Psychiatric Interviews for Teaching: Anxiety

Psychiatric Interviews for Teaching: Anxiety

December 3, 2019 55 By Stanley Isaacs


– Hello, Julie Thomas? – Yes, Hi. – Hello there. My name’s Dr Vehdi, I’m one of the new GPs in the practice… – Right
– and I’m seeing you today instead of Dr Jones who’s your usual GP. – Yes, he is, yeah yeah. – First of all, what would you like me to call
you? – Oh, Julie’s fine, yeah. – Ok. Right Julie, so what is it that’s brought
you to see me today? – Well, it’s the same thing that I see Dr
Jones about, it’s my heart. – Yeah, yeah, I understand that you’ve been
in to see him a few times over the last few months. Would you mind if I ask you to go
over again what the problem is, perhaps in your own words so that I get an understanding
of it? – No, not at all, it’s just I keep getting
these situations where my heart starts to really, really race like boom
boom boom boom boom boom.
– Right – I get chest pains,
– Aha
– I can’t catch my breath. It’s making me feel funny talking
to you about it! – Right
– And, um, so my heart starts to race, I can’t get my breath and then
I get chest pains and I get very afraid that I’m going to have a heart attack. – Right, right and you’re feeling a little
bit anxious just here with me? – I am,
– Ok.
– yeah, just talking about it – Ok, ok
– I can feel it starting to come up.
– Right, take your time, take your time. – Ok, thank you. – So, your heart starts to race, it really beats
really fast and you feel like you can’t catch your breath, is that right? – Yeah, that’s exactly it, yes yeah. – How long’s all this been going on for Julie? – I think it’s probably about six months,
basically, yeah. – Right Ok. And can you remember what happened to start it all off? – Er, well, I think, urm, we have had
some problems at work,
– Right – erm and erm I’ve felt more stressed about work than I normally do, and basically I was
just trying to get into town one day on a day off and it was very hot, one of those
funny hot days, and it just happened; my heart started to race and race and race and I couldn’t
get my breath. I was just, like, gasping for breath, then I started to get chest pains
and it was just awful. And I managed to sit down and call my husband
– Right
– and he came out, he actually left work to come and get me. – Right, so that sounds like quite an unpleasant
experience for you, at the time. – It was awful, it was really, really frightening,
yeah. – And when that was happening to you, Julie,
when you were in the middle of town, what was it that you thought was going on? – I thought I was having a heart attack. – You thought you were having a heart attack? – I really did, yeah, and each time it happens
I’m so afraid that that is what’s happening. – Right, ok. – So, you know, I started to try and avoid situations
where I might get like that, basically. – Right, so what kind of things are you finding
yourself avoiding? – I can’t get into town now without my husband
taking me because my husband has to take me to and from work.
– Right
– And I also thought I shouldn’t do anything to put any strain on my heart at all, so I don’t do much exercise or anything
at the moment – Right
– and other things as well. – And other things, what sort of other things
are you not doing? – Well, just some personal things. – Personal things, ok. I guess I’m wondering
if you’re talking about your sex life there. – Yeah,
– Right
– I just feel that I shouldn’t, you know, do anything like that because it just might put too much strain on me. – Right so you’re avoiding sex in case that
puts you’re heart rate up? – Yeah, yeah.
– Ok, ok. How’s that affecting things between
you and your husband? – It’s not, I mean, yeah, my husband’s getting
really fed up with it, to be honest doctor. – Right, aha. – He’s been really, really kind and really
supportive but I think it’s starting to affect his life quite a lot now.
– Right
– He wanted me to go to the pub last week, and I absolutely promised that I would, because I’d begun
to stop wanting to go out because I’m so afraid it’s going to happen. And I promised
and promised him I’d go to the pub and then when it came to it I just couldn’t, I just
sat on the sofa and it started to happen again. – Right – And then I was worried if I went to the pub
I’d actually get ill in the pub.
– Right – And then it’d be really embarrassing for everybody
so I just said I couldn’t go,
– Right – and I think he’s getting a bit to the
end of his tether now,
– Right – because it just seems to have come out of the blue, and I’ve never suffered from
anything like this before. – So it sounds like he’s getting to the end
of his tether, but it also sounds like you’re pretty fed up with the whole thing as well
– Yeah, yeah.
– Julie, is that right? – Yeah, I am actually, yeah, yeah. – Ok, so just so that I’ve got the story straight,
this all began about 6 months ago, before that had you had anything like this? – No, not at all, I mean, I think we had a new
manager at work, I work in a bank actually, and then we had a new computer system put
in and so it became very much more stressful for all the staff, not just me,
– Right
– and I can sort of see I was under a lot more pressure – Right
– and that could be affecting me. – So just to make sure I’ve got the right
way around it, it began 6 months ago, pressure at work,
– Yeah
– you went to town, you had the first of these attacks,
– umm umm
– and then since then you’ve had some more of them,
– Yeah, yeah
– and now it’s kind of got to the point where you don’t want to go out,
– I don’t no.
– you don’t go to town by yourself… – No, I don’t want to risk it to be honest.
– Right, right. You’re not going to the pub, you’re not
socialising like you used to,
– No, no. – and you’re avoiding things like exercise and things like
sex,
– Umm, umm – and that’s having a bit of a, taking its toll on your relationship. – It is a bit, yeah yeah.
– Ok, ok. And, looking at your…I know you’ve had an ECG
– Yeah, yeah
– that Dr Jones organised for you a couple of months ago
– yeah
– what have you been told about the results of that? – Well, Dr Jones said that it was ok
