Wk 7 Assignment 1

 

Assignment 1: “Captain of the Ship” Project – Obsessive-Compulsive Disorders

In earlier weeks, you were introduced to the concept of the “captain of the ship.” In this Assignment, you become the “captain of the ship” as you provide treatment recommendations and identify medical management, community support resources, and follow-up plans for a client with an obsessive-compulsive disorder.

Students will:

• Recommend psychopharmacologic treatments based on therapeutic endpoints for clients with obsessive-compulsive disorders
• Recommend psychotherapy based on therapeutic endpoints for clients with obsessive-compulsive disorders
• Identify medical management needs for clients with obsessive-compulsive disorders
• Identify community support resources for clients with obsessive-compulsive disorders
• Recommend follow-up plans for clients with depression disorders

To prepare for this Assignment:

• Select an adult or older adult client with an obsessive-compulsive disorder you have seen in your practicum.

In 3–4 pages, write a treatment plan for your client in which you do the following:

• Describe the HPI and clinical impression for the client.
• Recommend psychopharmacologic treatments and describe specific and therapeutic endpoints for your psychopharmacologic agent. (This should relate to HPI and clinical impression.)
• Recommend psychotherapy choices (individual, family, and group) and specific therapeutic endpoints for your choices.
• Identify medical management needs, including primary care needs, specific to this client.
• Identify community support resources (housing, socioeconomic needs, etc.) and community agencies that are available to assist the client.
• Recommend a plan for follow-up intensity and frequency and collaboration with other providers.

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00:00:00TRANSCRIPT OF VIDEO FILE: 

00:00:00_____________________________________________________________________ 

00:00:00BEGIN TRANSCRIPT: 

00:00:00[sil.] 

00:00:10Panic Disorder and Agoraphobia 

00:00:10SHARI SMALL Anxiety disorders. They impact nearly 20 million people in America alone. In fact, they are the most common psychiatric disorders affecting both children and adults. And with the increasing stress of living in the 21st century, both of global and personal level, the subject is getting more attention than ever. There are several anxiety disorders identified in the Diagnostic and Statistical Manual for Mental Disorders, commonly known as the DSM. Though they share a common theme of excessive, irrational fear and worry, each anxiety disorder has its own distinct features and challenges. In this program, we are going to explore panic disorder and agoraphobia. Many people have moments of panic in their lives. 

00:01:00UNKNOWN What was wrong? 

00:01:00SHARI SMALL But for some these experiences can become quite extreme. 

00:01:05UNKNOWN I can’t breathe. 

00:01:05SHARI SMALL To the point that one might feel as if they are going crazy, suffocating or even dying. 

00:01:10UNKNOWN You know, I think I need to go to the hospital. 

00:01:15SHARI SMALL These are called panic attacks. One of the central features of panic disorder. 

00:01:20Tory Nersasian, Psy.D. 

00:01:20Psychologist 

00:01:20TORY NERSASIAN People will actually report they feel like they are having a heart attack or that they are dying and the response, the physical response is not in response to any cue in the environment that should cause that type of feeling. 

00:01:30SHARI SMALL In general, a panic disorder is diagnosed when a person has experienced at least two unexpected panic attacks and developed persisting concern about having further attacks or changes his or her behavior to minimize such events. 

00:01:45UNKNOWN I had another panic attack. It happened out of the blue. 

00:01:50UNKNOWN Really? 

00:01:50SHARI SMALL Untreated, the disorder can become quite disabling. 

00:01:55Sharron Thrasher, Ph.D. 

00:01:55Psychologist 

00:01:55SHARRON THRASHER They start to narrow and narrow and narrow their lives in order to prevent the situation that they think brought it on in the first place because they often, they don’t really understand that it may have nothing to do with the surroundings or the circumstances or anything. It’s just their body that has a kind of a faulty panic switch. 

00:02:10UNKNOWN Since it happened in the car, I think I’ve been nervous about driving around town. 

00:02:15UNKNOWN Be able to get around. 

00:02:15UNKNOWN I know that and if I could control it, I would. It’s just… Well I, I’ve just really been worried about it. That’s all. 

