Brief Culturally Adapted Cognitive Behavior Therapy (CBT) for Panic Attacks; A Case Study Muhammad Aslam Clinical Psychologist & CBT Therapist Recovery Clinic President Institute of Cognitive Behavior Therapy (ICBT) DEMOGRAPHICS • Name I.H • Age 35 Years • Sex Male • Education MBA • Marital Status Married • Children Nil • Siblings: 04 • Occupation Job in mobile company History He was working as a Services Manager at Mobotelecom Mobile. When a payment of thirty thousand dollars was mishandled, the company told him he would have to cover the amount personally. This situation caused him considerable stress, which was further exacerbated by his heavy workload. Another factor was that he was not having children, Which continued to perpetuate his problems.. Assessment Formal • Psychological testing (Hospital Anxiety and Depression Scale) Informal • Interview • History taking Symptoms • Fear of dying • Difficulty in • Palpitation concentration • Giddiness • Chest pain • Sweating • Stomach pain • Trembling • Gastric Problem • Irritation • Muscle tension • Depress • difficulty in breathing • Hot flashes or chills Session 1 Agenda • Education on Panic Attacks • Examples related to Anxiety • Hospital Anxiety and Depression Scale (HAD) • Literature on Deflate the Danger (coping with panic attacks) • Coping statements( This is not dangerous, this is just anxiety, there is no emergency, I can control this) • Home Assignment • Leaflet on Panic Attacks • Literature on Deflate Danger • Leaflet on Coping statements • Prepare for CBT Pre-testing Score Sr # for Pre testing Sr# for Pre testing Anxiety Anxiety items Depression Depression score items score 1 2 2 2 3 2 4 1 5 2 6 0 7 0 8 2 9 2 10 1 11 2 12 1 13 1 14 0 Total 18 Total 07 Session 2 Feedback & warm up Agreed to continue therapy Agenda Comparison of heart attack symptoms and panic attacks symptoms • Education on Panic Attacks • Relaxation Exercise • Thought Distraction Home Work • Relaxation Exercise • Thought Distraction • Leaflet on Coping statements Session 2 cont Comparison of heart attack symptoms and panic attack symptoms Heart Attack Symptoms Panic Attack Symptoms 1.Severe and continues pain in chest 1.In panic attacks first heart beat increases 2.Not more than three attacks 2.Every time person feels fear of death 3.There is no fear every time 3.Giddines is a panic attack symptom not heart attack symptoms 4.Heart patients can not run 4.In panic attacks person have negative thinking 5.Heart patients cannot live without heart medicines 5.After few minutes panic condition gets himself better 6.During heart attack cold sweating 6.In panic attacks person can walk 7.Heart patient can not walk during heart attack 7.Gastric problem is a panic attacks symptoms 8.Cold sweating is also symptom of panic attacks 10.Stomach, abdominal pain is a panic attacks symptoms Session 2 First Fear Negative Self Talk Second Fear My heart beat is increasing Emotional reaction to body symptoms Panic this will cause heart attack heart beat sweating , chest This is not getting better something pain constricted breathing Dangerous is going to happen to me Body symptoms rapid heart beat sweating , chest pain constricted breathing Positive Self Talk or coping statement This is just anxiety , My illness was severe before that Detachment Flowing Coping but nothing happened now nothing will happen with bodily Symptom I can handle these symptoms Nothing wrong will happen with me This is not dangerous Session 3 Feedback & Warm Up He reported panic four times at night over the last week. According to him, he is feeling 30% better. Agenda, Detection of Mood and Thought Incident Thoughts Mood/Emotions Physical Symptoms Behavior He woke up due to 1. Now the heartbeat Anxious/fear/worry Palpitation/weakness Breathing exercise sleep disturbance at will increase, which will night. cause a heart attack. 2.This is not getting Fear/worried Palpitation/restlessness Cry, laid down on bed better. /worry 3. This will get better Relax/ confident Decreased palpitation Slept once again, now, nothing to worry about. Home Assignment Detection of Mood and Thoughts Leaflet on Mood and Thoughts Client Home Work Diary ( Detection Of Mood and Thoughts) Incident Thoughts Mood/Emotions Physical Behavior Symptoms His wife said that you 1. My condition is Anxious/worry Palpitation/ warm body Breathing exercise must find a job getting upset. immediately. 2. Why am I unable to Worry Laziness/warm body Start thinking find a job? 3. If my body gets Satisfy No Physical Symptom Talked with wife warm, let it get warm; nothing will happen to me. 4. I will get a job; no Relax No Physical Symptom Continued to talk need to worry. with wife Client Home Work Diary ( Detection Of Mood and Thoughts Incident Thoughts Mood/Emotions Physical Symptoms Behavior I woke up at 3 o'clock and 1. Now heartbeat will Anxious/Fear Palpitation/ warm Reminded went to the washroom increase, which will cause a body session talk and laid down on the heart attack. bed. 2. Then I thought there is Relax/satisfied Palpitation gets Checked pulse nothing to worry about; it better. & Again laid would be better soon. down on bed. When I woke up in the 1. 1. Something unknown is Fear/anxious Palpitation Checked pulse morning. happening to me. increased 2. Now heartbeat will Fear/anxious Palpitation Tried to relax increase, which will cause a increased and drink heart attack. water. 3. Soon, it will get better. Relax Palpitation gets Busy in work normal. Session 4 Feedback & warm up 50 % improvement in symptoms. Agenda, Cognitive Errors & Connection between Thoughts and Physical symptoms • Development of Panic Attacks • Phase 1 Circumstances (Internal or external) Traffic rush  Phase 2 slight increase in unusual or unpleasant body symptoms (i.e. palpitation, breathing difficulty, or warm body, Sweating .etc.)  