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Linda - A case study

This page uploaded 31 July 2009
By Jane Gierlicz ( Psychologist )

Linda first came to see me last year. She was in her mid twenties and quite desperate for help. She was six months pregnant with her first child, and wasn't coping with the ante-natal visits to her hospital. She was terrified of the prospect of having to spend time in the hospital for the birth of her baby, due in a few short months time. It was apparent talking to Linda that the prospect of birth, and impending motherhood, was of no more than a normal concern for her - although the pregnancy was unexpected, her and her partner Jim had both been eager to be young parents and were very excited by impending parenthood. The stumbling block for Linda was the hospital. She was to give birth in a large city hospital and the ante-natal visits and maternity ward were on the fourth floor of the building. Her fear was that if 'something' happened whilst she was in the hospital, easy escape to outside was difficult. What was this 'something' that Linda was so frightened of?  
About seven years before seeing me Linda had had a panic attack. She'd been on her way to school on the train and had experienced the frightening surge of adrenaline and associated anxiety symptoms - the increase in heartbeat, feeling hot & sweaty, trouble getting her thoughts together, but most importantly a great sense of fear and panic about what was happening. She wanted to run, to flee, but wasn't able to - she was stuck on the train 'til the next station dealing with her fear and discomfort. When the train stopped she got off, even though it wasn't her stop, and slowly she started to calm down - it probably took about 30 minutes. Linda was mystified by the experience - she couldn't understand it. She went home to her mother and together they went to the doctor. This was the first of many trips to medical specialists to have her symptoms investigated. Around this time Linda had a further three attacks. None were as difficult or as terrifying as the first, but still very frightening. She became very aware of how she was feeling and if she felt slightly anxious she became concerned that another panic attack was imminent. All medical investigations proved normal - while this was a relief it left unanswered the question of what had happened. Eventually her General Practitioner and other specialists suggested panic attacks, and on researching it herself Linda came to the conclusion that this was probably what she'd experienced.  
As a way of limiting the likelihood that she'd experience another attack, Linda had begun to limit her lifestyle. Although she understood what a panic attack was, she didn't know how to stop them or control them so she would make sure that she wasn't anywhere where escape was difficult, just in case she did have a panic attack. She got through most of a degree at University by sitting close to the door in lectures or tutorials, but just couldn't finish the last semester. She worked as a shop assistant after giving up a more demanding receptionists job because escape was physically more difficult from the area she worked as a receptionist. For the ante-natal appointments she attended these with her mother or Jim, they would wait in the waiting room and call her when her appointment was due. Linda spent little time away from home - essentially she was doing what she had to do but little else.  
As I said when Linda came to see me she was desperate, not only because of the impending birth, but also because I was about the 10th Psychologist she'd seen and was concerned that she wasn't going to get the help she needed. She'd been assessed by the Psychiatrist at the hospital and was considered a serious risk for Post-Natal Depression. She'd then been referred to the hospital Psychologist but felt that their contact was not helpful.  
After carefully assessing and understanding Linda's difficulties and the history of these, I came to the conclusion that Linda was suffering from Panic Disorder - she'd experienced panic attacks that were causing significant distress and were having a big impact on her life.  
Our work began with a clear explanation and discussion of the fight-flight system. This is the system that underlies our anxiety response and is responsible for the myriad of confusing symptoms when we're feeling anxious. We talked about not only the physiological symptoms, but also the very important changes in thinking that occur when you're anxious. Essentially when you're anxious you become more and more focused and preoccupied with the thing you're worried about, and overestimate the probability that the feared thing will occur. For Linda this was the first time the system had been explained to her in detail. The explanation was useful because it explained what was happening, made the symptoms understandable, and also alleviated her worry that she was going mad. Linda had secretly harboured a fear that the change in the way she was thinking was an indication that she was going mad or had Schizophrenia. I was able to reassure her that this wasn't the case, what she was experiencing was extreme anxiety.  
When Linda was very anxious and preoccupied with worry it was pointless trying to talk herself down from this, that is, talk to herself rationally about her fear that she was going to have a panic attack. Her mind was too preoccupied. Therefore we focused on developing her skills to relax herself. Learning a slow breathing technique was probably the most important skill Linda learnt. With practice Linda was able to use this very effectively to control her anxiety. I also taught her an isometric relaxation exercise, which she practised when time allowed. Linda and I then moved on to her fear of having a panic attack. For Linda any sign of anxiety was a sign of an impending panic attack, something which she had no control over. We therefore developed a very simple three-step plan for controlling a panic attack:  
1st: Stop
2nd: Focus on your breathing, breath slowly
3rd: Say to self 'This is a panic attack, it's frightening but not dangerous and it will pass, what I have to do is keep breathing slowly'.  
Although very simple this was the key for Linda. It meant that she could start challenging herself to do things she had avoided because she had a plan for controlling the thing she feared - panic attacks.  
Linda slowly began doing things - she would shop at larger supermarkets and not leave at the first sign of anxiety which she had been doing, but rather she would stop and breathe through the anxiety. To people in the shop she appeared to be studying some grocery item intently but for Linda she was dealing with her Panic Disorder.  
She began socialising, attending restaurants and pubs with family and friends. Eventually she worked up to attending ante-natal appointments on her own. Finally we began working on the prospect of spending extended time in hospital following the birth.  
But before we'd begun Linda gave birth very suddenly and had to stay in hospital longer than she'd expected. I'm happy to say that Linda coped exceptionally well with this. Following the birth I saw her (and baby Mara) for probably four more sessions (12 in total). Linda was not hampered in her day to day activities. She was out and about with Mara shopping wherever she liked, socialising with and without the baby. She became fearful at one point that she might have a panic attack and drop Mara, but worked through this by pushing herself to hold the baby whether she was standing up or not, and breathing through her mild anxiety.  
When I last saw Linda she had enrolled to complete her last semester at University and also enrolled to complete a degree in psychology. We finished our contact on the understanding that she could return at any time if she felt she needed to, and I'm happy to report that I haven't seen her since late last year.  

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