00:02:25SHARI SMALL Where as the number and severity of the attack varies widely, the concern and avoidance behavior are essential features of panic disorder. To understand panic disorder, one must first understand what constitutes a panic attack. The DSM describes a panic attack as a discreet period of intense fear or discomfort in which 4 or more of the following symptoms developed abruptly and reached a peak within 10 minutes. Palpitations, pounding heart or accelerated heart rate. Sweating, trembling or shaking. Sensations of shortness of breath or smothering. Feeling of choking. Chest pain or discomfort. Nausea or abdominal distress. Feeling dizzy, unsteady, lighthearted, or faint. Derealization involving feelings of unreality or depersonalization of being detached from oneself. Fear of losing control or going crazy. Fear of dying. Paresthesias, a numbness or tingling sensations. Chills or hot flushes. About 10% of the population will at one time in their lives have a panic attack. A panic attack is distinguished from other forms of anxiety by its intensity and sudden episodic nature. 

00:03:40UNKNOWN Are you all right? 

00:03:40UNKNOWN I feel as if I can’t breathe right. 

00:03:45SHARI SMALL They may be further characterized by the relationship between the onset of the attack and the presence or absence of situational factors. In other words, there are three types of panic attacks. Unexpected where the attack comes out of the blue without warning and for no discernible reason. Situational. Situations in which an individual always has an attack, for example, walking in a stairwell and situationally predisposed. Situations in which an individual is likely to have a panic attack but does not always have one. Panic attacks can provoke a strong urge to escape or flee the place where the attack begins. 

00:04:25UNKNOWN You know, I need to get out of here. 

00:04:25UNKNOWN Do you want me to call someone? 

00:04:25SHARI SMALL And when associated with chest pain or shortness of breath can result in seeking aid from a hospital emergency room or other urgent assistance. While an average person may go to a doctor a few times a year, those with panic disorder average over 30 visits with about 40% of those being emergency situations. 

00:04:45TORY NERSASIAN Usually what happens is they’ll go into the ER, they get hooked up to all sorts of measuring devices and they realize no, this wasn’t a heart attack, this was a panic attack. 

00:04:55Joseph Schwartz, M.D. 

00:04:55Psychiatrist 

00:04:55JOSEPH SCHWARTZ I see people referred from emergency rooms after multiple visits with uh… these kinds of symptoms. 

00:05:00SHARI SMALL Though an attack generally peaks within ten minutes, some symptoms may last much longer. 

00:05:05UNKNOWN Shouldn’t we call a doctor? 

00:05:10UNKNOWN Just have to stay still. 

00:05:10SHARI SMALL Some research suggests panic attacks occur when an alarm mechanism in the brain erroneously fires falsely reporting that death is imminent. 

00:05:20SHARRON THRASHER When we think about the panic response as a normal response that everybody has to have, people who have panic disorder have kind of a response gone haywire. 

00:05:30TORY NERSASIAN It would be normal for a person to have these kinds of umm… physiological symptoms if they’re let’s say being chased by a perpetrator with a bat. Umm… you would have the fight or flight response that will be a normal occurrence. In panic disorder people actually have that response to cues in the environment that are not dangerous. 

00:05:50SHARI SMALL Not everyone who has panic attacks develops panic disorder. A panic attack can occur in the course of other anxiety disorders such as social phobia and generalized anxiety disorder or a major depressive disorder. Some are able to recognize a panic attack as a sign of high stress or anxiety and can let the experience come and go without any adverse impact upon their life. Others aren’t so fortunate and may actually develop panic disorder. According to the DSM, in order to formally diagnose someone with panic disorder both of the following must be present. One is recurrent unexpected panic attacks, in other words those that are not situationally bound. The next is that at least one of the attacks has been followed by one month or more of at least one of the following. A, persistent concern about having additional attacks. B, worry about the implications of the attack or its consequences. C, a significant change in behavior related to the attacks. 

00:06:55UNKNOWN No, no, it’s not like I don’t get out of the house or anything. It’s. 

00:07:00SHARI SMALL When panic disorder is diagnosed, there is a specifier of with or without agoraphobia, a pattern of isolation that will be explored later in more depth. 

