Socio Demographic Details

Name: -Mr K.K.

Date of Birth: 26/11/1988

Age: - 29 years

Sex: - Male

Education: - B.Pharm.

Occupation: Medical representative

Marital Status: - Married

Religion: -Hindu

Family Type: - Joint Family

Languages known: - Gujarati (mother tongue) English & Hindi.

Social-economic Status: - Medium SES

Domicile: - Urban

Source of Referral: Civil Hospital, Gandhinagar

Informants: Self, Mother and wife

Reliability & Adequacy: - Information given was reliable and adequate

Chief Complaints:

Experience of extreme fear of losing control

Frequent sweating, shaking hands & legs, increased heart rate 6 years

Excessive worry about having another episode

Involuntary muscular spasms in throat

Decreased confidence in daily activities 4 years

Total Duration: 6 years

Mode of Onset: - Insidious

Course of Illness: - Episodic

Progress: -Static
Precipitation factor: Witnessing a road accident

History of present illness:-

The patient was asymptomatic until October 2011. As reported by the patient while he was
driving his bike to reach work in the morning he witnesses a terrible accident where a truck
and another bike collided with each other and the bike rider was dead on the spot. After
witnessing this accident the patient went to his office and after sometime he started
experiencing intense fear along with symptoms like eyes watering, choking feeling in the
throat, chest pain, excessive sweating and breathlessness. He started to shout for help as he
thought he is having a heart attack. His colleagues immediately sought medical help and he
was brought to an emergency department of the nearby hospital. After preliminary check-up
the doctors assured him that he is fine and no organic cause was elicited in the examinations.
He came home and took a leave for a week. He felt better and forgot the accident and the
panic episode too.
He was asymptomatic till next 3 months. However, after 3 months he experienced the similar
episode of debilitating fear that he is losing control and he might die along with associated
physical arousal after a small argument with his father. He felt well after taking rest for a
while and was not very worried later too. But he started to experience these intense panic
experiences more frequently after a gap of two months without any apparent precipitating
factor. These episodes of panic started to arise while he was driving his bike, or when he was
in the cabin at work or when he visited different physician’s clinics as a part of his job. Once
he had such an episode of extreme anxiety and breathlessness inside the clinic of a
dermatologist. This clinician understood the symptoms and immediately referred the patient
to a psychiatrist in Ahmadabad.
The patient visited the psychiatrist and started taking medication for these episodes of panic.
The frequency of these episodes slowly decreased and he was completely symptom-free till
2013. The patient has stopped taking medicines in December, 2012 as he was feeling well
and he had developed some side effects because of the medication.
But in April 2013, he again started having these feelings of choking and discomfort. Tough
the intensity of fear was less in these episodes they started coming more frequently. He also
developed a symptom of involuntary spasm in his throat muscles which created difficulty for
him while speaking. The patient along with these symptoms started feeling anxious many
times about his health and feared that he might die due to extreme fear. He frequently feared
that he might have a heart attack or epileptic seizures which might lead to his death whenever
he has these anxiety attacks. He started avoiding driving his bike and chose to travel by
public transport for his job. Also, he started feeling sad and lost interest in pleasurable
activities. He felt tired most of the times and had constant negative thoughts and ruminations
regarding his future, health and family. The tics in the throat increased whenever he had to
speak in public or sale his products and it further decreased his confidence. He feared that
due to these spasms his jaw might dislocate or he might acquire some serious illness .His
work productivity decreased. He felt that he is becoming a failure and compared himself with
his other colleagues and their professional growth and increments. He started being socially
withdrawn and avoided talking to even his family members. Due to the fear of having more
side effects he did not seek any medical help for his on-going problems. These problems
continue till date in varying intensity and frequency.
Currently the patient’s wife him brought the patient to civil hospital Gandhinagar as his mood
continued to be sad and he was not eating anything for last 2 days.
In his biological functioning, sleep was reported to be disturbed due to repetitive
anxiousness and worry. He gets up because of these thoughts many times during the night
and is unable to go back to sleep after some time. Appetite and sexual interests are decreased.
He has lost 5 to 6 kilograms in last 1 year.

Personal care is well maintained.

