Abstract
Keywords
Anxiety disorders are among the most prevalent mental illnesses that affect a person’s functioning, productivity, and quality of life. 1 Panic disorder is characterized by recurring, unexpected acute panic episodes, along with associated anxiety about future attacks, leading to the development of phobic avoidance or any other alteration in behavior as a result of the attacks. 2 While medication-assisted treatment for panic disorder is effective, the potential side effects may make it difficult for patients to follow through on their treatment plans. Due to this, effective psychological interventions for panic disorder are crucial, as either a stand-alone treatment or as an adjunct to pharmacology. 3 Cognitive behavioral therapy (CBT) is the psychosocial intervention with most research backing it up. 4 In recent years, there has been a surge in the application of third-wave psychotherapy, and implementing mindfulness-based cognitive therapy (MBCT) has shown considerable improvement in panic attack symptoms.5,6,7,8 However, to the researcher’s knowledge, no study has used an integrated therapeutic application of CBT and MBCT.
We have described a case of panic disorder that has been successfully treated over 16 sessions using the core principles of CBT and MBCT. The principles have been adapted from the manuals cognitive therapy for anxiety disorders by David Clark and Aaron Beck, 9 and mindfulness-based cognitive therapy for depression by Segal et al. 10 The case study aims to familiarize mental health professionals with a modified approach that shows effectiveness in treating panic disorder.
Case Description
Ms. E.P., a 31-year-old married woman, suffered from a history of panic attacks that prominently involved symptoms such as shortness of breath, increased heart rate, heaviness in the chest, and fear of dying. Through the clinical interview, it was observed that the symptoms had an abrupt onset, an episodic course, and a deteriorating progress. The predisposing factor in the case of Ms. E.P. was her shy, reserved, and apprehensive persona. The precipitant was witnessing the sudden death of her paternal uncle due to a heart attack, and the factors that perpetuated the illness were her apprehensive personality, excessive sensitivity to body sensations, and low discomfort tolerance. Ms. E.P. has infrequently been on medication since the onset in 2013 until 2021. During her pregnancy, the medical reports and medication prescribed were lost and could not be procured for better clarity on previous treatment.
In June 2023, she visited the outpatient department (OPD) of the hospital with the chief complaints mentioned above, which had reoccurred since January 2023 after she suffered from a gastrointestinal infection. Ms. E. P. reported that frequent gastrointestinal infections manifested in the form of stomach aches, nausea, and heartburn. During one such incident of gastrointestinal infection in January, she suffered a panic attack after a gap of more than a year. The symptoms during the attack were shortness of breath, increased heart rate, dizziness, and a sense of heaviness in the chest. She reported that these symptoms lasted for 10–15 minutes, during which she was preoccupied by an overwhelming fear of dying from a heart attack. Ms. E. P. reported trying to control her physical symptoms by thinking of positive events in her life while having an attack. Post- attack, she stated being fearful of suffering from similar attacks, which restricted her daily routine for a few days. She also reported feeling demotivated to take any initiative and felt that her entire life would revolve around seeking treatment for her health issues.
Ms. E. P. stated that since January 2023, she has been undergoing significant distress due to her condition. She mentioned that these symptoms usually occurred when she was distressed due to certain stressors in her life or her physical health complaints. She reported being frequently caught up in a cycle of ruminative thoughts surrounding her health and the future of her child. She added that although she had a supportive husband, she reported feeling guilty about making him suffer due to her illness. She also mentioned being less productive at work and would avoid high-stress jobs to avoid the probability of a panic attack.
Ms. E. P. mentioned that she underwent a Upper gastrointestinal (UGI) scopy in April 2023 due to persistent gastrointestinal issues; the reports revealed the presence of a small hiatus hernia in the abdomen for which she has undergone the necessary treatment. When it came to her panic attack symptoms, she mentioned visiting her family physician for instant relief from her symptoms but was not aware of psychiatric treatment for her condition. After her recent attack in June 2023, she reported being referred to the OPD of the hospital and was put on medications, namely, antidepressants (Escitalopram) and sedatives (Clonazepam), along with psychotherapy.
Upon arrival at the OPD, a detailed clinical interview of the patient and her husband, who accompanied her for her treatment, was conducted. The presence of associated psychiatric disorders such as agoraphobia, generalized anxiety disorder, mood disorders, and baseline assessments were assessed (Table 1). The therapeutic plan was discussed with the patient. Before treatment initiation, she was asked to maintain a panic log, which included noting the day and date, the situational trigger that led to the panic attack, the severity of her anxiety symptoms on a subjective unit of distress 0-100, the associated physical sensation, and her interpretation of her physical sensations.
