Employees who suffer from anxiety-driven panic attacks will require extra support in the workplace. The following case study describes the type of help available and the involvement of occupational health in the treatment process.
When cable fitter John Jenkins had his first panic attack, he immediately thought that he was dying. Without any kind of warning, he developed pains in his chest and he could not breathe. He was working alone that day and quickly threw his tools into his van and was at the accident and emergency (A&E) department within minutes. Investigations showed that Jenkins' heart was fine; he was medically sound.
However, when he had his second panic attack four days later, he was in the middle of a meeting with six colleagues. Again, he experienced chest pains, sweating and his whole body began to shake. He abruptly left the meeting and locked himself in the toilet for 15 minutes, before getting a taxi to A&E. He was convinced that he was experiencing a heart attack and was adamant that the hospital had got its diagnosis of "panic and stress" totally wrong.
His supervisor had taken note of Jenkins' behaviour and when he asked him if he was ok, Jenkins put on an act and claimed that he was desperate for the bathroom and that he was feeling absolutely great.
The next day, Jenkins had his worst panic attack, while installing some cable in a trench in the middle of a busy shopping area. He was left gasping for breath and needed two of his colleagues to lift him out of the trench and lay him on the floor. An ambulance was called and he was taken to hospital once again. More exhaustive testing showed no physical pathology. However, he was becoming anxious, which was represented by: difficulty concentrating; agitation; frequent urination; avoidance of meetings and colleagues; loss of appetite; irritability; and insomnia.
Jenkins had always been a worrier; even as a child he could recall worrying about his parents, school, money, friends and pets. He feared that danger was just around every corner.
He visited his GP, who asked him if he was experiencing any difficulties at home or at work, or if he was feeling stressed about any other matters. Jenkins explained that his job was always stressful and challenging, but he had always been able to cope with the pressure as he had worked for the company for almost 20 years. His GP diagnosed panic attacks and stress, offered him a prescription of oral medication for benzodiazepines and recommended that he come and see the counsellor based at the practice.
Both were refused by Jenkins and he continued to work. However, his colleagues began to notice that he had gone from being cheerful and funny to serious and barely communicative. Jenkins' supervisor called him into his office to discuss his welfare and performance. Jenkins again put on an act of denying any problems before finally breaking down and weeping. He told his supervisor that he was convinced he was either about to die or go completely mad and that he needed help. He was also worried that his manager would tell his colleagues about his "breakdown" and that he would be labelled a "nutter".
Jenkins' supervisor reassured him that nobody would hear anything about this from him and that he wasn't the only member of the team to experience emotional distress.
Jenkins found this information comforting. He was advised to visit the company's occupational health adviser (OHA).
Reluctantly, he met with the OHA, who explained how the occupational health department worked and that the service was ultimately about making him feel better and working well again.
As part of an overall assessment, the OHA conducted brief anxiety and depression questionnaires, known as psychometrics.
The PHQ-9 is a nine-item depression scale of the Patient Health Questionnaire. The PHQ-9 is a powerful tool for assisting primary-care clinicians in diagnosing depression, as well as selecting and monitoring treatment.
Jenkins made it clear that he would not take any medication and that he did not want to go off sick, as he felt that he would be viewed as a weak link and probably be sacked.
Panic disorder remains a major health problem and is associated with high levels of disability and medical care, compounded by difficulties accessing appropriate treatment."
The OHA emphasised that mental health issues are far more common than many people believe and that the company was very much aware of how important employee wellbeing - both physical and emotional - is.
Jenkins was asked by the OHA if he knew anything about cognitive behavioural therapy (CBT). He admitted that he did not; he also stated that he did not like the sound of it. The OHA gave Jenkins a brief outline of CBT. He then made a referral to a qualified cognitive behavioural psychotherapist approved by the company.
Jenkins was offered 10 sessions of cognitive behavioural psychotherapy and was diagnosed by the psychotherapist with panic disorder without agoraphobia.
What is panic disorder, with or without agoraphobia?
Panic disorder remains a major health problem and is associated with high levels of disability and medical care, compounded by difficulties accessing appropriate treatment (Craske and Barlow, 2006).
