DENNIES HOLT: CASE STUDY
University of Mindanao Digos College
College of Arts and Science
Psychology Program
Roxas Ave., Digos City
PSY 222
Dennis Holt: A Case of Panic Attacks
300.01 (F41.0)
STEVEN DAVE T. DURADO
February, 2021
DENNIES HOLT: CASE STUDY
Dennis Holt: A Case of Panic Attacks
300.01 (F41.0)
Diagnostic Profile
I.
Introduction
A. Client’s Profile
Dennis Holt, the subject of the case, was in his 30s, legally separated from his
wife, and worked as an insurance sales representative.
Dennis was an only child whose father was an accountant and his mother was
an elementary school teacher. Dennis’ case has fully disclosed his obnoxious
relationship with his father – whereas, Dennis’ father has been profoundly
uttering his idealistic expectations to Dennis in every aspect of Dennis’ life,
either academic or career path.
Dennis has been a cautious person ever since a child. Nonetheless, he had
able to make some friends and joined some activities in his school. Dennis
started to get academic setbacks when he entered college. In his perspective,
it is associated with his anxiety. In his sophomore year, Dennis began to suffer
from gastrointestinal complications.
Dennis’ state, however, did not restraint him in having a romantic life. Dennis
had a girlfriend, Mary, who came from the same college as Dennis. Realizing
he had enough of college, Dennis decided to seek a job in insurance firms.
Mary, as well, dropped out of college and went on the same path with Dennis.
Dennis and Mary lived reasonably comfortably and happy as a couple working
on insurance firms.
Due to a conflict in interests, Mary and Dennis got divorced. Dennis continued
living alone in an apartment and working as an insurance sales representative.
Four years it has been after Dennis’ divorce, Dennis met Elaine – whose
interests are akin with Dennis. The two planned to get tied up in their most
favorable time.
DENNIES HOLT: CASE STUDY
B. Reasons for Referral
Dennis, as indicated in the case, had been experiencing panic attacks
occasionally. As well, Dennis had been apprehensive and self – conscious, despite
having a fruitful career.
Dennis first and foremost felt indications of nervousness during his first-year stay
in college. Dennis felt the palms of his hands would start to sweat lavishly. At that
point, his breathing would turn out to be at an accelerated pace and narrow, and
his mouth would turn out to be extremely dry. On the most exceedingly awful
events, his brain went clear.
Dennis continued to experience stomach problems in subsequent years at college.
Manifestations were deteriorating suchlike discontinuous obstruction, cramping,
and loose bowels that endured for a while. Dennis had a gastrointestinal
assessment, nonetheless, there were no pathological causes found for his misery,
and is just determined to have irritable bowel disorder. Dennis was given drugs,
however, indications continued.
Dennis, at the age of 24, he suffered his first panic attack. When Dennis and his
wife, Mary, and their colleagues were at the dinner theatre. Dennis started to get a
nervous feeling in his throat and chest as dinner was about to end. He was
incapable of receiving his breath, and he seemed sure that he would faint on site.
Incapable of speaking or moving, he was in a living nightmare in his seat. Dennis
also started feeling dramatic chest pain and palpitations in the heart.
Six months later, Dennis had his second attack, when he was on the road alone in
the rush hour. Dramatically the indications were the same. A high-powered
benzodiazepine, commonly used in treating anxiety and insomnia, was
recommended for Dennis with alprazolam (Xanax). It helped him to relax and treat
his stomach problems, but it was recommended that he lower the doses due to
side effects.
Dennis was much more hesitant with his prior incidents to go with Mary in the
evening and holidays. In jammed open realm, Dennis became very apprehensive
and often vigilant of where and when his car was going. He was attempting to
escape highway rush-hour. Dennis eventually stops circumstances with huge
crowds.
DENNIES HOLT: CASE STUDY
II.
Justifications
Base on the given study, as manifested by Dennis, therefore, provided evident
considerations to diagnose Dennis with comorbidity of Panic Disorder, 300.01
(F41.0). This as well is in accord with the met criteria provided in the DSM – 5.