Outcome Measures Pre- and Posttreatment.
Method
The intervention protocol has been divided into three phases: the treatment’s initial, intermediate, and final phases.
The Initial Phase (Sessions 1–6)
Psychoeducation
Due to a lack of clear understanding of the nature of the illness, Ms. E.P. was psycho-educated in each session about the initiation and maintenance of panic attacks using the panic log book from the CBT manual for anxiety disorders. Based on her assessment scores and data from the panic log book, she was explained the relationship between her hypervigilance and physical sensations leading to catastrophizing beliefs and initiation of panic attack symptoms.
Ms. E.P. experienced cued panic attacks as a result of being hypervigilant towards internal bodily sensations. This hypervigilance led to catastrophic misinterpretations such as “I am going to die due to some physical complications” and “Controlling the bodily sensations is beyond my abilities, and I will never deal with it,” thus leading to a full-blown panic attack. Additionally, her premorbid personality reveals that she is reserved and apprehensive. Her apprehensive persona, coupled with cognitive distortion such as magnification and catastrophizing, tied her to worries about the future rather than living in the present moment, thus affecting her personal and professional domains. The sessions also involved providing information regarding the difference between symptoms of panic attacks and heart attacks with relevant reference material. Additionally, she was psycho-educated regarding medication adherence, and her apprehension surrounding medication consumption was addressed.
Panic Logbook
The subsequent sessions involved a re- view of the panic logbook. Taking an incident from the logbook, the associations between the interpretation of symptoms and increased physical sensations were depicted to let her independently identify her primary catastrophic misinterpretation. After the initial review, one more section was added to her log book, wherein she had to generate a less threatening explanation (if any) for her physical sensations. This was done to assess her reappraisal capacity. The panic log book was maintained throughout the sessions to keep a record of her symptoms.
Symptom Induction Exercises
These were introduced within sessions and as homework practices to challenge her beliefs regarding bodily sensations directly. The catastrophic misinterpretations were activated during the symptom induction exercise, and the link between the threat schema and symptom exaggeration was highlighted. The two symptom induction exercises used were breathing through a narrow straw for 2 minutes to experience shortness of breath leading to activation of threat schema, “I want to stop; I am feeling uncomfortable.” The second exercise was jogging for two minutes, leading to difficulties in breathing and increased heart rate and activation of the threat schema “I might suffer from a heart attack.” The symptom induction exercise was the first direct exposure to her feared symptoms and proved to be effective in reducing her catastrophic misinterpretations regarding bodily sensations.
Diaphragmatic Breathing
Although Ms. E.P. identified the link between her catastrophic thoughts and exacerbation of the symptoms, she still had episodes of panic attacks. For this purpose, diaphragmatic breathing was introduced to control physiological hyperarousal while she refrained from generating catastrophic misinterpretations. By the end of six sessions, the occurrence of full-blown panic attacks had relatively reduced. This paved the way for the introduction of MBCT.
Intermediate Phase (Sessions 7–13)
Introducing MBCT
Elements of MBCT were introduced to explain the importance of decentering from faulty appraisals of bodily sensations and fostering present-moment awareness. The well-known raisin exercise from MBCT was introduced as the first in-session exercise to facilitate present-moment awareness.
Body Scan
Body scan meditation was introduced in the next session as part of a home-based practice to bring awareness to each body part while being nonjudgmental. A body scan was conducted after a symptom induction exercise during subsequent sessions. The aim was to allow her to descend from her catastrophic misinterpretations about her induced bodily sensations and observe those sensations without forming any inferences.
Pleasant Experience Calendar
As noted in the case history, Ms. E.P. felt hopeless due to frequent panic attacks. An experience calendar was introduced and encouraged to be maintained to increase awareness of positive experiences in her everyday life. This proved to be one of the highly effective practices, according to the patient.
Three-minute Breathing Space (Daily, Thrice)
Ms. E.P. was introduced to 3-minute breathing space wherein she considered the breath an anchor to decenter from ruminations and be more present in the moment. In subsequent sessions, Ms. E.P. was invited to bring a difficult thought to her mind while using the breath as an anchor. She brought awareness to the unpleasant physical sensations and observed them with curiosity rather than reacting to them.
