Cognitive Behavior Therapy Terminates Dependence on Psychiatric Pharmacology: A 6-year Chronic Case of Generalized Anxiety Disorder-ft

Science Insights Medicine, 05 June 2017
2017: e000111
Doi: 10.15354/sim.17.sc051
 
Short Communication (Original)
Cognitive Behavior Therapy Terminates  Dependence on Psychiatric Pharmacology
A 6-year Chronic Case of Generalized Anxiety Disorder
Anand Prakash, PhD;*,∆ Nutan Kumari, MD†,∆
 
Author Affiliations
*: Clinical Psychology & Chief Advisor of Foreign, Students, Department of Medicine, Ibn Sina National College for Medical Studies, PO Box-31906, Jeddah- 21418, Saudi Arabia
†: Department of Anatomy, Katihar Medical College, Katihar, Bihar, India.
∆: Correspondence to: Dr. Anand Prakash, Email: anandprakash72@yahoo.com, Tel: (+)966-554 729 221 Or Dr. Nutan Kumari, Email: drnutanroy70@gmail.com
 
Sci Insigt Med. 2017;2017:e000111. doi:10.15354/sim.17.sc051
 
SUMMARY

Generalized anxiety disorder (GAD) commonly observed in both sexes.  Generally patients don't prefer to visit psychiatric clinic/ hospital for treatment of GAD for several reasons. However, their affirmative decision to such treatment is often directed to psychiatric treatment as a first choice rather than psychological intervention. The present study is a case report of a 21-year old female with chronic GAD suffering for last six years. The case was firstly registered to a medical clinic and thereafter referred to psychiatric clinic for further intervention. Initially she was successfully treated by psychiatric medication, but later she relapsed when attempts failed for terminating psychiatric pharmacological treatment. Eventually, she was referred to the author for possible psychological intervention as the client was willing to lead life without medication. She was comprehensively examined through interview, the Hamilton Anxiety Rating Scale and treated by cognitive-behavior therapy (CBT) of intervention helping her slowly and successfully stopping psychiatric treatment and leading independent life. Details of the psychological assessment and intervention have been presented in this case report.■

Keywords:  Generalized anxiety disorder; Clinical interview; Mental status examination; Cognitive-behavior therapy

 
 
Generalized anxiety disorder (GAD) is a kind of free-floating anxiety which is characterized by excessive and uncontrollable worries about incidents and activities.G
      In fact, anxiety and fear are normal emotional development in personality but become clinically significant when start inferring with life course. Thus, it is important for clinicians to differentiate developmentally appropriate level of anxiety and clinically significant level of worries for proper diagnosis and treatment. Similarly, it must be distinguished from other types of anxiety disorders in terms of nature and specificity of worries of the individual (1). The symptoms of GAD include inordinate apprehension, tension, fatigue, restlessness, inadequate sleep often chronic in nature and fluctuate with current stress level of the individual, and the individual with anxiety must have 3 to 6 physical symptoms for six month to be diagnosed with GAD (2). Usually it begins during pre-adulthood to adulthood stage but it is likely to occur even before with comparison to other anxiety disorders (3). Often its co-morbidity is associated with mood disorders and social phobia, and, twicely common for women as compared to men in prevalence (4). Sometimes persons with GAD have high level of suicidal tendency but especially in elderly stage of development (5).
      The purpose of the present case study is twofold. At one hand, the author aimed at to present a female client of early adulthood in the eastern culture (usually not reported) who was referred to a qualified clinical psychologist for relevant intervention, and on the other hand, to re-establish and spread knowledge and information about CBT in treating such psychological disorder where psychiatric treatment is not effective curing the disorder, as well as, questions are frequently raised against efficacy of psychological intervention in mental healthcare.
 

