The presenting patient is Daniela, a 24-year-old graduate student at Columbia University. Daniela has dealt with anxiety since early adolescence. The first time when she started to feel anxiety was when she was being severely bullied by a girl in her 8th grade class. One thing in particular that this girl did, was make her beg for money on the streets and then give it to her after she was done. Daniela distinctly remembers an instance in which the bully locked her in an empty bedroom in her boyfriend’s apartment in a sketchy neighborhood. She reported feelings of nausea, dizziness, heart racing, and fear of not being able to escape the situation. Daniela continued to struggle with these sensations through high school and undergraduate years, especially on buses or other modes of transport. She reports having constant fear of not being able to escape, vomiting, or fainting while on the subway or bus. This past semester her panic attacks became so intense that they have begun to disrupt her sleep. Daniela says that she frequently has to take a cab to and from activities to avoid the subway due to fear of having a panic attack, which is becoming expensive. Sleep-deprived and financially strained, she felt it was best to seek the counseling services at school. Due to her symptoms of panic attacks (dizziness, nausea, racing heart) and fear of not being able to escape a situation and loss of control in public, she has been given a diagnosis of panic disorder with mild agoraphobia.
Cognitive Behavior Therapy with Exposure
Cognitive Behavior Therapy (CBT) has shown to be the most effective type of therapy for treatment of anxiety disorders such as panic disorder and agoraphobia (Barlow, 2008; Tilton, 2010). CBT involves enhancing the development of skills in cognitive restructuring and behavioral exposure to reduce panic anxiety and confront underlying fears. Most studies of CBT for panic disorder and agoraphobia involve 10-20 weekly treatment sessions, which involve psychoeducation, self-monitoring, relaxation training, cognitive restructuring, and exposure therapy (Barlow, 2008; Aslam, 2014). In order to help Daniela develop resistance to her dysfunctional thoughts associated with riding the subway and bus, she will learn more about the connection between thoughts, emotions and physical symptoms when she uses public transportation, as well as how to question her automatic thoughts that arise upon entering a train car or bus. Due to the fact that CBT is designed to be a time-limited therapy, Daniela and I plan on working together twice a week for six weeks, ideally a total of twelve sessions (with follow-up sessions as needed). Daniela will first come in for an initial interview, which utilizes The Anxiety Disorders Interview Schedule, 4th ed. to scan for differential diagnosis (Barlow, 2008). She will be required to keep a panic attack record as a form of self-monitoring, which is to be completed each time following a panic attack (Barlow, 2008). In addition, Daniela will keep a daily mood record, which also encourages self-monitoring behaviors (Barlow, 2008). Upon arrival at each visit, Daniela will complete the Beck Anxiety Inventory, to compare differences in anxiety in each session (Hassiotis et al., 2011). The aim of this therapy is to help Daniela understand her irrational fear of inability to escape and loss of control while on public transportation, and how to apply the techniques that she will learn during these sessions to manage the onset of panic attacks in everyday life.
Initial Sessions 1 & 2 During our first session, Daniela and I will spend time on the psychoeducation aspect of CBT, and work on the development of a strong therapeutic alliance. The goal is to educate her about what Panic disorder and agoraphobia are and how her symptoms are related to the diagnosis. Daniela will learn about the relationship between thought, emotion, and behavior so that she understands that her panic attack symptoms are not