Panic Disorder
300.01 (F41.0)
DIAGNOSTIC CRITERIA
GIVEN FACTS
Criterion A
Criterion A
Recurrent unexpected panic attacks. A panic
attack is an abrupt surge of intense fear or
intense discomfort that reaches a peak
within minutes, and during which time four
(or more) of the following symptoms occur:
1. Palpitations,
pounding
accelerated heart rate.
heart,
or 1. This criterion had been cited in the case
when Dennis was at the dinner theatre
with his wife, Mary, and their colleagues.
And, was restated when he was driving
alone in the jammed traffic.
2. Sweating.
2. This criterion was indicated in the case as
Dennis lavishly perspiring as he entered
the room in his first year in college.
3. Trembling or shaking.
3. This criterion was not indicated in Dennis’
case.
4. Sensations of shortness of breath or 4. This criterion was firstly introduced in the
smothering.
case when Dennis was in his college
year and was then cited again during his
first attack at the dinner theatre and
second attack when he was driving alone
in rush-hour traffic, 6 months later.
DENNIES HOLT: CASE STUDY
5. Feelings of choking.
5. This criterion had been cited in the case
when Dennis was at the dinner theatre
with his wife, Mary, and their colleagues.
6. Chest pain or discomfort.
6. This criterion was clearly mentioned in the
case when Dennis had dinner with his
wife and colleagues. And, was re-utter
when he was driving alone in the jammed
traffic.
7. Nausea or abdominal distress
7. This criterion was indicated in the case
when Dennis was in his sophomore
years, leading him to be diagnosed with
irritable bowel syndrome.
8. Feeling
dizzy,
unsteady,
light- 8. This criterion had been cited in the case
headed, or faint.
when Dennis was at the dinner theatre
with his wife, Mary, and their colleagues.
9. This criterion was not cited in Dennis’
9. Chills or heat sensations
case.
10. Paresthesias (numbness or tingling 10. This criterion was not mentioned in
Dennis’ case.
sensations).
11. Derealization (feelings of unreality) 11. This criterion was not mentioned in
or
depersonalization
(being
Dennis’ case.
detached from oneself).
12. Fear of losing control or “going 12. This criterion was not mentioned in
crazy.”
13. Fear of dying.
Dennis’ case.
13. This criterion was not mentioned in
Dennis’ case.
Criterion B
Criterion B
At least one of the attacks has been followed
by 1 month (or more) of one or both of the
following:
1. Persistent concern or worry about 1. This criterion was indicated in the case as
additional panic attacks or their
Dennis persisted to drive in the right lane
consequences (e.g., losing control,
due to his fear of a sudden attack on the
having a heart attack, “going crazy”)
road.
DENNIES HOLT: CASE STUDY
2. A significant maladaptive change in 2. This criterion was cited in the case as
behavior related to the attacks (e.g.,
Dennis was refusing to go out with Mary
behaviors designed to avoid having
on weekends. As well, Dennis’ attempt of
panic attacks, such as avoidance of
escaping
highway
exercise or unfamiliar situations).
stopping
environments
rush-hour
with
and
huge
crowds, support this criterion.
Criterion C
Criterion C
The disturbance is not attributable to the This criterion was not achieved. As cited in
physiological effects of a substance (e.g., a
the case, Dennis’ Irritable Bowel Syndrome
drug of abuse, a medication) or another
diagnosis has contributed to Dennis’ mental
medical condition (e.g., hyperthyroidism,
disturbance. In the case it was mentioned
cardiopulmonary disorders).
when Dennis had a dinner with his wife and
their colleagues. It was clearly mentioned in
the case how concerned Dennis was that he
might have a gastrointestinal attack.
