Case Study – The Case of Agnes

The Case of Agnes

The following is a case study analysis of Anxiety, Somatoform, and Dissociative Disorders. The writer will present an analysis of a selected case as described in the text, Case studies in abnormal behavior (8th ed.) by Meyer R., Chapman, L.K., & Weaver, C.M. (2009). The writer will also provide a brief overview of the selected case as well as analyze the biological, emotional, cognitive and behavioral components of the disorder. The case selected is “The Case of Agnes”.

Overview of Case Study

The character in this case study is known as Agnes, a woman who was brought in to the community mental health center in the eastern seaboard city by her daughter who believed that her mother was mentally ill. Her family included of a husband and one daughter. Agnes believed that she suffered from “heart disease”, but her physician reassured her that it may be anxiety and tension. Agnes may have being suffering from anxiety disorder known as Agoraphobia, which is classified in the DSM-IV-TR as a fear of being left alone or finding oneself in public places in which one could be embarrassed and unable to find help in case of sudden panic attacks (Meyer, Chapman & Weaver, 2009). The biological, emotional, cognitive and behavioral components of this disorder are discussed in this paper.

Current Description

According to the text, Agnes is a thin 43 year-old married white female who was taken to the mental health center in her hometown in the eastern seaboard city by her 22 year-old daughter, who feared that her mother was mentally ill. She claimed that her mother wanted to accompany her everywhere she went and that placed her in an awkward position. Agnes has always been a tense person and has reported experiencing agoraphobic symptoms for about seven years with symptoms becoming even more intense over an extended period. Agnes also believed that she suffers from heart disease and often complains about experiencing irregular heart beat. Her physician does not believe it is anything but tension and anxiety. Agnes uses tranquilizers to relieve severe bouts of anxiety. She never experiences these symptoms at home even after engaging in heavy household chores. Agnes worked as a secretary after graduating from high school. Though she dreamed of getting a college degree, she never pursued it instead she continued working as a secretary and helped her husband to finish his last year in college. In the early years of marriage she was fairly stable in her functioning, but her problems with this disorder increased over the years.

Predisposing Factors

Agnes’s childhood years were not unhappy. Her father was an authoritarian but he was warm and loving to his children. Agnes’s father drank liquor and in his drunken state, he would whip her rebellious brother (Meyer, Chapman & Weaver, 2009). Her mother was a passive and very submissive woman and showed symptoms of agoraphobia although she never sought treatment for herself. According to the text, Agnes was a “good student” and “teacher’s pet” and had a few friends with whom she would communicate about her problems (Meyer, Chapman & Weaver, 2009). Agnes was not physically attractive and this hindered her from overcoming her withdrawal patterns. She did not participate in school activities, neither was she very sociable. This lack of interest helped to promote her peers lack of attention toward her. Agnes married a man who bore similarities to her father’s authoritarian style. Agnes gave birth to one child, followed by a miscarriage. This was her first panic experience but it was soon brought under control by medication administered to her in the hospital. Agnes’s daughter was very independent and Agnes felt threatened by her own sense of need.

The more independent her daughter became, the more liable to anxiety Agnes became (Meyer, Chapman & Weaver, 2009). Agnes did not seek advice from different physicians regarding her symptoms, but adhered to the advice of her personal physician. Her experience of panic made her realize what being helpless meant and for her, it was a very frightening experience. She learned a variety of behaviors that would keep her from going through this panic experience, and these behavior patterns proved to be successful but it meant giving up such things that were important to her, including her husband and daughter, who were very irritated by her behavior. Agnes only became more alone emotionally.

Components of the Disorder

According to Meyer, Chapman & Weaver, 2009, a person who suffers from Agoraphobia is identified by an irrational fear of leaving their home and its immediate surroundings. This often happens after having various panic attacks. The DSM-IV-TR diagnoses are Agoraphobia without History of Panic Attack, Panic Disorder, and Panic Disorder with Agoraphobia (Meyer, Chapman & Weaver, 2009). Agoraphobia is described as avoidance of any situation, especially being alone, where people fear that they would be embarrassed or unable to receive help in case a panic attack does happen (Pollard & Zuercher-White, 2003 as cited by Meyer, Chapman & Weaver, 2009).