Initially called agoraphobia with panic attacks and later renamed panic disorder (PD) with or without agoraphobia (American Psychiatric Association, 2004), PD is one of the most researched anxiety disorders due to its high rate of lifetime prevalence (about 5.1% of adults in the US; anecdotally, this figure is estimated to be around 4% in the UK).
In order to be diagnosed with PD, a patient must have suffered recurrent and unexpected panic attacks over a minimum period of one month, followed by persistent concern about having additional attacks. Panic attacks are commonly accompanied by uncontrollable fear, worry about the implications of the attacks (eg losing control or having a heart attack), or a significant change in behaviour relating to these symptoms.
Many people with the disorder attend A&E believing that they have heart problems. According to the National Institute for Health and Clinical Excellence (NICE): "For people who present with chest pain at A&E services, there appears to be a greater likelihood of the cause being panic disorder if coronary artery disease is not present or the patient is female or relatively young" (NICE, 2007).
What is cognitive behavioural therapy?
CBT is one of the major orientations of psychotherapy (Roth et al, 2005) and represents a unique category of psychological intervention because it derives from cognitive and behavioural psychological models of human behaviour that include, for instance, theories of normal and abnormal development, and theories of emotion and psychopathology.
Cognitive therapy is based on the clinical application of the more recent, but now also extensive, research into the prominent role of cognitions in the development of emotional disorders.
The approach usually focuses on difficulties in the here and now, and relies on the therapist and client developing a shared view of the individual's problem.
This leads to identification of personalised, usually time-limited, therapy goals and strategies, which are continually monitored and evaluated.
Panic attacks are commonly accompanied by uncontrollable fear, worry about the implications of the attacks, or a significant change in behaviour relating to these symptoms."
The treatments are inherently empowering in nature, the outcome being to focus on specific psychological and practical skills (eg reflecting on and exploring the meaning attributed to events and situations and re-evaluation of those meanings) that are aimed at enabling the client to tackle their problems by harnessing their own resources.
The acquisition and utilisation of such skills is seen as the main goal, and the active component in promoting change with an emphasis on putting what has been learned into practice between sessions ("homework").
Thus, the overall aim is for the individual to attribute improvement in their problems to their own efforts, in collaboration with the psychotherapist. Cognitive and/or behavioural psychotherapists work with individuals, families and groups.
Patient details and referral
Jenkins is a 40-year-old married man with a 17-year-old son and works full time as a cable fitter for a large telecommunications company. The referrer reported that Jenkins had recently experienced panic attacks while at work and this was impairing his psychological wellbeing and occupational functioning.
Presenting problems of the patient
Jenkins reported that he was experiencing symptoms of panic attacks, anxiety and worry, which he felt were spontaneous and started four to six weeks earlier.
Cognitive behavioural assessment and mental state examination
Jenkins' assessment and formulation of his problems took place over two appointment sessions. He attended the psychotherapy practice independently. Information was collated through means of clinical interview and self-report questionnaires.
The assessment and examination considered issues such as initial observations about Jenkins and his environment, including the relationship with his family and colleagues.
His "affect" (mood) was assessed along with how his anxiety physiologically affected him, including feelings of muscle tension, headaches and tingling in his fingers.
The behavioural component of his condition meant that Jenkins was worrying excessively; he would not work alone in case he had another attack and he kept seeking reassurance from his colleagues and his wife when anxiety symptoms increased.
An assessment of Jenkins' cognition showed good attention and concentration during both assessment and treatment, though he made statement such as: "If I don't worry, something bad might happen to my son."
Jenkins attended 10 sessions of CBT and completed the full course.
This included setting specific treatment goals (these should be specific goals that can be measured) and formulating Jenkins' problem in a cognitive behavioural framework. Jenkins had the following specific treatment goals:
- Regulate sleep pattern - sleep from around 11pm until 7am, with less than one hour of wakeful periods in the night.
- Achieve a healthy lifestyle, ie eating and exercise - attend the gym three times per week on the way to work and eat less fatty/high-calorie foods.