00:07:10UNKNOWN Have you been taking any drugs or medications in the last several months or had any medical condition? 

00:07:10SHARI SMALL The next of the criteria is that these panic attacks are not due to the direct physiological effects of a substance such as stimulants or of a general medical condition. 

00:07:25UNKNOWN Have you ever been seen by a counselor or therapist? 

00:07:25SHARI SMALL Or not better accounted for by another mental disorder like social phobia or obsessive compulsive disorder. In a given year, 1 to 2% of the US population has panic disorder with a lifetime rate even twice that number. It typically begins during late adolescence or early adulthood. In fact roughly half of all the people who have panic disorder develop the condition before age 24. Though it can surface at any age. Panic disorder is twice as common in women as in men and studies have found a familial and genetic link. Research shows that panic disorder can coexist with other disorders, most often depression. 

00:08:05UNKNOWN I’ve been feeling a little down and, I don’t know. 

00:08:10SHARI SMALL Substance abuse is also common. Appropriate diagnosis of these disorders is important to successively treat panic disorder. One sobering statistic is that approximately 20% of people with panic disorder will attempt suicide. Since the sensations of panic disorder often mimic symptoms of a heart attack or other life threatening medical conditions, an accurate diagnosis is often not made until extensive and costly medical procedures fail to provide a correct diagnosis or relief. Some may go years without learning that they have a treatable mental illness. 

00:08:45TORY NERSASIAN That can be really hard for some people to take because this is a psychological issue and not a physical problem and when we go back to all the stigmas about mental health umm… some people actually go through a period of denial where they don’t believe the doctors or they feel angry that, that’s the diagnosis they receive. 

00:09:00SHARI SMALL The frequency and severity of one’s panic attack varies from person to person. An individual might suffer from repeated attacks for weeks while another will have short bursts of very severe attacks. Typically an early age of onset of panic disorder carries greater risk that it will become chronic and cause more impairment. 

00:09:20UNKNOWN I’m just worried that it’s gonna happen when I’m alone. Yeah, I mean, I mean what if no one finds me? What, what… What will happen, I mean, hearing about people all the time being found in their, it’s too late, I mean… 

00:09:35SHARI SMALL People with panic disorder can’t predict when or where their panic attacks will occur and many develop intense anxiety between episodes. 

00:09:45UNKNOWN I don’t want to risk going there. That’s where it happened last time. 

00:09:45TORY NERSASIAN A person leaves their home has a panic attack. Doesn’t know why, doesn’t know what the trigger was but knows that it occurred outside of the home. They may leave the house the next day and maybe it occurs again or maybe it doesn’t. Maybe it occurs in a few more days. What happens as the person starts feeling like every time I leave home, I have no control over my physical body. 

00:10:10SHARI SMALL Some people’s lives become so restricted that they may start to avoid normal everyday activities, just grocery shopping or driving or perhaps only go if accompanied by a spouse or another trusted person. When people’s lives become this limited which happens in about a third of those with panic disorder, the condition is called agoraphobia. The ancient term agoraphobia is translated from Greek as fear of an open marketplace. Agoraphobia today is described as severe and pervasive anxiety about being in situations from which escape might be difficult or avoidance of situations such as being alone outside of the home, traveling in a car, bus or airplane or being in a crowded area. 

00:10:55JOSEPH SCHWARTZ People become confined to their homes umm… and uh… some are confined to their bedrooms and it’s hard for them to leave that, that protected space. So agoraphobia is uh… the expression of an attempt to manage the panic, to prevent the panic. 

00:11:15Nancy Webber, Ph.D. 

00:11:15Psychologist 

00:11:15NANCY WEBBER That prevents people from going out in the world, going out into their communities, to perform some of those tasks that are necessary to have productive lives. 

00:11:25SHARI SMALL Agoraphobia occurs in the context of two disorders. A diagnosis called panic disorder with agoraphobia and agoraphobia without history of panic disorder. In both disorders, however agoraphobia is described as occurring in response to panic attacks or panic-like symptoms. Though there are debates on this subject, the prevailing view in psychiatry is that agoraphobia is more often a complication of panic disorder. 