Thoughts Are Not Facts
Although the sessions implicitly signaled the message that our thoughts are not always facts, Ms. E.P. was explicitly educated on ways to relate to her negative, anxiety-provoking thoughts as mental events and not facts. The “behind the waterfall” metaphor from the MBCT manual was used for this purpose.
Relaxation Training
Considering Ms. E.P.’s anxious personality, Jacobsons’ Progressive Muscle Relaxation (JPMR) was introduced as a long-term home-based practice for general relaxation. This relaxation training was introduced with the objective of:
Learning to recognize tension in parts of the body. Learning to let tension go in specific muscles.
Final Phase (Sessions 14–16)
Relapse Prevention
By this time, sessions spanned over 2 weeks. The main focus was on reiterating Ms. E.P. to decenter from anxiety-provoking thoughts when the mind was in autopilot mode, and this was done using:
Daily Mindfulness Practice
Daily mindfulness techniques from the repertoire of techniques practiced were selected to promote awareness of thoughts, feelings, and emotions and to be non-judgmental.
Creating a coping toolkit:
The patient was psycho-educated regarding the specific measures to be taken in case of experiencing a partial or full-blown panic attack.
Outcome
By the end of 16 sessions, the frequency of panic attacks had depleted from one to two attacks every 2 weeks to not experiencing panic attacks in the last month. Ms. E.P. could realistically look at her bodily symptoms by observing them and accepting them rather than forming catastrophizing explanations.
The informant stated that her amount of reassurance seeking from others had significantly reduced.
She engaged in more pleasurable activities than before with her husband and daughter, as the pleasant experience calendar helped her recognize and value her everyday experiences.
Challenges and Hurdles
Ms. E.P. visited OPD after a recent episode of a panic attack. She was highly discouraged due to the recurrence of her symptoms; hence, during the initial sessions, the therapist had to focus on encouraging the patient to seek treatment. When the patient was found to be in the contemplation phase, the actual therapy work began.
While maintaining the panic logbook, Ms. E.P. initially faced difficulties noting the thoughts associated with the physical sensations. Instead, she jotted down her beliefs rather than her actual thoughts. This required frequent in-session practice using CBT’s cardinal question, “What was going through my mind?” to help her understand how to notice and write down her thoughts.
Encouraging Ms. E.P. for symptom induction exercises was also a challenge, especially during the first symptom induction session, as she feared having a panic attack. Hence, Socratic questioning was used to identify her beliefs regarding conducting the symptom induction exercise and necessary encouragement.
MBCT’s initial focus on observing one’s breath and bodily sensations was challenging as she would get distracted when certain intrusive thoughts crossed her mind. However, over time, Ms. E.P. successfully brought awareness to her physical sensations and observed them as they are rather than catastrophizing.
Limitations
A long-term follow-up could not be completed as the patient relocated for job purposes; however, a quick client review on voice call revealed stable progress since treatment.
A comparison with other traditional treatment protocols could enhance the study design; however, given that this work is a single-subject case study conducted in a therapeutic environment, providing such a comparison was not possible, thus limiting its generalizability. However, a potential direction for further research could involve a randomized controlled trial comparing one form of traditional psychotherapy with the integrated therapy protocol for the treatment of panic disorder to enhance its replicability.
Even within the context of the individual case, findings may not be directly applicable to another individual due to differences in personality, family conditions, and symptom presentation, requiring certain changes in the sequence or aspects of the treatment protocol.
Conclusion
The present case study depicts the efficacy of an integrated therapeutic approach using elements of CBT and MBCT in the treatment of panic disorder. The pre- and posttreatment ratings on rating scales, the therapist’s observation, and the patient’s feedback indicated that there was a significant improvement in Ms. E.P.’s condition. The sessions focused on changing catastrophic misinterpretations and developing an attitude of “acceptance.”
The treatment protocol incorporated an integrated therapeutic approach for the successful treatment of panic disorder. This integrated treatment protocol was chosen over traditional protocols based on the client’s symptom profile and personality. Using CBT facilitated providing in-session evidence that her panic attack symptoms are a result of catastrophic misinterpretations. This helped Ms. E.P. gain a sense of control over her symptoms and, in turn, enhanced her treatment motivation. Additionally, MBCT assisted in decentering from her negative thought cycle and served as a major tool for relapse prevention, allowing her to be more present and accepting of her thoughts rather than struggling with them.