Often, when we are presented with a case it can be difficult to find a way forward. To aid clinical decisions, it is sometimes necessary to break down the decision making process into stages. The problem based learning task below does just that. Here I was given a case study and we methodically worked through the problem to get to a solution.
Reena fears that she is experiencing the precursors to a heart attack. Reena avoids going to the gym, or out of the house alone, other than to work. Reena carries out safety behaviours whilst driving. Her GP feels that physical symptoms are due to panic attacks and as such has recommended that Reena seek IAPT support. She has been assigned a PWP trainee which she is concerned about. She presents with mild depression and moderate anxiety symptoms.
Identify what you already know to work toward resolving the problem
- Heart palpitations, racing and pounding are all symptoms of panic disorder (DSM-5, 2013)
- Physical exertion (i.e. exercising at the gym) can bring on symptoms similar to those experienced when anxious or panicking
- Avoidance of situations which may increase physical symptoms is common in clients who suffer from panic disorder (Richards & Whyte, 2011)
- Seeking reassurance is common when facing an anxiety provoking situation
- Reena has a supportive friend who she listens to, who may be able to support her in treatment if needed
- It is a GP’s responsibility to investigate and ascertain whether the client’s heart is sound; a PWP, qualified or otherwise, is not able to make judgements regarding this
- The recommended medications for panic disorder are SSRI and TCA antidepressants but psychotherapy should be he first port of call (NICE, 2011)
Identify what you need to know in order to work towards resolving the problems.
I would want to do a full assessment including:
- Assessing risk
- client’s history including triggers and previous incidences
- how long symptoms have occurred
- how quickly they peak and subside
- nature of thoughts during palpitations
- thoughts, emotions, physical sensations and behaviours during last instance of panic and whether this is typical
- whether she worries about other health difficulties to assess for health anxiety
- what thoughts go through her mind before going to go out to assess for agoraphobia
- client’s goals and barriers to working towards those goals
- the client’s attitude to starting to go to the gym, and going out alone again
I would also want a discussion with GP to understand extent of the investigations he has made, and also to collect a brief history to see if illness anxiety disorder could be evident
How and where you can access new information to lead towards the resolution of problems
- Discussion with client
- Discussion with GP
- Mobile use when driving https://www.gov.uk/using-mobile-phones-when-driving-the-law
Treatment plan
- Phone work initially if she felt unable to leave home
- Full assessment
- Psycho-education about the qualifications of PWP trainee and what they are trained for, education about tendency for catastrophisation, hyper-vigilance, avoidance and safety behaviours
- Graded exposure to gym / going out alone / driving without safety behaviour
- Behavioural Experiments if assessment indicated that self-monitoring or avoidance of gym was due to fear of symptoms
- Cognitive Restructuring of catastrophic thoughts if detailed assessment indicated this would be necessary
- Give educational material to housemate if permission given
Signposting
- Education about law regarding mobile use while driving