00:11:50JOSEPH SCHWARTZ You can have panic with agoraphobia and panic without agoraphobia though again I think that if you leave panic untreated, you, you long enough, you, you often get agoraphobia. 

00:12:05SHARI SMALL The DSM categorizes agoraphobia as A, anxiety about being in places or situations from which escape might be difficult or embarrassing or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms” 

00:12:20UNKNOWN No, I think, I’m just gonna stay here. 

00:12:25SHARI SMALL B, the situations are avoided for example travel is restricted or else are endured with marked distress or with anxiety about having a panic attack or panic like symptoms or require the presence of a companion. 

00:12:40UNKNOWN I just don’t know what I’d do if I got out there all alone and had a panic attack and… 

00:12:45UNKNOWN C, the anxiety or phobic avoidance is not better accounted for by another mental disorder such as social phobia or obsessive compulsive disorder. 

00:12:55UNKNOWN So for you, it’s not really about the social contact. 

00:13:00UNKNOWN No, no, not at all. It’s more about being out some place where I might have one of my panic attacks. I just wouldn’t know what to do in the situation. 

00:13:05SHARI SMALL Among the general population approximately 2 to 5% report symptoms of agoraphobia without a history of panic disorder. However in most anxiety disorder clinics, the majority of people presenting for treatment for agoraphobia also have panic disorder. Agoraphobia is found to be twice as common among women. Some of these gender difference however maybe attributed to social or cultural factors that encourage or permit the greater expression of avoidant coping strategies by women. Obviously, those with Agoraphobia can experience significant interference in their lives. Some are unable to travel, work, keep house or attend appointments. 

00:13:45SHARRON THRASHER I worked with a few students who are Agoraphobic and umm… as you can imagine it really affected them because they were just too uncomfortable even throughout the classes and try to live the life of a student without going to classes is pretty difficult. 

00:14:00TORY NERSASIAN That becomes of course incredibly debilitating. The more you avoid that which makes you panic, the smaller your world becomes. 

00:14:10SHARI SMALL Fortunately, there are several effective treatments that have been developed for panic disorder and Agoraphobia. 

00:14:15UNKNOWN I’m glad that you came in today. 

00:14:20UNKNOWN My neighbor was kind enough to bring me here. 

00:14:20SHARI SMALL Panic disorder is actually one of the most treatable of the anxiety disorders responding in most cases to carefully targeted psychotherapy and medications. 

00:14:30UNKNOWN At work, everything going okay? Any changes. 

00:14:30SHARI SMALL It’s also been found that early treatment of panic disorder can often prevent Agoraphobia. But careful initial assessment is necessary. There are times when medical and psychiatric disorders can coexist. 

00:14:45SHARRON THRASHER It does happen that sometimes people who have panic symptoms really do have a medical condition that has to be checked and maybe they have an arrhythmia, maybe they have some, something going on umm… in some part of their body that is causing them to have a physical sensations that are, that mimic the ones of panic. So umm… usually, if somebody comes in to see me and they have those symptoms, I almost always recommend that they go have a physical. 

00:15:10SHARI SMALL Cognitive and behavioral approaches teach patients how to view the panic situations differently and demonstrate practical ways to reduce anxiety. 

00:15:20UNKNOWN That’s, that’s when my heart starts pounding. 

00:15:20SHARI SMALL In the cognitive portion of the therapy, the therapist usually conducts a careful search for the thoughts and feelings that accompany the panic attacks. 

00:15:30UNKNOWN What are you thinking right before it starts to pound? 

00:15:30UNKNOWN What if I, I can’t escape this situation or what if I lose control? What if I’m in a public situation with people around and I do something to embarrass myself or… 

00:15:45SHARI SMALL These mental events are discussed in terms of the cognitive model of panic attacks which supposes that those with panic disorder often have distortions in their thinking of which they maybe unaware. 

00:15:55UNKNOWN What I would like you to try to do is to stop and pay attention to your, your thought process. Where your mind is, what you’re thinking of the minute, these attack start. 

00:16:00SHARRON THRASHER Try to get them to gain more and more insight about the thoughts that snowball into the cycle of fear and so we try to do when we’re breaking that cycle with somebody in terms of their cognition is teach them to stop at that first step. 

