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Table 3 Patients’ performance in each session

From: Cognitive behavioral therapy for postpartum panic disorder: a case series

The protocol Patient 1 (Chihiro) Patient 2 (Beth) Patient (Tammy)
1) Assessment and goal setting
(Session 1)
Symptoms associated with panic: Asphyxia, palpitation, shortness of breath, strong fear
Catastrophic interpretation: “Being stifled and suffocating”
Inflated responsibility: “I am a mother, but I can’t protect my child if a panic attack occurs. I must make an effort to absolutely not cause a panic attack.”
Goals: Learning to cope with breathlessness and gradually becoming free from it. Being able to ride in a vehicle without problems and finally living without worrying about panic attacks.
Symptoms associated with panic: Palpitations, fluttering, dizziness, hand tremors, feeling faint.
Catastrophic interpretation: “If I feel my heart beat rapidly, I will fall down soon.”
Inflated responsibility: “If something happens to me, my husband’s job will suffer, and he will be negatively evaluated by his boss/colleagues. My panic attack will have a bad influence on the child’s rearing and education. Hence, I always have to immediately recognize and deal with the physical discomfort.”
Goals: Visiting the office she worked and her friend’s house with her children by train. Getting a haircut by a hairdresser for the first time in a year. Overcoming the daily breathlessness, dizzy, and worrying about the next panic attack.
Symptoms associated with panic: Tightness, heat, sweating, palpitation, fear of insanity.
Catastrophic interpretation: “If I recognize my physical symptoms, I will feel suffocated, my body will heat up, and I will lose control over myself.”
Inflated responsibility: “If I feel the beginning of a panic attack, I cannot play with or take my children anywhere. I must be in control of my physical symptoms.
Goals: Playing with children and living everyday life without worrying about panic attacks.
2) Phyco-education
(Session 2)
First, the therapist told them: “Pregnancy is a period during which physiological, psychic, hormonal, and social changes take place, increasing the risk of psychiatric morbidity in this stage of a woman’s life [40].” “Some women experience pregnancy as a source of happiness, satisfaction, and self-fulfillment. Others experience a change in their mental health, such as the development of anxiety [41].” Second, the therapist introduced the concept of PD and the CBT model of PD [34]. All patients who listened to this information said that “PD fits my symptoms of anxiety or panic attack.”
3) Case-formulation
(Session 3)
See Fig. 1. Situation: At a husband’s promotion party, standing next to her speaking husband
Schema: I fall over feeling scared and dizzy
Negative thought: I’m nervous; I’ll fall flat on this
Self -focused image: If I fall down, I will be judged as a mentally weak person
Anxiety: Palpitation, asphyxiation, wandering, heat, sweating
Safety behaviors: Apply strength to your body not to fall down, grasp the husband’s arms firmly, say “OK.”
Situation: Enter the hairdresser’s alone and sit in a chair
Schema: A panic attack occurs if you do not cope with breathlessness immediately
Negative thought: Feeling suffocation will get worse
Self-focused image: I’m struggling and suffering myself
Anxiety: Asphyxiation, hace and neck feel flushed with heat, restless, fear
Safety behaviors: Breathe deeply, drink water, go outside the store and take in deep breaths of the outside air
4) Safety behaviors
(Session 4)
Wear loose clothes, refrain from exercise, always worry about the condition of the throat, and have her family accompany you when you go out. Do not put a burden on the body as much as possible, do not go out as much as possible, use the Internet to immediately check any concern, as well as the necessary place to visit. Do not take a hot bath, refrain from playing with children, do not lift children, refrain from going out, stop going out.
5) Re-constructing the self-image
(Session 5)
Shoot me when I feel stuffy and watch it on the video. When I feel dizziness or flutter, I stand in front of the mirror and observe realistic situation. Watch the role play video when you are on the train.
6) Attention training
(Session 6)
Visual: Counting the colors in the consultation room.
Taste: Drinking tea and describing the taste.
Hearing: Children’s voices and footprints.
Tactile feeling: The feeling of holding a baby.
Visual: Counting the color of the counseling room, verbally describing the children’s appearance
Taste: Drinking tea and explaining the taste
Visual: Look at the landscape
Smell: Depict the smell
Hearing: Explain the sounds you hear
7) Behavioral experiments
(Sessions 7–11)
Interceptive exposure: Excessive Breathing; Stair dash from first floor to 9th at the hospital.
Situations of in vivo exposure: Exposure to anxiety situations (nearby small parks, fast trains, road trips while sitting in the back seat of a car, and amusement parks).
Interceptive exposure: Breathing through a straw; Turn around on a swivel chair; Stair dash.
Situations of in vivo exposure: A train at each station; Limited express trains; Shopping malls.
Interceptive exposure: having a shower on face; handstand; squat; walking hardly.
Situations of in vivo exposure: Driving a car with children; Large parks in the suburbs; Express trains over more than one hour.
8) Re-scripting early panic memories
(Session 12)
Intervened in panic attacks that occurred during hospitalization for second child delivery. Intervened in a panic attack that occurred at her husband’s promotion party. Intervened in the panic attack that occurred in the beauty salon after the miscarriage,
9) Modifying pre- and post-event processing
(Session 13)
Don’t over-reserve and don’t take a break after it’s over. go out without preparing too much, worrying about physical illness, or examining various things. Don’t rehearse in my head, come back home, or consult husband.
10) Opinion survey
(Session 14)
Chihiro noticed that even if she had a panic attack, surprisingly nobody would blame her or care. Beth was worried when she had a panic attack in public. Tammy, as expected, reaffirmed that people around her were tolerant of panic attacks.
11) Schema work
(Session 15)
The catastrophic interpretation has been transformed into a safer one, saying, “Even if I get stuffy, I’ll be relieved.” The catastrophic interpretation was corrected from “I will not fall even if I have a tightness.” to “If I go out, I will not feel tight because I will not be paying attention to it,” and “I can cope with tightness.” The catastrophic interpretation has been corrected to be safe, “It will be manageable even if I feel stuffy, or sealed, or receiving emergency hospitalization, etc.”
12) Preventing relapse
(Session 16)
Daily exposure to tightness and asphyxiation. If Chihiro can’t respond on her own, she must go to the hospital without hesitation. If Beth can’t cope, she must go to the hospital. She must take her children to the park regularly even if she feels uneasy If I cannot cope, I will go to the hospital.
Play with children without hesitation. Having experience that the tightness and heat flushes daily by interceptive exposure.