homework given: Panic diary was given again to be filled thoroughly.

Session No.3 Time of session: 45 minutes

Session Agenda

Psycho-education, socialization, paired association task, body focus task

Review of previous session: The previous session was reviewed by summarizing the client’s symptoms and his performance on the questionnaires. This helped in bridging the gap between previously told symptoms and new information which was to be provided in the present session.

Homework review: Panic diary was reviewed. Clarifications were obtained for information that were vague.

Techniques

Psycho-education (Wells, 1997)

Rationale: To orient the client towards his symptoms, their development, precipitating factors, treatment plan and prognosis. Procedure: Psycho-education was conducted to address queries of the client about the illness i.e. what it is. why was it happening, what other symptoms could emerge, what should be the measures taken, are medicines necessary, what can be the psychological treatment plans, how long will the client take to recover and what is the probability of complete eliminations of symptoms. The information was provided under the light of recent researches and the diagnostic statistical manual. The process of psycho-education was also accompanied by informing the client about what was required from him. The role of the therapist was clarified and client was told to help himself at maximum. Therapy protocol was discussed i.e. the no. of sessions, duration of sessions and expectations of the client from the therapist. Importance of homework assignments was also discussed. Outcome: . It helped to broaden the insight if client regarding his symptoms.

Socialization (Wells, 1997)

Rationale: To make the client understand the development and process of his disorder. Procedure: The client was explained the CBT model of Panic disorder to make him know how the problems develop and form a vicious cycle. The precipitating and maintaining factors of panic attacks were also elaborated so that he would understand the dimensions of his problem and recognize the points of treatment. Idiosyncratic examples of bodily symptoms experienced by the client were illustrated during the session, interpretation, and avoidance behaviors were put into the model for more clarification. Outcome: The client was initially reluctant in accepting that exacerbation of his symptoms were due to his thinking patterns but the model was revised after reattribution strategies, and at that point he agreed with the model and understood it adequately

Paired association task (Wells, 1997)

Rationale: To orient the client towards the underlying mechanism of his cognitions. Procedure: It was executed in which he was given pair of words in which one minor symptom was associated with another extreme bodily condition, for example, increased heart rate with heart attack, inability to breathe with suffocation etc. The task was presented by asking the client to read the pair of words out loud without explaining the rationale. Within 10-15 seconds, the client had furrows on his forehead and was looking anxious. A whole minute of reading the pairs caused him to get more fearful and he started breathing heavily. The words were then removed and the client was asked what he interpreted from the activity. Outcome: He got some understanding of its purpose which was then further explained by the therapist. He was clarified that the more he misinterpreted his symptoms, more he was prone to exacerbate them. He clearly understood this technique that beliefs of catastrophe exacerbate anxiety.

Body-Focus Task (Wells, 1997)

Rationale: To elaborate the phenomenon of selective attention and misperception. Procedure: The client was asked to focus on the palm of his hand and in second time his face for 3 minutes. He was given a mirror and was asked to look closely to all aspects of his face or hand. After the time had elapsed he was asked about the things he noticed. His response showed that he had noticed more negative features on his face. This point was then taken by the therapist to explain to him how constant monitoring of oneself can cause distortions in perception and focus on unreal aspects of the situation. He was given his own example that when he repeatedly checked his pulse and heartbeat, he mostly misperceived them which made him more concerned. Outcome: The task was helpful in making the client understand the consequences of his behavior and how they contributed towards the vicious cycle of thinking and avoiding.

Homework given: To practice body-focus task again at home. Read and understand the CBT model in detail

Session No.4 Time of session: 45 minutes

Session Agenda

Psyho-education revised, Disconfirming client’s beliefs and reassurances, normalizing

Homework review: The client was asked if he felt convinced about overemphasis and selective attention. He reported that he did those tasks and noticed that the things which were focused more proved to have more negativity in them.

Techniques

Psycho-education revised

Rationale: To relieve the client’s stress about duration of symptoms and treatment. Procedure: The client kept on asking how long the symptoms will take to subside. He was again educated about his own role in decreasing the symptoms and improving his health. The factors that contributed towards a better prognosis were discussed. The importance of treatment adherence was emphasized and role of medicines was also clarified. Outcome: The client felt relieved after hearing that the symptoms can also go away completely. He also agreed to work upon his health with dedication.

