Case Study
Patient Demographic: Name: Jeanne Clinical Issues: Fear and panic Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F41.9 Unspecified Anxiety Disorder Age: 35 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Latin American Marital Status: Married Modality: Individual Therapy Location of Therapy : Community Center  
Mental Status Exam: The client appears tearful and overwhelmed. Her affect is mood congruent with her reported symptoms of panic, stress, and guilt. The client has a poor sense of control over her current mental state, leading to ideas and fears of not being able to cope with her current circumstances. She reports having panic attacks and expresses feeling overwhelmed by the demands of motherhood and home life. The client has difficulty concentrating on tasks, as well as changes in her eating habits, sleeping patterns, and overall mood, leading to worries about managing her responsibilities as a mother. She expresses an understanding of her situation and an awareness that her current mental state is not sustainable in the long-term. She has also expressed a desire to seek counseling as a first step towards managing her anxiety.
Presenting Problem: First session You are a therapist at a community center. The client is a married, 35-year-old mother of two young children. She is a stay-at-home mother, and the family is financially dependent on her husband's income. He works long hours and is very tired when he finally gets home, leaving most of the household tasks and childrearing to the client. She tells you, "About eight months ago while driving my car, I began having hot flushes, sweating, and feeling like I was going to die. It has happened multiple times since then. What if my kids are with me, and it happens again while I'm driving? I can't stop thinking about it." She states that her husband drove her to the session today because she has been afraid to drive since her first panic attack.    She describes another incident two weeks ago while getting her hair cut. She began feeling like she had a heart attack. She tells you, "I sat straight up in the middle of having my hair shampooed and just ran out the door. The room felt so small all of the sudden and I couldn't stand it. It's so embarrassing. It doesn't make any sense." As she wipes tears from her eyes, she shares, "I'm becoming more and more afraid to leave my house by myself. I'm not even going to church anymore. The idea of being in a closed room full of people freaks me out. I'm terrified I'm going to have another 'attack.' I can't tell when another one will come on, and I don't even know how long it will last. Please, help me. I'm no good to anyone right now - not me, my kids, or my husband."    She tells you that she had a "bad experience" with medications in the past and wants to try counseling before considering medications again. She expresses feeling afraid that she will never "get better." She also states she feels like a "bad wife and mother" because she cannot control her anxiety. You discuss the principles of panic-focused CBT and mindfulness-based stress reduction to effectively treat her.  Fourth session At the start of today's session, the client hands you a copy of a hospital discharge form. She went to the emergency room two days ago with severe dyspnea and fear of dying from a myocardial infarction. Upon arrival at the hospital, the client reported paresthesia, pounding heart, and chest pain. She appears "frazzled" and disheveled during today's session. She describes the circumstances leading up to her trip to the hospital. She reports that her husband has been emotionally distant and is becoming increasingly frustrated with her anxiety. Finally, he told her that "this has been going on long enough" and that she needed to "get her act together." After this conversation, the client experienced a panic attack and stated that she was "terrified" that she was dying. Her husband arranged for their neighbor to watch the kids and drive her to the hospital.    You tell the client that she must stop thinking she will die or progress in therapy will be unlikely. You reassure her that the physical sensations she feels during a panic attack are not life-threatening, even though they may feel that way. You discuss the importance of her bringing compassion and attention to her body rather than jumping into "fight, flight, or freeze" mode. The client appears anxious and has poor eye contact with an averted gaze. She is continuously wringing her hands together and bouncing her legs. She has trouble concentrating, as evidenced by her asking you to repeat questions. The client tearfully states, "I'm ruining my family. What if I die? Who will take care of the kids?" You provide empathy and walk her through a relaxation technique.  Ninth session You have seen the client weekly, and she is progressing. She arrives at today's session on time. She appears calm, alert and focused. She states that she has been actively journaling her thoughts and feelings. This has been helpful for her in identifying themes in her faulty cognitions. She tells you that she is surprised by how much she is learning about herself, including how much her past has influenced her current beliefs.    She showed some psychomotor agitation by pulling on the strings of her blouse. The client expressed that she and her husband have been trying to implement a date night which has helped their relationship and for him to better understand what Panic Disorder is. She said that having meaningful conversations with him and having his support in times of panic has helped reduce the attack's length. However, the client did express that she cannot shake the fear of dying and leaving her children. You discuss with her the potential triggers of these panic attacks and discuss ways to manage them.    As she leaves, you see that she has bruises on her arms as she is getting ready to leave and says she was "roughhousing" with her husband. You are unsure if she is telling the truth, making you wonder about everything she has been saying about her husband. You discuss with her the option of attending couples therapy to help them work through any issues they may face. She says she is open to it but worried about bringing up deeper issues surrounding their relationship. You reassure her that she and her husband will have a safe space to discuss any topics and remind her about the counseling.
Other Contexts: The client has two young children, ages four and six, both of whom have been diagnosed with ADHD. She has been married for ten years. Her husband is 47, twelve years her senior. He works full-time, and she is a stay-at-home mom.    For the past year, the client has reported feeling overwhelmed with the demands of motherhood and home life. She feels that her husband does not understand her struggles, nor does he contribute enough to their household responsibilities. This lack of support from her husband has caused her to feel a deep sense of resentment. She is also concerned that her children are not receiving the support they need from their father, as his involvement in their lives appears to be minimal.    The client expresses frustration with her lack of motivation and has become increasingly more anxious and irritable over the past several months. She reports difficulty concentrating on tasks. She feels her stress levels are rising and she is having recurrent panic attacks. In addition, she has noticed changes in her eating habits, sleeping patterns, and overall mood. These changes have caused the client to worry about managing her responsibilities as a mother. The client has been a full-time stay-at-home mother since the birth of her older child. Before that, she was a salesperson and shift manager at a local women's clothing boutique for several years. Since becoming a stay-at-home mom, the client has felt increasingly isolated and disconnected from the outside world. She fears she has lost her ability to successfully manage conversations with strangers, her skills in sales and marketing have eroded, and she no longer feels as confident in herself. Previous Counseling: The client has been hospitalized as she feared she was having a heart attack which turned out to be a panic attack. According to he client, her husband (her designated emergency contact person) was responsible for creating the conditions that resulted in her being hospitalized. 

Question: Immediately after telling the client that you will call the authorities regarding the bruises you see on her arms, she jumps up and aggressively moves toward you. What should you do first?
(A): Acknowledge the outburst as part of her ongoing psychodrama, and ask the client what she should do next.
(B): Treat the action as a potential assault and call for help.
(C): Tell the client to return to her seat and explore the nature of the outburst.
(D): Call for your supervisor to help you intervene in the situation.

Correct Answer: Tell the client to return to her seat and explore the nature of the outburst.
Explanation: The client apparently acts out when confronted with intense feelings. This could be a sign of progress. It is best to try to de-escalate the situation before taking any other action. It is important to try to help the client manage her emotions constructively. Therefore, the correct answer is (B)
Competency: core counseling attributes