00:16:20UNKNOWN I’d like to try some breathing exercises with you now. Are you willing to try them? 

00:16:25UNKNOWN Yeah, yeah, I guess. 

00:16:25SHARI SMALL The behavioral portion of the cognitive behavioral therapy may involve systematic training and relaxation techniques. 

00:16:30UNKNOWN When you breathe, we’re gonna try to relax and slow your breathing down. So place your hand on your abdomen. 

00:16:40SHARI SMALL Patients may learn to control their breathing and avoid hyperventilation, a pattern of rapid shallow breathing that can trigger or exacerbate panic attacks. Overall, cognitive behavioral therapy has proven to be quite effective. 

00:16:55UNKNOWN Now, we’ll focus on showing you when you’re panicked, how you hyperventilate. So it’s hyperventilate. 

00:17:00SHARI SMALL Another behavioral approach is called exposure therapy. 

00:17:00UNKNOWN And that’s what happens when you have a panic attack. You breathe really fast. So I want you to see what that feels like, so that you can then adjust to slowing your breath down. So try breathing really fast in and out. 

00:17:10SHARI SMALL Here they explore the client’s internal sensations associated with their panic. 

00:17:15JOSEPH SCHWARTZ If the story suggest that people’s panic is induced by hyperventilation, sometimes you demonstrate to that, that to them by getting them to hyperventilate, reproduce their symptoms and that can, can help people to manage their behavior. 

00:17:30UNKNOWN So in your journal, you indicated that you went downtown twice to see brother. 

00:17:35UNKNOWN Right and umm… I got a little tensed. So we left. But each time I went a little bit further. 

00:17:40UNKNOWN Has that been helping? 

00:17:45UNKNOWN I think so. He thinks so. 

00:17:45SHARI SMALL With exposure therapy one can learn to alleviate some of the fears involved with panic disorder and agarophobia. In this approach people are slowly exposed to the fearful situation until they become desensitized to it called systematic desensitization. 

00:18:05UNKNOWN How are you feeling? 

00:18:05UNKNOWN Okay. Umm… can we turn around soon? 

00:18:10UNKNOWN Yeah, we can turn around. 

00:18:10SHARI SMALL This step by step approach helps them gradually master their fears and enter situations that seemed overwhelming before. 

00:18:20JOSEPH SCHWARTZ Though there are many ways to intervene in panic and agarophobia, once that agarophobia has developed umm… usually need to get people to confront their uh… their fears and tolerate their anxiety and really push the walls back. 

00:18:35TORY NERSASIAN Final step is repair it. We start lower down on hierarchy and repair relaxation with the actual trigger that makes the person anxious. Over time, we are essentially deprogramming the brain and the misfiring signals. We are now programming the brain to relax to those cues in the environment. 

00:18:50SHARI SMALL Certain prescription medications can provide relief for clients with panic disorder and agoraphobia. They are used to decrease anticipatory anxiety as a way to prevent panic attacks or reduce their frequency and severity. 

00:19:05UNKNOWN Have the new medications been helping? 

00:19:05UNKNOWN They seem to have calm me down a bit. 

00:19:10UNKNOWN Uh… any side effects? Have you felt… 

00:19:10SHARI SMALL Two types of medications that have been shown to be effective in the treatment of panic disorder are antidepressants and benzodiazepines. The research is ongoing. Many believe that a combination of medication and cognitive behavioral therapy represents the best alternative for the treatment of panic disorder and agoraphobia. In fact, appropriate treatment by experienced professionals can reduce or prevent panic attacks in over 70% of people with panic disorder and early treatment can help keep the disease from progressing to the later stages where agoraphobia develops. When patients find that their panic attacks are less frequent and severe, they are increasingly able to venture into situations that had been off limits to them. With new education, research and treatment on the horizon comes a hope that people these kinds of anxiety disorders will lead less impaired and more fulfilling lives. 

00:20:10[credits] 

Obsessive-Compulsive Disorder

5:39 / 20:15

(Naples, FL: 

National Educational Video, Inc.

, 2015), 20 minutes