CASE IDENTIFICATION

AD (changed name) was a 21-year old female who was living in a small town of Darbhanga in Bihar, India. She was the fourth child and completing bachelor in Pharmacy, among five including one brother and four sisters. She belonged to a Hindu family of middle socio-economic status. Her father was senior teacher of language in a government-owned secondary school and mother was also a teacher in primary school. Her two elder sisters were married and settled, and another was completing masters in dentistry and brother was completing under-graduation from a government college in Patna- capital of Bihar. In nutshell, she belonged to a well-knitted family with good interpersonal terms. She achieved all developmental milestones at appropriate age level. She was good in studies and running on scholarship throughout.
 

HISTORY OF PRESENT ILLNESS

The problem began when AD was preparing for board examination before six years. She started feeling loneliness, fear of failure in examination, fear of death, fear of losing mother. She became excessively worried about these issues, started weeping spells becoming depressed. Her problems were increasingly severe within few months as included some more worries. She started feeling loneliness and unable to complete daily chores being alone outside home. Gradually, fears related to prospective employment, life after marriage with tremendous familial responsibilities made her indecisive, distracted from current scholastic responsibilities and anxious all the time.  All these conditions and activities were interfering with her daily activities including studies and familial responsibilities. Gradually it became a part of her daily routine; however, she felt internally bad, uncomfortable as she was very ambitious and goal-directed person who confided her abilities and skills for personal growth, independent living and professionally outshining others in life. Eventually she failed to abandon these feelings and acts, slowly became more serious making her parents worried about and taking her to a psychiatrist for treatment. As per the shown prescription, the psychiatrist diagnosed her with GAD and prescribed her lorazepam (2 mg, twice a day) three weeks and propranolol (50 mg, per day) when required for its indication like chest choking/pain, tremor, high blood pressure etc. The prescription helped her a lot in recovery and she was advised in first follow-up to consume lorazepam (1 mg, daily) at bedtime, which she continued for more than 5.5 years. During consuming prophylactic dose she tried a lot fade and stop medication but unsuccessfully; and eventually symptoms relapsed and compelled her to continue medication against will and desires as she wanted to abolish her dependency on psychiatric medication for further survival and independent living. Hereafter, she was advised by the treating psychiatrist to consult for psychological intervention along with running pharmacological treatment. She asked her previous medical physician (the second author) to get a referral for psychological treatment and thus, she consulted the first author for effective intervention..
 

CLINICAL AND PSYCHOLOGICAL ASSESSMENT

Her clinical assessment including clinical interview and mental status examination diagnosed her a person with GAD as per the diagnostic guidelines of DSM-IV (6). During the assessment, she was cooperative, oriented and insightful. Her anxiety-related thought, behavior s and conflicts were conspicuously recognized. She was little depressed, dependent on mother and having some sleep disturbance, which appeared secondary to the psychopathology. No thought-, psychomotor and other psychological disorders were found. The complexity of the symptomatic profile was moderate to severe on the Hamilton Anxiety Rating Scale. The therapeutic assessment was conducted through applied behavior analyses. The assessment unveiled pertaining to the possible psychological dynamics of the problem revealed that the severity of the client’s problem was often catalyzed by her failure in daily life-related aspirations & achievement, criticisms, negative comments in surrounding, loneliness, academic stresses, and thinking about impending conflicting situation making her self-centered and ruminating in difficult situations. These factors affected her self-confidence, fading of psychiatric drug and led dependence on the same. As results, she could take self-initiatives in any course of desirable planning and actions affecting her professional internship and successful coping in daily life. Nonetheless, she had a good insight into the problem at cognitive level, social support system and prognosis. She supported by her parents and siblings to consult for psychological intervention after five years of psychiatric treatment.
 

