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Health and social care (therapy in contemporary care)
Assessment of Mr. James condition-
Mr. James is showing signs and symptoms of panic disorder with agoraphobia. There are high incidence and prevalence of panic disorder with agoraphobia which is usually associated with increased risk of psychiatric morbidity in the form of depression; suicide; alcohol/substance abuse; minor tranquilizer addiction; generalized anxiety disorder; social, simple, and sexual phobias; and impaired social, marital, and vocational functioning (Markowitz, Weissman, Ouellette, Lish & Klerman, 1989). Such patients with panic disorder usually experience sudden and repeated attacks of severe anxiety or fear which can last up to several minutes. The symptoms can be so strong and may resemble to heart attack (Hatfield R.C., 2014). Mr,. James had similar strong feeling of heart attack when he experienced the panic attack. These attacks can occur at anytime, anywhere and therefor such patients tend to worry so much about such panic episodes that it affects their normal social life and can lead to isolation (Hatfield R.C., 2014). Similar way, Mr. James is getting isolated from the society due to fear of having panic attack in public place.
Psychological disorders are usually run in a family. Patients usually have one or more relatives who are having any kind of psychiatric disorder (Hatfield R.C., 2014). In a similar way, patient of panic disorder with agoraphobia usually have someone in family who is having or had such disorder. In case of Mr, James, the family history shows that his mother and his ant had this disorder. Even his ant was isolated for 7 years because of this condition. It’s clear from his family history that genetic is main factor for developing this condition. Other important aspect is surrounding environment. The surrounding environment has both positive and negative impact on person’s mental status (Hatfield R.C., 2014). In case of Mr. James, his wife is also experiencing psychiatric disorder i.e. depression and is on SSRI. Even his all 3 sons are also experiencing sort of psychological disturbance. The stress originated from such environment is another pre-disposing factor for developing PD with agoraphobia in Mr. Jame.
Epidemiology of Panic disorder with Agoraphobia-
Almost 1.5% to 3.7% of the general population is affected by Panic disorder (PD). PD is usually associated with significant impairment and disability. Individuals with PD often initially present to the primary care setting due to the physical characteristics of the disorder (e.g., chest pain, dizziness, shortness of breath). Prevalence of PD in primary care is much higher than in the general population, with a reported median prevalence of 4% to 6%. Despite this high frequency of PD in the primary care setting, the disorder continues to be poorly recognized and often undertreated, which can impact the course of illness (Francis, J. L., 2007). Agoraphobia is a type of anxiety where patient develops a fear of being caught in places or situations from which escape might be difficult or embarrassing, or in which help may not be available in the event of having a panic attack (APA 2000). It is usually associated with panic disorder and in the general population about one quarter of people suffering from panic disorder also develops agoraphobia but this proportion is much higher in the clinical samples (Kessler R.C., 2006).The presence of agoraphobia is associated with increased severity and worse outcomes (Kessler R.C., 2006).
Recent guidelines from the National Institute for Health and Clinical Excellence recommend three types of intervention in the care of individuals with panic disorder, any of which should be offered promptly, taking into account the preference of the patient (NICE 2011). According to the NICE guidelines, the interventions that have evidence for the longest duration of effect, in descending order, are psychological therapy, pharmacological therapy (antidepressant medication) and self-help.
Psychological therapies which may be useful for Mr. James-
There are multiple psychotherapies which can be used to treat Mr. James. Below are few of them-
1. Cognitive behaviour therapy (CBT)-
NICE guidelines (2011) recommend the use of cognitive behaviour therapy (CBT) for the treatment of PD with agoraphobia. In case of Mr. James, CBT need to be
initiated at the earliest to avoid further complications. Usually, CBT for panic disorder is administered according to the manuals of Clark 1986 and Barlow 2000. Its main components are represented by psychoeducation, breathing retraining, Progressive muscle relaxation (PMR), cognitive restructuring, behavioural experiments, interceptive exposure and in vivo exposure. In case of Mr. Jame, he needs timely session of CBT and regular monitoring of symptoms.
2. Psychoeducation -
In psychoeducation, therapist provides brief information about their psychological disease to the patient. In this context, therapist need to explain to patients that their symptoms can be interpreted in the light of a certain cause-effect model, according to a more general theoretical framework that can vary across the different psychological approaches (Pompoli A. et. al., 2016). Here in this context, therapist need to explain the role of family history to Mr. James and need to help him to understand the condition and also need to ask for his take-part in the treatment of PD.
3. Supportive psychotherapy-
This type of therapy focuses on the direct measures to ameliorate symptoms and maintain, restore or improve self-esteem, ego function and adaptive skills (Winston A., 2004). Although different techniques can be used like encouragement, rationalising and reframing, anticipatory guidance, etc. The therapeutic alliance represents the most important element of this therapy (Winston A., 2004). Rogerian client-centred psychotherapy is probably the most representative example of supportive psychotherapy (Rogers C.R., 1980). In this approach, within the context of a warm, empathic and nondirective therapeutic relationship clients are led to become aware of their true feelings and to fully accept themselves as they are, including imperfections and dysfunctions (Pompoli A. et. al., 2016). Here supportive counselling sessions will be important to help Mr. James to overcome the phobia associated with the PD attack.
4. Physiological therapies-
Physiological therapies are represented by a set of different possible treatments that use some kind of physical training like breathing retraining, relaxation techniques, biofeedback etc. (Pompoli A. et. al., 2016). These manly focuses on controlling the manifestation associated with anxiety. It helps patient to improve mental status through physical activities (Pompoli A. et. al., 2016). Breathing retraining and relaxation techniques are the most studied and used therapies among the physiological therapies which are proposed for the treatment of panic disorder. In case of the breathing retraining, different strategies have been proposed by various psychologists, although most manuals and studies describe instructions in abdominal breathing as their central technique (Meuret A.E. et.al. 2012). Progressive muscle relaxation (PMR), as formalised by Bernstein and Borkovec (Bernstein D.A. & Borkovec T.D., 1973), can be taught to panic patients in order to reduce general tension and achieve a body state that lowers the risk for stressors to elicit panic. The applied relaxation is a slightly different form of physiological therapy where in relaxation training and exposure are combined together for better effect (Ost L.G., 1987). Daily sessions of breathing techniques and applied relaxation session will help Mr. James to reduce the anxiety associated with PD