Criterion D
Criterion D
The disturbance is not better explained by This criterion was not achieved.
another mental disorder (e.g., the panic
attacks do not occur only in response to Disturbance
caused
by
other
mental
feared social situations, as in social anxiety disorder was not discussed in the case in
disorder; in response to circumscribed particular, as Dennis was not fearful of a
phobic objects or situations, as in specific specific object. Also, the social anxiety
phobia; in response to obsessions, as in disorder and OCD guidelines were not met
obsessive-compulsive disorder; in response by Dennis. Though Dennis was mindful of
to reminders of traumatic events, as in himself, he didn't follow the BDD criterion.
posttraumatic stress disorder; or in response No traumas causing Dennis' distress have
to separation from attachment figures, as in happened in the situation. Dennis was
separation anxiety disorder).
eventually divorced, but in the event that he
was devastated, it was not reported.
DENNIES HOLT: CASE STUDY
III.
Treatment Recommendation
Panic-Focused Psychodynamic Psychotherapy
Treatment
Panic-focused psychodynamic psychotherapy (PFPP) is
Overview
a manualized treatment for a panic disorder including
twice a week meeting for 12 weeks. PFPP centers around
distinguishing a hastening upsetting life occasion going
before the beginning of panic disorder side effects and the
significance either cognizant or oblivious, that occasion
has for the patient. Intrapsychic clashes from adolescence
just as clashes emerging from sexual inclinations are
examined during this treatment to increment passionate
mindfulness and encourage goal (Milrod, Busch, Cooper,
& Shapiro, 1997).
PROCEDURE
Phase 1
(Busch & Milrod, 2008)
During this process, the therapist will be concerned with
the recognition of the nature and substance of panic
symptoms of Dennis arising from discussing panic
situations,
stressors
and
feelings.
In
addition, Dennis' developmental history including panic
episodes in his previously unfolded, leading to assessing
the early perceptions and images of self and artifacts that
may play an active role in the panic of Dennis. The first
step will try to relieve the panic symptoms of Dennis.
Phase 2
At this point, the therapist will be working with Dennis to
detect key panic disorder conflicts. Disagreements over
rage and sovereignty as well as to other complexities will
be given to Dennis’ awareness. As well, defense
mechanisms,
such as response growth,
remedial
degradation, and denial, are discussed as attempts to
prevent emotional panic symptoms, often unconsciously.
DENNIES HOLT: CASE STUDY
The advent of the transition will help the therapist to
examine these contradictions and defenses in the
therapist-patient connection. The aim of this process is to
resolve panic and relapse vulnerabilities.
Phase 3
In the third (termination) step, the therapeutic partnership
(Termination)
ends with mixed feelings around resentment, autonomy
and separation. The therapist will support Dennis in
articulating feelings about the therapist's absence so that
problems can be identified and the panic recurrence risk
minimized. Increased confidentness and an increased
sense of confidence to accept mixed emotions, facilitated
by this patient-driven approach, helps to enhance the
psychosocial role.
Benefits
Not only endures but also improves one of the values of
psychodynamic therapy over time. In addition, selfesteem is increased, the desire to have more fulfilling
relationships is established, self-confident skills are
increased, knowledge of self and others is increased, and
a broader spectrum of emotions understood and accepted
and the patient will increasingly face challenges and
problems (Shedler, 2010).
Risks
Be that as it may, restrictions of Psychodynamic treatment
incorporate it is less organized than CBT, longer-term
commitment required can be costly due to length of
treatment, talks about childhood/personal history which a
few may not wish to do, requires translation from the
advisor which lacks objectivity, depends on hypothetical
builds that are troublesome to demonstrate – for
illustration, oblivious intellect and it is troublesome to test
in an experimental way (Jacobson, 2013
DENNIES HOLT: CASE STUDY
Rational Emotive Behavior Therapy
Treatment
Rational Emotive Behavior Therapy (REBT) is a
Overview
psychotherapy directed to action that involves cognitive,
behavioral and emotional strategies. It is used extensively
in different forms of psychological issues such as
individuality, mood disorders and even panic attacks to
alter cognitive processes, attitudes and actions (Mydin &
Yusooff, 2010).