Disconfirmation of beliefs

Rationale: To decrease the client’s reliance on irrelevant material on the Internet and consider the doctor’s and therapist’s words more competent. Procedure: Many examples about information from the Internet that misled people were discussed and the authenticity of information present on online websites was explicitly explained. He was convinced that guidance given by professionals on a one-to-on e basis is more beneficial than random facts and figures on the Internet. Outcome: The client seemed convinced by the discussion and decided that he will not draw conclusions by reading information on the Internet.

Mini-survey (Wells, 1997)

Rationale: To normalize the client about the existence of same symptoms in all individuals. Procedure: The client was taken to 5 people who were interviewed if they felt some of the symptoms felt by the client himself. They were also asked about the situations in which they felt such symptoms and how they coped with them. The client was allowed to question the people in detail to remove any ambiguities. Outcome: He understood that people also experience the same symptoms either at different times or all at the same time but their reasoning and attributions are different from those of the client.

Homework given: To continue physical activities and keep a check on the other reasons those are causing physical symptoms to occur rather than the probability of worse health consequences.

Session No.5 Time of session: 45 minutes

Session Agenda

Behavioral Reattribution tasks (Hyperventilation provocation task, Physical exercise)

Homework review: The client was asked about his progress in refraining from reassurance and how his family responded to the survey technique. He reported that all the members felt those symptoms but nothing happened to them neither did they stress over those signs.

Techniques

Hyperventilation provocation task (Wells, 1997)

Rationale: To induce panicogenic sensations in the client which were then related to disconfirm client’s beliefs. Procedure: The client was asked to walk on the lines of the tiles and breathe heavily. The activities helped in inducing symptoms such as increased heartbeat, sweating and dizziness in the client. After 2 minutes of heavy breathing the client was asked about his beliefs. His beliefs were then challenged as he induced the symptoms himself and nothing further happened. Outcome: His previous beliefs of dying or getting a heart attack were thus disconfirmed.

Physical Exercise tasks (Wells, 1997)

Rationale: As the client used to avoid strenuous activities so his heartbeat would remain stable, physical exercise was done to disconfirm beliefs. Procedure: The task was introduced by making the client run up and down the stairs outside the session room where the environment was congested. The client repeatedly stopped in between as he thought that he would have a heart attack but he was made to do it for another minute. He checked his heartbeat and pulse from time to time but he was explained by the therapist how it is least likely to have a heart attack just on the basis of the present symptoms. Outcome: At the end he was convinced that he would not die and nothing would happen to him rather his symptoms had many other reasons.

Homework given: To continue doing some physical exercise and record the times he felt the symptoms but nothing further happened.

Session No.6 Time of session: 45 minutes

Session Agenda

Verbal Reattribution (Education about adrenaline rush), Decreasing avoidance (Using metaphors)

Homework review: The client did some physical activity which he reported during the session. The activities were utilized to disconfirm the client’s beliefs.

Techniques

Education about adrenaline rush (Wells, 1997)

Rationale: To educate the client regarding the multiple factors that may be attributed for his physical symptoms. To make him reattribute his symptoms to other, more relevant and plausible factors. Procedure: The client was told about the adrenaline rush in which there is increased hormonal flow when the individual gets excited. In addition, he was also told why heart rate increases during stress and how one could not get faint when the heart was beating faster. He was also given counterevidence from his own situations and then related with the empirical basis for more conceptual clarity. Outcome: The research based evidence proved to be a significant factor which reduced the client’s intensity of beliefs.

Decreasing avoidance behaviors (Wells, 1997)

Rationale: To make the client realize the consequences of his avoidance behaviors and how they were helping in strengthening the client’s beliefs. Procedure: The client was given multiple examples, analogies and metaphors which suggested that people who tend to avoid certain circumstances end up in a cycle where they are never exposed to counter evidences. The prophecy keeps on fulfilling itself rather than the disconfirmation of his/her belief. Outcome: He understood the irony in those examples and realized that until he would quit his avoidance behaviors he will never know what happens in those situations.

Homework given: The client was asked to restrict his avoidance behaviors such as drinking water, checking heartbeat, asking someone to check blood pressure rather stay in the situation and observe what happens.

Session No.7 Time of session: 45 minutes

Session Agenda

Verbal Reattribution (Questioning the evidence/counter evidence and questioning the mechanism)

Homework review: The client was asked about the times he felt the symptoms and what other factors were responsible in causing them. He reported that many times he felt the symptoms after eating food or climbing the stairs or when he was watching a stressful video. His own observations helped in shaking his beliefs.