PSYCHOLOGICAL INTERVENTION

The client and her family / caretakers were properly informed about the diagnosis and nature of desirable treatment in GAD. She was taken for psychological intervention by the cognitive-behavior therapy with proper consent and familial approval. Her major anxiety-provoking thoughts and conflicts comprised of: anxiety related to traveling alone for personal headway and leaving family for selfishness, apprehension related to death alone, death of mother; nature of fellow interns not matching with her, why no teaching in internship, future studies, apprehension pertaining to job matching with salary and perks, impending fears and conflicts related to selection of spouse and life after nuptial knot. The mutually decided treatment planning and proceedings comprised progressive muscular relaxation, gradual exposure through flooding and implosive therapies, cognitive therapy, thought stopping, reappraisal, restructuring, activity scheduling, cognitive restructuring and brief group counseling including family members (7). The client was called twice a week at the fixed time for psychological intervention.
      For intervention, initially she was advised to continue her prophylactic dose of psychiatric drug until asked. During the first two sessions of the psychological treatment, she was taken for training on the Jacobson's progressive muscular relaxation to be applied everyday at home. It was aimed at teaching her to realize feeling of tension and relaxation of body and mind affecting daily life situations.  Review of her daily life was conducted till the end of treatment program to check her successful compliance and to find out any obstacle to be resolved. For family support in treatment program one of her sisters was found very close to her who became ready to help her at home as per therapeutic guidelines to be implemented. Since AD was apprehensive of the internship program, therefore, she was taken for gradual exposure therapy through systematic desensitization, flooding and implosive therapies in some sessions at the clinic and home alleviating her symptoms of anxiety. In the technique of exposure, the client repeatedly confronts apprehensive situations gradually causing slowly decrement in anxiety level of the client towards coping with the situation and anxiety both. Such exposure can be gradual (e.g., systematic desensitization) or in flooding and implosion (e.g., in vivo and in vitro exposure). In relation to the present case, this technique was implemented on both behavior al and cognitive level until the anxiety of the client came down. Simultaneously, she was provided balloon therapy to control drastic symptoms of anxiety, which she completed successfully. The balloon therapy requires a client to cover face with the balloon / or a plastic bag and blow it up by inhaling and exhaling in the same until feeling of suffocation would be unbearable. She was counseled and taught to apply the same through generalizing the same in difficult situations of daily life for relaxing herself.   All these interventions helped her a lot and she seemed to realize effectiveness of these techniques in controlling anxiety. Thereafter, she was taken for cognitive therapy and reappraisal wherein her negative thoughts related to fear of death, separation from mother and family for career development, professional situations of internship, dependence on others etc. were challenged, and trained her to perceive difficult life situations in a less threatening way rather than strangulating and creating impasse.  For improvement of adequate sleep during normal sleeping hours, she was taught and advised to practice paradoxical intention along with some other relevant lifestyle modifications, e.g., no consumption of tea/coffee after 5:00 PM, use of bed only for sleeping rather than studies/ eating, conversation table etc.; use of cotton made loose and comfortable dress for sleeping, eating curd with dinner etc.  Up to this phase of treatment (i.e., around 10th session), she was observed found confident of herself to take self-initiatives for further intervention.  Therefore, in 11th session, she was asked and taught to begin fading of psychiatric medication. She was asked and advised with mutual consent to increase gap slowly between previous and prospective dose of medication following all previous treatment guidelines. She started the same under supervision at home successfully and she took a total of twenty-two days for complete termination of the psychiatric drug. She was closely reviewed and reinforced in follow-up visits of psychological treatment. But, suddenly on the day she was confirmed successful, she could not believe herself and became apprehensive as if she could have relapsed.  For the purpose, she was provided cognitive restructuring and some sort of counseling by applying the transtheoretical model, which is highly useful especially in substance abuse.  In addition, thought stopping was also applied which helped AD control her automatic recall of anxiety-provoking ideas and thoughts disturbing her previously. In this technique, the client is taught to interrupt the flow of apprehensive thoughts to deal more effectively with both situations. In the beginning, the flow of thoughts is induced by the therapist and is interrupted with a sudden stimulus, e.g., saying ‘stop it’ loudly while slapping the desk by the clinician. It is repeated for ten minutes. Hereafter, the situation of thought inducing is continued but it is interrupted by the client him/herself with the repetition for another ten minutes. Thereafter, the process of interruption by the client is continued but it is done silently in place of loud and emphatic interruption. AD was quite benefited by this technique in terminating her anxiety-inducing memories and thoughts. The cognitive restructuring which focused on helping AD to learn to take time and look critically at the negative thoughts and feeling of anxiety in various situations, and reduce misinterpretation of the same. This technique of intervention makes explicit use of cognitive concepts to understand and modify overt behavior helping the client in gradually replacing negative self- verbalizations with the positive statements. It facilitates more logical and effective problem solving to the existing problems and reduces the probability of similar problems occurring in the future. Thus, it contributes significantly in increasing self-efficacy, which comprises self-control, self-monitoring, self-reward and self-evaluation as well. It helped AD in quick recovery in forthcoming sessions and effective compensation of personal, social and educational losses. Later, few sessions were focused on family counseling comprising her kingpin family members. Since her problem was also facilitated by expressed emotion of family and friends, therefore, significant persons from these domains were benignly called and included in her intervention program. They were taught about the nature of the problem, its severity affecting psycho-social functioning and their role in treatment. They were confirmed that the purpose of their scolds and criticisms was not against of AD, but since she was caught by a clinical problem and related negative cognitive and emotional development, therefore, she was unable to interpret their comments positively, rather misconstrued the same which snowballed her symptoms of GAD. They were advised to reinforce her positive outcomes. At last, AD recovered from all symptoms of GAD and associated depression and sleep disturbances in seventeen sessions of psychological intervention. At last, she started steering her life without psychiatric medication for last two months with desirable level of performance in development of professional career.
 