In role functioning, he carries out his day to day activities with much effort than earlier and
undergoes increased fatigue and sad moods, especially during the evening time.

Negative history

No history suggestive of the following:

 Loss of memory, identity, wandering and stupor

 Intrusive memories or flash backs
 Any irrational and excessive fears of specific objects or situations
  Suicidal ideation
 Repetitive and intrusive thoughts and behavior that are uncontrollable
 False unshakable beliefs that are out of keeping with cultural and educational
background
 Perceptual disturbances
 Substance abuse
 Seizures, head injury and high grade fever resulting in altered consciousness
 Intellectual disability

Past medical and psychiatric treatment history:

The patient was under a treatment of a private psychiatrist 4 years ago but discontinued the
treatment after 7 months.

Family history

28 years 29 years 25 years

The patient lives in a joint family along with his parents, wife and a 2 year old son.
Consanguinity between the parents was not reported. There was no history of mental illness
in the family. The patient’s sister is 4 years younger to him. She is married and lives in
Ahmedabad. The patient’s father is a retired teacher and his mother was a homemaker. The
patient and his family have no big concerns about finances as the patient earns well and his
father also receives a pension.

The family is closely bonded. They all support each other through all the difficulties. The
patient reported that he does not talk much with his father and is emotionally closer to his
mother. He feels distant from his father as he was the one because of whom he could not
pursue his desired career and could not marry the girl he loved. The patient reported that his
wife also is very caring and wants the patient to get well soon.

Personal history

Birth & Developmental history:

The patient was a full-term normal delivery baby. Birth cry was present. Developmental
milestones were age appropriate.

Home atmosphere in childhood:-

Patient’s home environment was not very congenial and he reports witnessing frequent
quarrels between his grandparent and his mother where many time his mother was a victim of
domestic violence. He had close bond with his mother and sister. He recalls receiving harsh
punishment and scolding by his father. No evident disorder or issue during childhood or
adolescence was reported.

Scholastic history & extracurricular history:

The patient was an above average student in studies. He participated in many sports and
extracurricular activities like acting, painting and story writing. In fact the patient wanted to
pursue performing arts as his career but was discouraged by his father because this field did
not guarantee any financial safety. He chose to do Diploma in Pharmaceuticals and then did
his Bachelor’s degree in the same field.

Occupational History:
After completing his B.Pharm, the patient joined as a Medical representative in Sandoz
Pharmaceuticals. He has been working there since last 5 years. He likes his job and is
satisfied with it. However recently due some psychological difficulties he has been less
productive than before at his work.

Marital and Sexual history:

The patient reported that he was in love with a girl and wanted to marry her but his father
opposed to this inter-caste marriage and since then the patient became distant from his father.
He had hard time in getting over this break-up and after many requests by his mother he
finally agreed to get married in an arranged manner. The patient got married 3 and half years
ago and loves and cares for his wife. Both of them enjoy healthy marital relationship.

The patient has had monogamous sexual relationship with his wife and no problem were
reported in this area of their marriage.

Premorbid Personality

Interpersonal relationships with family members were good. He was always more attached to
his mother. In later years he became distant from his father due to some differences of
opinions. He had many friends and enjoyed their company. He was a sensitive person and
easily felt ashamed when criticized. He was prone to anxiety and irritability when under
stress. He was always responsible towards his family and daily work. He was very particular
about moral values, and also has strong belief in God.

MENTAL STATUS EXAMINATION

General appearance and behavior: Patient’s general appearance was well kempt and
tidy, appropriate to his age, hair well groomed and eye contact was fully maintained.

Attitude towards examiner

Patient was cooperative. Rapport was easily established.

Psychomotor Activity:

His psychomotor activity was normal.

Speech:

His speech was normal, spontaneous and the content was relevant, coherent and goal
directed.

Mood and Affect

Subjectively the mood was reported to be sad.

Subjective mood: “Man udas rehta hai. Hamesha dar sa lagta hai ki muze kucch ho jaega to
mere family ka kya hoga”

Objective mood: It was observed to be anxious and depressed. The mood was appropriate to
the situation and was congruent to thought.

Thought:

Form of thought:

No abnormalities were found.

Stream of Thought:

No abnormalities were found.