REBT Principle
REBT founder Albert Ellis indicated that people blame
(The ABC
external events erroneously for unhappiness. However,
Model)
he argued that our understanding of these events lies at
the core of our psychological distress. Ellis has developed
what he calls the ABC Model to describe this method
(Cherry, 2020).
A – denotes to Dennis’ activating event or situation that
triggers his negative reaction or response.
B – refers to Dennis’ beliefs or irrational thoughts he might
have about an event or situation.
C – refers to the consequences, often the distressing
emotions, that result from Dennis’ irrational thoughts or
beliefs.
(Legg, 2018).
TECHNIQUES
(Ackerman, 2020)
Problem
This technique meant to help Dennis address the A in the
Solving
ABC model and address head-on adversities or triggering
Technique
incidents. Common methods of problem solving include
expertise in problem solving, assertiveness, social
competences, decision-making and dispute resolution.
DENNIES HOLT: CASE STUDY
Cognitive
Cognitive methods of restructuring concentrate on helping
Restructuring
Dennis shift his unreasonable convictions. Measures
Technique
include the opportunity to relax Dennis. Next, letting
Dennis explain how his pessimistic mood came into being.
Allowing Dennis to examine the moods he felt. Next,
letting Dennis write down his automatic thoughts as he felt
his mood. Dennis' "hot thoughts" are the most relevant.
Next, allowing Dennis to find proof supporting his hot
thoughts. Afterwards, allow Dennis to begin identifying the
proof against his hot feelings. At this point, allowing
Dennis to find out about the situation in a fair and
balanced way. Let Dennis, finally, now observe his mood
and decide on his next move.
Coping
If Dennis is unable to change and struggles despite his
Techniques
use of rational thinking, he can have help with coping
techniques. These can include relaxation, hypnosis,
meditation, attention and breathing.
Benefits
Like all cognitive treatments, REBT can help patients such
as Dennis to change their self-defeating thinking so they
can feel more and change their behavior, which will make
them more suitable and productive in certain conditions
and lead to behaviors that help the Dennis to achieve
defined goals (ADC, 2019).
Limitations
The client must be prepared to deal with their issue. REBT
uses homework often and if the client is not committed to
help on them during the session, he/she has a certain bet
that they do very little homework. As well, it uses some
emotionally powerful and degrading techniques. Activities
such as disgraceful assault can be difficult for the
customer to really enjoy and understand the purpose and
its value. And people with a low level of frustration will fight
(Turner, 2016).
DENNIES HOLT: CASE STUDY
Eye Movement Desensitization and Reprocessing (EMDR) Therapy
Treatment
EMDR therapy is a sequential, centered approach to
Overview
treating traumatic and other symptomatic disorders by
reconnecting the client to trauma-related memories, selfthought, feelings and body sensations in a healthy and
measured manner (riddle, 2020).
PROCEDURES
(Menon & Jayan, 2010)
History Taking
The clinician can detect the readiness of Dennis and
and Treatment
recognize any secondary benefits which sustain his
Planning
current problem through a detailed history. The clinician
defines the suitable therapeutic target by evaluating
unstable behaviors, signs and particular features. For
sequential treatment, goals are set which have been the
foundation for Dennis' pathology.
Client
The therapist and Dennis will establish a therapeutic
Preparation
relationship at this time. The therapist will help to establish
reasonable expectations. He/she will train Dennis to
complete the incomplete sessions and to maintain
stability between and over the sessions. Dennis will be
instructed by the therapist to use metaphors and to stop
the signal during the treatment session to provide control.
The therapist will explain the symptoms of Dennis and
makes Dennis understand the active treatment of the
trauma.
Assessment
Dennis and the therapist together detect the target
memory of this session. This is the phase. Dennis is then
instructed to recognize the most striking image of this
memory and to elicit negative beliefs that give us an idea
of the irrationality of the event in question. There will also
be positive beliefs that suit the objective and that
contradict his emotional experiences.
