Case Study
Patient Demographic: Client Age: 41 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Behavioral Health Type of Counseling: Outpatient Presenting Problem: Fear and Panic Diagnosis: Agoraphobia 300.22 (F40.00)
Mental Status Exam: Mental Status Exam: The client appears her stated age, and she is dressed in casual attire. Her affect and mood are anxious. She is tearful and seems extremely distressed when recounting her panic attacks. The client denies suicidal or homicidal ideations but does endorse feeling hopeless about her condition. She is unsure if she will benefit from counseling and expresses mixed feelings about seeking help. The client denies audio and visual hallucinations. Fam
Presenting Problem: You work in a behavioral health outpatient center. Your client is a 41-year-old Caucasian female presenting with symptoms of fear and panic. The client has a history of anxiety and depression but explains that her anxiety has worsened within the last year and that she has begun to experience panic attacks. She states that she has an “overwhelming fear” of elevators and stairwells. When exposed to these situations, she has trouble breathing, begins to feel dizzy, and hyperventilates. The client remembers having her first panic attack while staying at a hotel one weekend. She was taking the stairs and suddenly felt intense fear and panic. On the same trip, she had a similar experience when taking the elevator. The client quit her last job due to travel requirements, and she is currently unemployed. She stays away from stairwells and elevators as much as she possibly can. When unable to do so, she asks her son to accompany her.
Other Contexts: The client receives psychoeducation on various treatment interventions for agoraphobia. She understands the risks and benefits, and you review informed consent each session. The client would like to work on her fear of stairs first, which is less anxiety-provoking than elevators. She expresses an understanding of exposure exercises and is willing to give them a try. You and the client use a Subjective Units of Distress Scale (SUDs) to measure the intensity of each anxiety-provoking situation, which can range from 0 units (no distress) to 100 units (extreme distress)

Question: Which of the following exposure exercises would be most effective for this client?
(A): Walk up and down the stairs with her son or a safe person during initial exposures.
(B): Walk up and down the stairs with prescribed antianxiety medication to use PRN.
(C): Walk up and down the stairs, pausing to use relaxation strategies when the SUD rating increases
(D): Walk up and down the stairs and repeat the exposure until the SUD rating drops by half.

Correct Answer: Walk up and down the stairs and repeat the exposure until the SUD rating drops by half.
Explanation: Walking up and down the stairs and repeating the exposure until the SUD rating drops by half is the most effective exposure exercise. For exposure exercises to work, the client must experience increased levels of anxiety. The client’s ability to tolerate increased anxiety levels through prolonged exposure creates new neuropathways in the brain. This new neuropathway leads to the downregulation of the amygdala, which is responsible for the brain’s flight-or-fight response. Using relaxation strategies, using a safe person during the exposure, and having an escape plan by carrying medication are all contraindicated because they do not allow the client to experience the increased anxiety that is required for exposure therapy. Therefore, the correct answer is (B)
Competency: counseling skills and interventions