The fear controls their world, thus they are fearful of being alone in public places. Because of this, their behavior patterns and experiences are disrupted (Meyer, Chapman & Weaver, 2009). Specific diagnoses of Panic Disorder associated with Agoraphobia or without Agoraphobia are: (1) Recurrence of attacks, and (2) Continuous attacks being followed by one month of repeated episodes of (a) person’s concern about attacks, (b) Person’s concern about what would happen if they were experiencing an attack, or (c) a complete change in behavior as a result. To diagnose a panic attack, the DSM-IV-TR requires a specific episode of the fear and/or discomfort and the presence of at least four of the symptoms during the attacks, as listed below:

1. Palpitations, accelerated heart rate
2. Chest discomfort
3. Choking sensations
4. Feeling faint or dizzy
5. Feelings of unreality or depersonalization
6. Paresthesia (numbness or tingling)
7. Hot or cold flashes
8. Sweating
9. Shaking or trembling
10. Nausea or abdominal distress
11. Fear of dying
12. Fear of going crazy or losing control.

Panic attacks can last for hours, but they typically last for about 15 minutes during which time the individual is at a high risk of suicide. Meyer, Chapman & Weaver, 2009 states that about one-third to one-half of these individuals develops agoraphobic patterns.

Biological

Agoraphobia is described as a person’s fear of being outside or otherwise being in a situation from which one either cannot escape or from which it would be difficult to escape. Most of the time, the disorder is full blown because of panic disorders. Some theories associated with the biological factors are:

• Fight or flight reflex: According to theory, panic disorder is associated with the body’s natural ‘fight or flight’ reflex which is the body’s way of protecting the individual from stressful situations (www.nhs.uk). Anxiety causes the body to release the hormone – adrenalin, causing the individuals breathing and heart rate to increase. Fight or flight reflex if brought on abnormally will cause panic attack (http://www.nhs.uk).
• Neurotransmitters: Another theory is that a lack of balance in levels of neurotransmitters in the brain affects mood and behavior and can lead to a high level stress response in some conditions, developing feelings of panic (http://www.nhs.uk).
• Fear Network: This theory proposes that the brain of individuals with panic disorders may be wired differently from most people, causing abnormality in functioning in parts of the brain which generates emotion of fear and the effects associated with fear (http://www.nhs.uk).
• Spatial awareness: Researchers have found a link between panic disorders and spatial awareness. Spatial awareness is associated with a person’s ability to judge their location in relation to people and things around them. Those who suffer from this disorder lack sense of balance and space that can result in them feeling overwhelmed and disoriented in crowded places, setting off a panic attack (http://www.nhs.uk).

Another biological factor for Agnes’s disorder could have been genetic as the text stated that her mother has shown symptoms of Agoraphobia over the years but never sought medical attention. According to the text, onset of the disorder usually occurs between the ages of late adolescence or the mid 30’s. If the disorder occurs before age 20, it is very likely that an immediate member of the family has suffered from a panic disorder (Meyers, Chapman & Weaver, 2009). Emotional

Agoraphobia symptoms are characterized by certain fears that are common to most people with this disorder. These are: The fear that an attack will occur

• Being alone
• Loss of control or mind in public
• Being embarrassed
• Fear of helplessness
• Avoidance behavior

Fear of crowds or anywhere that presents difficulty in escaping. Whenever a panic attack occurs in public, the person with agoraphobia believes that they are in danger and does everything to avoid a recurrence in the future. Many people with agoraphobia either remain at home or limit their livelihood to that which they believe is accommodating for them (http://www.sound-mind.org). Cognitive

The cognitive components of the disorder include beliefs that certain sensations are dangerous. For example: increased heart rate is believed to be a sign of heart attack or having a stroke. Shortness of breath is considered as a sign of suffocating, while dizziness could mean that the person will faint or lose control over the body. Clark, 1988 describes such cognitions as “catastrophic misinterpretations” where normal feelings of anxiety and some harmless physical sensations are interpreted in a dramatic way signaling physical and or mental issues (Clark, D.M (1988).