Phase 3 Internalization Internalization symptoms makes them more noticeable And easily magnified) (i.e. palpitation, breathing difficulty, or warm body, Sweating .etc.)  Phase 4 Catastrophic Interpretation (Telling yourself the symptoms are dangerous, e.g. I'll suffocate. My heartbeat is increasing, which will cause a heart attack. Home Assignment This is not getting better. Something dangerous is going to happen to me. • Thought Diary #1  • Leaflet on Cognitive Errors Phase 5 Panic • Physical Exercise Session 4 Client Home Work Connection between Thoughts and Physical symptoms Catastrophic thoughts Body Symptoms 1.Now heart beat is increasing it will cause heart attack Palpitation, warm Body 2. This is not getting better Warm body 3. Soon this will get better Palpitation decreased 4. Nothing will happen Normal palpitation and body was relax Session 5 Feedback & Warm UP 70 % better Agenda, Challenging to one Automatic Negative Thought Incident Thoughts Mood/Emotion Evidence Evidence s That support That does not support the thought the thought He woke up 1. My heartbeat Anxious/ Fear 1.Palpitation 1. Ecg is normal. at midnight. is increasing, 2.Sweating 2. During a walk and running, the heart beat increases, but nothing happens which will 3. Palpitation is not a symptom of heart disease. cause a heart attack. 4. All physical tests are normal. 5. From the last 6 months, there is no heart attack. 6. The doctor told me this is not a heart disease; this is just anxiety. 7. The athlete ran fast, but nothing happened to their heart. 8. This is my negative thought. 9. I am getting better from psychotherapy sessions. 10. When I change my thoughts, my heart beat gets normal, which means these are only my thoughts. Feedback at the end of session Home Assignment Thought Diary #2 to challenge his negative thoughts at home. Client Home work Diary #2 (Challenging to one automatic negative thought) Incident Thoughts Mood/ Evidence Evidence Emotions That support the thought That does not support the thought He woke 1. My heartbeat is Anxious/ 1.Palpitation 1. Ecg is normal. up at increasing, which will Fear midnight. cause a heart attack. 2.Sweating 2. During walking and running, the heartbeat increases, but nothing happens. 3. There is no severe and continues pain in the chest. 4. When I was playing hockey, my heart rate increased, but this was not dangerous. 5. Palpitation is not a symptom of heart disease. 6. All physical tests are normal. 7. From the last 6 months, no heart attack 8. The doctor told me this is not a heart disease; this is just anxiety. 9. The athletes ran fast, but nothing happened to them. 10. I am getting better from psychotherapy sessions. 11. When I started running, my heart was beating rapidly, but nothing happened. 12. This is just my negative thought. 13. If I am heart patient, then I could not be able to run. 14. When I change my negative thought with positive thought, my heartbeat gets normal. 15. When I saw fighting people many times, and then my heart beat was also very fast, but this was not dangerous Session 6 Feedback & Warm Up 95 % better Agenda, Alternative Thoughts Incident Thoughts Mood/E Evidence Evidence Alternative thoughts motions That support the thought That does not support the thought He woke 1. My Anxious/ 1.Palpitation 1. Ecg is normal. 1. If my beat up at heartbeat is Fear 2.Sweating 2. During a walk and running, the heart beat increases, increases or midnigh increasing, but nothing happens decreases, this t. which will 3. Palpitation is not a symptom of heart disease. shows my heart is cause a ok. heart 4. All physical tests are normal. 2. Rapid heartbeat attack. 5. From the last 6 months, there is no heart attack. makes the heart 6. The doctor told me this is not a heart disease; this is more strong. just anxiety. 3. These are just my 7. The athlete ran fast, but nothing happened to their thoughts. heart. 4. This is not 8. This is my negative thought. dangerous. 9. I am getting better from psychotherapy sessions. 10. When I change my thoughts, my heart beat gets normal, which means these are only my thoughts. Home Assignment Thought Diary #3 Change negative thoughts into positive. Client Home work Diary #3 ( Alternative Thoughts) Incident Thoughts Mood/ Evidence Evidence Alternative Thoughts Emotions That support the thought That does not support the thought He woke 1. My heartbeat is Anxious/ 1.Palpitation 1. Ecg is normal. 1. If the heart will beat rapidly, it will be stronger. up at increasing, which will Fear midnight. cause a heart attack. 2.Sweating 2. During walking and running, the heartbeat increases, but 2. This is my negative thought. nothing happens. 3. There is no severe and continues pain in the chest. 3. If it is increasing, then there is no problem. 4. When I was playing hockey, my heart rate increased, but 4. If heartbeat will not increase or decrease, then this was not dangerous. there will be a problem. 5. Palpitation is not a symptom of heart disease. 5. If my heart is beating fast, it means I am okay. 6. All physical tests are normal. 7. From the last 6 months, no heart attack 8. The doctor told me this is not a heart disease; this is just anxiety. 9. The athletes ran fast, but nothing happened to them. 10. I am getting better from psychotherapy sessions. 11. When I started running, my heart was beating rapidly, but nothing happened. 12. This is just my negative thought. 13. If I am heart patient, then I could not be able to run. 14. When I change my negative thought with positive thought, my heartbeat gets normal. 15. When I saw fighting people many times, and then my heart beat was also very fast, but this was not dangerous Post Testing Sr # for Post testing Anxiety Sr# for Post testing Anxiety items score Depression Depression items score 1 1 2 0 3 1 4 0 5 1 6 0 7 0 8 1 9 0 10 0 11 0 12 0 13 0 14 0 Total 3/18 Total 1/7