Techniques

Questioning the evidence (Verbal Reattribution) (Wells, 1997)

Rationale: To make the client identify evidence and counter evidence of thought in order to disconfirm his beliefs. Procedure: The client was asked to write down the evidences he had that a panic attack would occur or that he would die because of his symptoms. He listed down his symptoms that made him think that he had a heart condition and it may prove fatal. On the other hand he listed down counter evidences for all the past times he experienced a panic attack but nothing happened and also about future events. Outcome: It was evident from the list that there was less evidence about a panic attack to occur or an accident to happen. This made the client realized that the probability of a panic attack to occur was majorly in his head rather than a fact.

Questioning the mechanism (Wells, 1997)

Rationale: To educate the client and bring into awareness the actual mechanisms of his fears and the discrepancy between actual and perceived threat. Procedure: He was first inquired if he knew how heart attack or fatal diseases were acquired and what mechanisms were operative in these conditions. After his reporting, he was briefed about the actual processes that were involved in making an individual prone towards heart conditions or medical diseases (genetic factors, dietary habits, abnormal blood tests etc.). Outcome: The technique was helpful in educating the client as he was eager to know the true reasons of such diseases and felt relieved that he had none.

Coping Cards

Rationale: To make the client give positive self-instructions and us them in the time of anxiety. Procedure: The client was given 5” by 5” cards on which coping statements such as ‘I am OK’,’ I am physically fit’, ‘I can handle the symptoms’, ‘The symptoms may be due to some other reasons’ were written. He was asked to keep the cards with him or attach near his working table so that he can use them whenever he experienced his symptoms. Outcome: The cards helped in reminding the techniques he had learnt in therapy and giving positive feedback to himself. They also helped the client to tackle anxious situation by staying in them rather than avoiding.

Homework given: He was asked to work on his cognitions whenever he thoughts about his symptoms or future panic attacks. He was asked to analyze evidences in his mind and disconfirm his beliefs by the techniques learnt during session. Moreover the coping cards were also given to practice when he faced stressful situations.

Session No.8 Time of session: 45 minutes

Session Agenda

Relapse prevention, therapy blueprint, post-assessment

Homework review: The client reported that he used the strategies that were taught to him and they were helpful in subsiding the symptoms. Coping strategies were employed by the client by memorizing and using them during strenuous activity.

Techniques

Relapse Prevention and Therapy Blueprint

Rationale: To aid the client in future situations, in case of any relapse. Procedure: After the client was gone through all the techniques and he had practiced them at home, he was again explained all the techniques in one session and how it had helped him in dealing with the symptoms. He was given a therapy blueprint which summarized the major techniques done, situations in which that technique could be applied and its procedure.

Post-assessment

Visual Analogue

Table 6: Pre and Post-treatment Ratings of the Symptoms According to the Client

Symptoms	Pre-treatment Ratings (0-10)	Post-treatment Rating (0-10)
Increased Heart rate, sweating, dizziness, breathlessness, numbness	10	3
Fear of having a heart attack	9	3
Fear of losing control	9	2
Fear of dying	9	2
Fear of having a panic attack in the future.	9	4

Panic Rating Scale

Table 7: Pre and Post assessment of the Panic Rating Scale

Item #	Statement	Pre-Treatment Rating	Post-Treatment Rating
1	Number of panic attacks in the last week	10	2
2	Frequency of avoidance behaviors	7-8 times	2-3 times
3	Average rating of coping strategies	60% on average	2/8 on average
4	Average rating of beliefs on anxious thoughts	45% on average	20% on average

Outcome of therapy

There was a decline in client’s symptoms as assessed by the pre and post assessment. He reported that he was feeling better and his panic attacks were greatly reduced. He utilized the technique taught during therapy which helped him distinctly.

Limitations and Suggestions

The client had to leave for Dubai after his 8^th session hence more follow-up sessions could not be conducted. He was suggested to consult a psychologist for a follow-up session.

References;

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Revised
Bouton, M. E., Mineka, S., & Barlow, D. H. (2001). A modern learning theory perspective on the etiology of panic disorder. Psychological review, 108(1), 4.
Clark DM. A cognitive approach to panic. Behav Res Ther 1986; 24 :461–70.
Goldstein, A. J., & Chambless, D. L. (1978). A reanalysis of agoraphobia. Behavior Therapy, 9(1), 47-59.
Wells, A. and Papageorgiou, C. (2004). Depressive Rumination: Nature, Theory and Treatment. UK: John Wiley & Sons, Ltd.