DISCUSSION AND CONCLUSION

The present case was a typical example of GAD and the board examination of AD was an antecedent factor to the symptoms of disorder. Atypically, it started during examination period rather than due to/ after examination. Appreciably, she insightfully recognized her problems and consulted for treatment.  Since, herself was a student of clinical science, therefore, possibly her educational background prompted her for consultation without much delay. The clinical assessment and effective therapeutic steps revealed that severity of GAD was inevitably facilitated by personal negative thoughts, educational & interpersonal situations, and expressed emotions in family (8, 9, 10). Thus, there was a clear implication for prevention that parents should have been attentive and careful about all sorts of attention-seeking and apprehensive behavior s of AD, as well as, observant on impact of interpersonal exchanges on the clients' emotions and cognition as all these affected her psychosocial functioning badly in daily life. Furthermore, her educational background in clinical science (i.e., pharmacy) and support from her closest family member, her dentist sister (a resource from clinical background) prompted her for quick steps towards and understanding significance of psychological treatment with proper and adequate compliance along with ongoing desirable results. Since Ad was evaluated to be willing to lead independent life with excellence in professional education and career indicating a flickering sign of will power, therefore, she was guided and driven along this characteristic of her personality which contributed a lot in entire interventional exercises, recovery and future prevention. Eventually, AD was fully cured by psychological treatment to lead life without psychiatric medication for GAD.■
 

ARTICLE INFORMATION

Author Affiliations: Clinical Psychology & Chief Advisor of Foreign Students, Department of Medicine, Ibn Sina National College for Medical Studies, PO Box-31906, Jeddah- 21418, Saudi Arabia (Prakash A); Department of Anatomy, Katihar Medical College, Katihar, Bihar, India (Kumari N).
Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: N/A.
Obtained funding: N/A.
Administrative, technical, or material support: All authors.
Study supervision: All authors.
Conflict of Interest Disclosures: The authors declared no competing interests of this manuscript submitted for publication.
Funding/Support: N/A.
Role of the Funder/Sponsor: N/A.
How to Cite This Paper: Cognitive behavior therapy terminates dependence on psychiatric pharmacology: A 6-year chronic case of generalized anxiety disorder Sci Insigt Med. 2017;2017:e000111.
Article Submission Information: Received: April 25, 2017; Revised: May 09, 2017; Accepted: May 09, 2017
 

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