Content of thought: Content of thought suggested preoccupation with negative thoughts,

worry for his health, and ideas of helplessness.

Perception

No perceptual disturbances were found.

Cognitive functions:

Orientation:

Patient was well oriented to time, place and person.

Attention:

Attention was aroused and sustained as observed on Digit span backward and forward
test. His score was 5 on digit forward and 4 on digit backwards.
 Concentration:

The patient was able to concentrate on the tasks like serial subtraction of 7 from100 and
counting the months in reverse order and was not easily distractible.

Memory:

Remote memory was found to be intact as he could correctly give details about her
parent’s anniversary and her first school’s name.

Recent memory was found to be intact based on the correct answers given to the
questions like yesterday’s dinner, details of the last 3 episode of on her favorite TV show.

Immediate memory was also found to be intact as he correctly recalled all 3 unrelated
words he heard after a break of 1 minute.

General Intelligence:

General intelligence was found to be average, based on the simple tests of vocabulary,
general information, comprehension and calculation.

He has knowledge of synonym, antonyms, and proverbs and could describe objects with their
appropriate uses and functions.

He knew about the seasons of the year, geographical information of his state etc.

He could understand the situations presented to him on comprehension tests and was able
give appropriate answers to those like what to do when you miss a bus, or what to do when
your brother cuts his finger accidentally etc.

He could do simple calculations correctly based on addition, subtraction, multiplication and

division.

Abstract Thinking:

Abstraction ability was found to be at functional level based on the tests of similarities and
differences and at conceptual level for proverb testing.
He gave answers to table and chair, orange and apple based on their uses.

E.g. table is used for keeping things and chair is used for sitting. Both have many different
shapes; Orange has to be eaten by removing the peel and apple can be eaten just like that.
Orange is sour apple is sweet. On proverb testing he could give the intended meaning of
proverbs and not just the literal meaning.E.g. Haath Peele Karna- To get married

Ghar ki murgi Daal Barabar- Everyday things are boring even though they are special or
unique.

Judgment:
Personal, test and social judgment was intact as the patient showed ability to comprehend,
plan ahead and make decisions about the situations presented to him.
Patient’s personal judgement was intact as he could tell about what his plans are in the
future and how he is going to execute them.
His social and test judgment were found to be intact as his answers on the test questions
like what to do when you find that your neighbour’s house is on fire, or why and how do
we greet guests, showed understanding of the situation and selection of available resource
and accurate reasoning behind a particular action.

Insight

Insight is present and is at grade IV level. (Awareness of being sick, due to something
unknown in self)

Verbatim: “Muze pata hai problem mere sochne mai hai aur mei thik hone ki puri koshish
kar raha hu jisse mein apana future aur health ko theek kar sakta hu”

BASELINE ASSESSMENT

Tests administered and rationale

1) Hamilton Anxiety Rating Scale (HAM-A) to assess the level of anxiety.

2) WHO Quality of Life Scale to quantify the perceived quality of life of the patient.

Test findings
 1) On Hamilton Anxiety Scale the patient’s score was 29 indicating severe anxiety.
2) On the WHO Quality Of Life scale his global score was found to be 43 indicating
unsatisfactory quality of life as perceived by him.

Diagnostic formulation

Index patient K.K. 29 years old married male currently working as a medical
representative belonging to Hindu religion of middle socio-economic status living in a
joint family resides at Gandhinagar was referred for psychotherapy with the chief
complaints of Experience of extreme panic and fear of losing control, frequent sweating,
palpitation and increased heart rate, excessive worrying and ruminations, Involuntary
muscular spasms in throat and decreased confidence in daily activities since last 6 years
increased since last 2 days. Mental status findings show anxious and depressed mood,
content of thought included preoccupation with negative thoughts, worry for his health
and ideas of helplessness with intact cognitive function and insight was found to be at
grade IV which means awareness of being sick due to something unknown within self.

On psychological assessment, findings suggested presence of severe anxiety and impaired

quality of life.

Impression

Based upon the case history, mental status examination and assessment conducted the
patients profile gives an impression of F 41 panic Disorder.