DENNIES HOLT: CASE STUDY
Desensitization The disturbing event of Dennis is assessed in this phase
to alter the sensory experiences and associations related
to trauma. Another part of this phase is the increased
sense of self-efficacy and insight. During this phase,
Dennis is invited to take part simultaneously in the
objective image and eye movements and he is instructed
to be open to everything. Dennis is directed to take a deep
breath after each set of eye movements and to blank the
material he is focusing on.
Installation
The therapist tries to increase the cognition strength that
only the negative is replaced.
Body Scan
It's the stage Dennis is asked to check the body to figure
out if there is still any somatic reaction that is seen as
remnants of stress associated with the target case. If
present, this body feeling is targeted for further care by
the therapist.
Closure
The self-control techniques already taught are used
during this stage when reprocessing is not complete. This
allows Dennis to return to a state of harmony. In this step,
the therapist will clarify what to expect between sessions
and record disorders between sessions, in order to use
these targets for more sessions if appropriate.
Reevaluation
This is the evaluation process for optimal care and for
of treatment
additional goals to be reviewed.
effect
DENNIES HOLT: CASE STUDY
Benefits
EMDR therapy helps client to eliminate the power from
negative convictions, demonstrating that they are just an
interpretation of an incident and that there are various
more true and optimistic explanations. As well, it helps you
recover from trauma. EMDR care takes a different
approach than talk therapy and just a few sessions will
address problems which patients have been trying to
discuss for years. The client, too, does not need to share
all his memories in EMDR, which is very useful in cases
of
vocalizing
difficulties.
Finally,
it
can
enhance
relationships, job results, innovation, and wellbeing. by
transforming negative beliefs (BCC, 2019).
Risks
During the course of sessions, EDMR may increase
distressing memories, improved thoughts or physical
feelings, lightheadedness, vibrant dreams and new
traumatic memories. These symptoms are normally
resolved ongoing therapy. Individuals should share their
experiences with their therapist in order to focus on
potential memories and symptoms (Legg, 2019).
DENNIES HOLT: CASE STUDY
IV.
Comorbidity
DSM-5 requirements for panic disorder include frequent panic attacks,
accompanied by 1 or more attacks at least 1 month in the face of further panic attacks
or severe attack-related ill-adaptation behavior. Additionally, the DSM-5 (APA, 2013,
p. 213) detailed that in people with other conditions, particularly other anxiety disorders
(especially agoraphobia), major depression, bipolar disorder, and likely mild alcohol
consumption, the incidence of panic disorder is elevated. Lastly, the DSM-5 (APA,
2013, p. 214) highlighted that panic disorder strongly co-occur with general signs and
disorders including but not limited to dizziness, hyperthyroidism, asthma, COPD and
irritable bowel disorder.
For Dennis, the fact that amid his panic attacks, he, too, had Agoraphobia
which is clear with his story and experience. In the DSM-5 (APA, 2013, p. 217),
Agoraphobia was described as irrational or unreasonable concern for a number of
conditions in which a person considers it impossible, difficult or highly embarrassing to
flee or have access to support if panic-like symptoms or other impairments are present.
Dennis' fear of open spaces such as when Dennis was on a long bridge is a
significant symptom, which he eventually professed his discomfort. Furthermore, his
apprehension in the enclosed space was obvious when his wife Mary and her
colleagues had arranged Dennis at dinner. Dennis also displayed other signs because
of the feeling that it was not possible to flee, preventing the agoraphobic situation. This
was presented in the case as Dennis often raced to the right side of the road because
he expected a sudden attack.
These agoraphobic conditions often triggered Dennis' anxiety. Dennis had
refuted circumstances like social commitment because of the fear of future panic
attacks. Unfortunately, Dennis’ social life was significantly affected. That, too,
contributed to the demise of his relationship with Mary.
Finally, when he was in college, Dennis was diagnosed with Irritable Bowel
Syndrome. Dennis's medical condition, akin to the assertion from the DSM-5, had
helped to improve the frequency of his panic attacks. As the case indicated, his
medical condition made him uncomfortable and nervous during dinner. Dennis
eventually had bouts of panic.
DENNIES HOLT: CASE STUDY
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