The following describes the case of Mr B, who sought treatment for panic and acute anxiety. The case involves at least one diagnostic or therapeutic decision point. We invite your comments below. Dr Busch will review your responses and give his feedback in coming weeks.
Questions to consider when reading the case:
1: What psychodynamic conflicts were likely triggers for the patient’s panic attacks?
2: What psychodynamic approaches aided in relief of his panic?
Mr B experienced a severe panic attack 2 days after his 39th birthday. When he was evaluated in the clinic, he scored 12 out of 28 on the Panic Disorder Severity Scale (PDSS), a questionnaire used by clinicians to measure the severity of panic disorder.
The therapist initially explored the circumstances surrounding panic onset. Although Mr B acknowledged that he had been “stressed,” he was puzzled about the source of the panic attacks. He focused initially on problems at work: he was not comfortable with the pressure at work since his recent promotion. As therapy progressed, he realized that he had experienced some of the symptoms of panic several weeks before the full-blown attack when he had to reprimand or fire employees. Specifically, he felt tremors in his arms and a sense of loss of control.
Mr B had a difficult background. His father was a temperamental man who was especially intolerant of his son’s early reading and writing difficulties. He described his mother as self-absorbed, often neglecting him. On 3 occasions, his parents sent him away from home, once to relatives and twice to boarding schools, for reasons he did not understand at the time. As a child, he assumed he was sent away because he was “bad,” or he was being punished for losing his temper with his mother. His parents often fought and ultimately divorced.
Although his relationship with his father improved over the years, his mother became a lonely embittered woman who viewed herself as a victim of unfair life circumstances. She pressured Mr B to take care of her, which he perceived as attempts to draw him away from his wife and job. Although he was angry at his mother’s refusal to take better care of herself, he felt guilty saying no to her.