Intervention process

Initial sessions
The sessions 1-3 were mostly used for detailed case history taking and psychological
assessment. These sessions were utilised to build a strong rapport with the patient which
increased the trust of the patient in the therapist. The patient did not talk much in the
beginning and answered only when asked; but gradually he started to open up and initiate
conversations. He was encouraged to converse more about himself. The patient started being
spontaneous and started talking about his anxiety and other feelings.
Later the patient and his family members were psycho-educated about his illness using the
stress-vulnerability model. Importance of pharmacological management to lower his anxiety
level was explained to him. Everyday examples were used to explain this to him. They were
also informed in detail about the development and consequences of the disorder and were
given information regarding the probable course, importance and outcomes of psychotherapy.
The patient was motivated to keep up medical compliance as an adjunct to psychotherapy. He
was given opportunity to ask questions and these questions were answered with suitable
examples.

In the sessions 4 to 6 detailed conversation was done with the patient to understand how the
panic attacks developed. He was supported and encouraged to ventilate his feelings
associated with the traumatic experience he had during these episodes. The patient was
gently helped throughout the recollection of these painful events and he was reassured that he
is safe. He was asked whether he would like to overcome his fears and the therapist assured
that he can get better. The patient was made aware about the crippling experience of anxiety
associated with having another panic attack and he was told that he is not alone and many
people do suffer from such extreme fears. The patient was reassured and explained that how
his fears of having another attack are natural responses but currently they are unreasonable
and exceed the normal level. He was made aware about how panic attack is a “false alarm”
for danger, how it is not medically dangerous, it is not a sign of weakness and craziness and
though it is common, it includes unnecessary avoidance of social situations. He was also
explained about how exposure to situations he generally avoids will tend to desensitize his
learned fear, boost his confidence, and make him feel safer by creating new corrective
positive experiences. This reassurance increased the patient’s motivation to reduce his
anxiety.

The patient was taught deep breathing exercises to lower his current anxiety and autonomic
arousal. Breathing from stomach (diaphragmatic breathing) was taught to him with correct
relaxed postures, he was asked to observe the relaxed feelings in the body as he exhales in
form of relaxed shoulder blades, limp extremities and light feelings in the chest. The patient
immediately felt better after this exercise and it was observed through change in rate of his
speech and calm posture.
The technique of behavioural activation was introduced to the patient. He was asked to
utilize his free time in constructive way like casually chatting with his family members, going
out with his friends after work, doing a light aerobic activity, watching funny cartoon shows
and videos etc. routinely as they were pleasing activities for him. He was also instructed to
take routine small breaks from his work and develop casual friendly relations with his
colleagues. These activities in themselves were the reinforcement for the patient. After
routinely incorporating them in daily life he felt more enthusiastic about work and spending
time with the family members. Also, relaxing activities were made a daily routine for him.

After the initial sessions the patient’s motivation to change increased. He was committed to
the process of therapy and was eager to learn new things. He took small steps in reducing his
avoidance behaviours.