- Socialise with friends without worrying about son and experiencing an anxiety rating of 3/10 or less.
- Reduce/stop panic attacks.
- Reduce worrying to no more than 30 minutes daily.
- Feel happier - rate mood as at least 6/10 four days per week.
- Stop seeking reassurance for panic/anxiety symptoms (no attending hospital or asking his wife/colleagues for reassurance when feeling anxious).
- Attend and engage in work meetings with an anxiety rating of no more than 3/10.
- Attend lone-worker jobs and complete with an anxiety rating of no more than 3/10.
Clark's model of panic (Clark, 1986) was used to diagnose Jenkins' problem.
This involved socialisation to the CBT model and psycho-education relating to his diagnosis and treatment. Socialisation means to educate the client and help them gain an understanding about how CBT actually works and treats problems. It is also where the client is made aware that homework will be given at each session and how CBT is collaborative. Psychological education was focused around panic disorder, how it develops and why is does not go away. It is very important to revisit the formulation to highlight what behaviours and thoughts maintain the problem. Jenkins became aware that he had a fear of fear. A diary was introduced for Jenkins to record panic symptoms.
This session focused on anxiety management. It is important that when treating panic disorder, Jenkins should really understand how the survival/fight/flight response works.
It is a lesson in human biology relating to the client's problems. This helps with misinterpretation of anxiety symptoms that are a key factor in panic disorder. Jenkins was able to see how his body was preparing to run or fight as he prepared for what he thought was a dangerous situation.
This included an interoceptive exposure/hyperventilation provocation task, which is a behaviour technique used in CBT. It refers to carrying out exercises that bring about the physical sensations of a panic attack, such as hyperventilation and high muscle tension.
This was effective in provoking a wide range of panic-like sensations, such as dizziness, feeling hot, increased heart rate, tightness in the chest and visual changes. It was useful to challenge misinterpretations of these sensations, such as heart attack or fainting, and for building tolerance of anxious feelings.
Sessions five to seven
In these sessions of relaxation and exposure, Jenkins was taught how to utilise a relaxation technique called progressive muscle relaxation, where specific muscle groups are tensed and relaxed.
Sessions eight to nine
In these cognitive restructuring sessions, Jenkins was educated about thoughts/beliefs and thinking and how this affected his behaviour and mood. Within the session, unhelpful thinking habits (cognitive distortions) were reviewed. This enabled the identification of several of these habits that Jenkins experienced on a regular basis.
This session helped Jenkins to prevent future relapse by identifying the helpful changes that he made during therapy in all areas (thoughts, feeling, behaviours, physical sensations and relationships). It also identified signs of relapse and what to do to prevent symptoms returning or how to treat Jenkins' symptoms quickly, similar to an action plan of what to do.
Jenkins was initially resistant to CBT and often the first five minutes of each session would be about restoring his belief in the treatment. Eventually, his gradual improvement enabled him to meet his treatment goals and his psychometric scores reached sub-clinical levels.
One of the most important areas of growth for Jenkins was the knowledge and confidence that while anxiety could not be prevented, it could now be understood and managed."
The occupational health team at Jenkins' company supported him as he gradually returned to work over a three-month period.
One of the most important areas of growth for Jenkins was the knowledge and confidence that while anxiety could not be prevented, it could now be understood and managed.
The OHA trained to deliver the Mental Wealth Programme (Brennan, 2005) and introduced it as a general mental wellbeing option for employees within the company to attend as part of a prevention strategy designed to keep staff feeling well mentally.
Jenkins was able to return to all of his duties after six months and continued to utilise the skills acquired as part of his homework during CBT.
His employers also ran a training course on the Health and Safety Executive's six Management Standards (Health and Safety Executive, 2004) for dealing with stress for managers and supervisors.
Lisa du Plessis is a BABCP-accredited cognitive behavioural psychotherapist and is the director of Sunflower CBT in St Albans, Hertfordshire. Walter Brennan is a training consultant and former mental health nurse, and is the director of Oliver Brennan Training Ltd.
Author note: The name and occupation of the case-study subject have been changed.
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