Behavioral

Many people have the mistaken belief that those who suffer from agoraphobia are afraid of open spaces or are afraid of crowded spaces. This is not so. The truth is that these individuals are not afraid of open or crowded spaces, but they are afraid of what could take place in any of these places in the event that they should have a panic attack. They could become helpless and not able to communicate with anyone and it could cause embarrassment. Agoraphobics may develop depression, fatigue, tension,
spontaneous panic and obsessive disorders. The Agoraphobia disorder is developed usually after a series of panic attacks, usually occurring in public places such as shopping malls, public transportation, supermarkets, restaurants, theaters, traveling far from home and being alone (Hazlett-Stevens, H. (2006) . They occur randomly and with warning and this makes it difficult for the individual to know what is causing the reaction.

Conclusion

Agoraphobia is a disorder which is described as avoidance of any situation, especially being alone, where people fear that they would be embarrassed or unable to receive help in case a panic attack does happen (Pollard & Zuercher-White, 2003 as cited by Meyer, Chapman & Weaver, 2009). The DSM-IV-TR diagnoses are Agoraphobia without History of Panic Attack, Panic Disorder, and Panic Disorder with Agoraphobia (Meyer, Chapman & Weaver, 2009). The fear of panic attacks controls their world, thus they are fearful of being alone in public places. Because of this, their behavior patterns and experiences are disrupted. Specific diagnoses of Panic Disorder associated with Agoraphobia or without Agoraphobia are:

1. Recurrence of attacks
2. Continuous attacks being followed by a month of repeated episodes of person’s concern about attacks, Person’s concern about what would happen if they were experiencing an attack, or a complete change in behavior as a result.

The biological factors associated with this disorder are Fight or flight reflex; lack of balance in levels of neurotransmitters in the brain; fear, and spatial awareness. Fear is also an emotional factor that is common to most people with this disorder. Cognitive factors include the belief that certain situations are dangerous, while behavioral factors includes the knowledge that they could become helpless if and when a panic attack occurs in public places. There were a number of factors in Agnes’s life that could have contributed to her developing Agoraphobia. According to the text, she was timid and shy. Her parents could have been a major influence as well. Her father was very adamant about the kind of behavior that he expected from his children in particular from Agnes, and her mother was the biggest influence, having exhibited agoraphobic behavior herself.

Agnes’s lack of attractiveness and withdrawal from social activities or attention from males and her peers could also be a factor in the development of this disorder. Agnes’s diagnosis was Agoraphobia with panic attacks (Meyer, Chapman & Weaver, 2009). There are a number of treatments that may prove useful in dealing with agoraphobia. Cognitive behavioral and behavioral treatments have proved to be most popular in treating anxiety disorders. The American Psychiatric Association (APA) estimated a 1 year prevalence of Panic Disorder between 1% and 2% with up to one-half of these individuals also suffering from Agoraphobia (APA, 1994; Hazlett-Stevens, H. 2006). Some treatments that have been known to be effective are effective exposure which involves constant contact with the situation that the individual is avoiding while the person exhibits reasonable levels of anxiety. Lessons on progressive relaxation in agoraphobic situations can be beneficial.

References

1. (Myer, R., Chapman, L.K., & Weaver, C. M.). Case Studies in abnormal behavior (8th ed.). Boston, MA: Allyn & Bacon. http://www.nhs.uk/Conditions/Agoraphobia/Pages/Causes.aspx
2. http://www.sound-mind.org/agoraphobia-symptoms.html#.UmyRY
3. http://www.sound-mind.org/agoraphobia-symptoms.html#.UmyRY1XD8RY1XD8RY Clark, D. M. (1988). A cognitive model of panic attacks. In S. Rachman & J. D. Maser (Eds.), Panic: Psychological perspectives. Hillsdale, NJ: Erlbaum. www.springer.com/cda/content/…/cda…/9780387283692-c2.pdf?…0…
4. Hazlett-Stevens, H., & Craske, M. G. (2003). Live (In vivo) exposure. In W. O’Donohue, J. E. Fisher, & S. C. Hayes (Eds.), Cognitive behavior therapy: Applying empirically supported techniques in your practice.
5. Hoboken, NJ: Wiley. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.