Middle Sessions

Once the patient was actively motivated for the therapy and he was able to control his anxiety
through deep breathing exercises the therapy was shifted to exposure and response
prevention technique. A cognitive-behavioral conceptualization of how fear of having
another panic attack is maintained by a “cycle” of unwarranted anxiety and avoidance of
situations that are associated with panic attack and how this avoidance stops positive,
corrective experiences (E.g. avoiding driving bike, travelling alone etc.) was explained. How
treatment breaks this cycle by encouraging these corrective experiences was discussed with
him. The role of how exposure to the avoided stimulus situations serves as an opportunity to
desensitize learned fear, build confidence, and feel safer by building a new account of
successful experiences was explained. Then therapy was shifted to identifying his core
beliefs through self-talk. These beliefs were irrational and self-defeating. They included
statements like, “I am incompetent”, “I will die in one of the panic attacks”, “Others are
better than me”, “I am helpless”. Cognitive distortions like all-or-none thinking,
magnification, catastrophisation and overgeneralisation were also identified. These were the
major reasons for overwhelming anxiety and fear, preoccupation with the thoughts of dying,
and overall lack of self-confidence. The relationship between core beliefs and negative
automatic thoughts, relationship between thoughts, emotions and behaviour were explained
with examples. These identified self-defeating statements were disputed and the patient was
asked to check the validity of these statements through help of Socratic questioning and
behavioural experiments by evaluating past and present experiences. Cognitive restructuring
was done by changing his irrational beliefs and negative self-talk with positive, reality-
based cognitive messages that enhance self- confidence and increase adaptive action. He was
also taught assertiveness through role plays and modelled behavioural rehearsals in order to
increase his confidence where he was taught to say no, ask for help and engage in fulfilling
social interaction. He was also taught progressive muscle relaxation to gain increased control
over physiological arousal that happens in panic attack accompanied by crippling anxiety.
The patient was assisted in construction of a hierarchy of anxiety-producing situations
associated with panic attacks as well as a list of rewards was made for successful completion
of the task in hierarchy. The patient himself and family members were taught strategies to
facilitate the patient’s exposure or approach behavior towards avoided situations, including
positive reinforcement, modelling, shaping, extinction, following through, and consistency.
After the patient showed readiness to actually and gradually face the avoided situations and
he had learned the calming strategies properly, he was helped to participate in gradual
repeated exposure to avoided situations. In the beginning this was done with therapist being a
model to demonstrate correct approach behaviour and he was provided reinforcement after
successfully getting exposed to the feared situations. Finally the patient was helped to
gradually face the fear unassisted.
For the involuntary spasm occurring in his throat muscles he was taught to be more aware
and monitor when these symptoms worsen. A clear temporal relationship was established
between increased verbal tics and a psychosocial stressor. Thus the patient was taught self-
monitoring techniques where he was asked to be aware about situational cues that trigger
anxiety and tics. He was asked to keep a record of his anxieties, its frequency, intensity and
impairment it produced. The avoidance behaviours and catastrophic appraisal of situations
like taking leave from work, avoiding going out alone, staying in familiar places, were listed
and the patient was asked to apply relaxation techniques whenever he was aware of a anxiety
provoking cue. To counter the verbal tics he was asked to use the technique of paradoxical
intention, where he was asked to make exaggerated movements and voices through his
thoracic muscles in order to reduce the tics by being acutely aware of the relationship
between anxiety and tics. This technique helped the patient very much and he could control
these tics in a span of 2 weeks.
At the end of the middle phase of therapy the patient had established moderated control over
his anxiety and was applying the strategies on daily basis.

Terminal Sessions:
After the patient has achieved significant control over his anxiety and preoccupation with
having another panic attack, he was taught distraction techniques that helped him to shift his
focus from his worries and create newer associations. His efforts to maintain his well-being
were generously appreciated and positive feedback was provided for his success. He was
evaluated repeatedly for using the newly learned coping skills and control over anxiety was
established.
The patient was helped to resolve pent up emotion regarding his regrets of choosing a
disliked career and failure in his love life and anger towards his father. He was asked to
verbalise his grief and anger through expressive technique of psychodrama where he was
encouraged to enact on the difficult situations in his life. Role reversal technique was used to
help him resolve his issues with his father and was taught mindfulness based meditative
practices in which he was asked to accept his past gracefully without any regrets and practice
gratitude and forgiveness activities daily.
In the final sessions, the patient was helped to identify learned coping strategies and was
asked to use them routinely. Rehearsal of management of future situations or circumstances
in which lapses could occur was done with the patient. He was instructed to routinely use
strategies learned in therapy (e.g., continued exposure to previously feared external or
internal cues that arise) to prevent relapse which might push the patient into critical self-
conscious fears and avoidance patterns.
Periodic maintenance sessions were also scheduled and the patient was reassured that the
therapist will be available over phone and in person when required.
The patient’s confidence increased and his symptoms were lessoned significantly at the end
of the terminal session. His physical complains were almost eliminated. His productivity at
work improved and quality of life was enhanced significantly.

Outcome:
The patient was reassessed on the Hamilton Anxiety rating scale and WHO Quality of life
scale at the end of therapy process. His scores on both scales were found to be 11 and 78
which show significant reduction in anxiety and increase in the perceived quality of life.
Future plans:
The patient is expected to continue his progress and he is also expected to apply the skills he
has learned on regular basis to stay symptoms free.