– Right
– and there were no problems. And, you know, I did feel relief you know because obviously there has been heart attacks in my family, my dad died of one, you know, at 72,
– Oh right, OK.
– so I’m thinking it must be my heart, there must be something wrong with it – Right
– and I did feel pleased when Dr Jones said
that, but on the other hand nothing’s changed, you know, I’m still getting exactly the same
problems, – Right
– nothing, you know, I’m not getting any help with it, I just feel a bit like, well, so I haven’t
got a bad heart according to the experts, but I’m still getting all the same symptoms
and they’re getting worse and worse. – So even though the GP’s told you there’s
nothing to worry about with your heart, do you still worry that there might be something
wrong with your heart? – I do, I just can’t understand it, what do
you think it is, doctor? – Well Julie, I think I’d agree with Dr Jones,
I don’t think there is anything wrong with your heart. The reason I say that is that
you’ve had an ECG which has come back perfectly normal, and usually if there was a problem
with the heart the ECG would pick something up, also, you’ve got none of the risk factors,
really, for heart disease because you don’t smoke, your blood pressure (from what I can
gather from your notes) has always been fine, you’re fairly young, before this you were
pretty fit and active, and also, I know you’re worried about your dad having had a heart
attack, but actually, he was a lot older than you are, and so you’re not really in the
same risk bracket as he would’ve been. – Right – So I don’t think that there is a problem with
your heart, I guess what I’m wondering is whether actually what’s going on is a little
more what Dr Jones thought, whether actually this might be the anxiety that’s giving
you a lot of these symptoms. Have you ever thought it might be that rather than a heart
problem? – I think I’ve been thinking more recently
it could be, because my friend has panic attacks, – Right
– and I’ve discussed it with her and she said,
to be honest it just sounds like that. I’ve always thought it was my heart, and what I
can’t understand is how my brain is making my heart start racing like it is.
– Right, right, ok. Has anyone explained to you about
anxiety and panic attacks? – Not really, no. – Ok, well perhaps it’ll be helpful to sort of hear a little bit more about that.
– Yeah, ok. What we have on top of our kidneys is two little glands, and they’re called our adrenal glands,
-Right – and they produce a hormone called adrenaline,
have you heard of that? – Yes, I have heard of that.
– Ok. And what adrenaline does is it prepares us
for situations of fight or flight, is that a term you perhaps remember from biology at
school? – I do, I do, yeah, I do remember that. – Do you remember what we mean by fight or flight? – I think like if you’re in a scary situation you
either fight or run away basically,
– Yeah – your body sort of triggers that to do it.
– Yeah Yes. That’s exactly it, and what’s released
to allow you to do the fight or flight response is the adrenaline,
– Right
– so when your body needs you to get ready to do something, it surges out a load of adrenaline, and the adrenaline
basically gets you ready for action,
– Right – so it does things like it gets your heart rate up,
it gets your breathing speed up, so that you’re ready to run, it can sometimes make people
feel as though their mouth is dry, it can sometimes make people feel a bit lightheaded. Are those the kind of symptoms that you can get? – Yeah definitely, yeah definitely, all of those actually. – Right, ok. What often happens with people
with panic is that the first time that happens, the first adrenaline release occurs out of
the blue, and perhaps at times of stress, and you mentioned that there was stuff going
on at work, you’re feeling a bit stressed out, and in town it was a bit hot – so that
may have been what was behind that first panic attack. What happens to people is that once they’ve had one panic attack they go on to have more, and the reason for that is that
once you’ve had something like that happen to you, you’re kind of there thinking, ‘ooh
will this happen again.’ Is that something that you do? – Oh absolutely. I’ve started to really
monitor my heart, and when it starts to race I start to get worried, and then it starts
getting faster and faster, so it does feel… – Yes, yeah, You’re describing it exactly Julie, that’s what we call hypervigilance, so you’re there kind of keeping a bit of an eye on your heart,
– Yeah definitely
– and for most of us our heart rate will go up and down all through the day, but most
of us don’t worry about it because we don’t notice it, but because you’ve had a panic
attack, you’re there thinking ‘ooh what’s my heart doing?’,
– Yeah.
– and then the minute it starts to change you clock it, you notice it, and then you start to get anxious thoughts, so you might… – Start worrying, I really do. – Start worrying, yes so you. – I keep thinking is it going to be now, you know is my heart going to stop beating. – Right, so you get those kind of anxious thoughts,
– Yeah, yeah.
– and they’re very frightening, and because you’re thinking ‘goodness me, could my
heart stop?’, that’s making you more anxious, and that causes even more adrenaline to be
released, and that makes the symptoms even more pronounced, and that makes you believe
even more that there’s something wrong with you. Does that make sense, as to what might
be happening? – It does make sense, doctor. – One of the things that you have been doing,
which is something a lot of people with anxiety do, is that you’ve started to avoid doing
things that trigger it off. – I have, yeah, like not walking to town or
anything, I just won’t do it anymore. – Exactly, exactly. And whilst in the short term that
alleviates you’re symptoms because you don’t have to get panicky, what’s happening is
that the more you avoid doing things, the less likely you are to ever get around to ever
finding out whether or not anything awful really happens. – Right, yeah, right. – Does that make sense? – It does, it does make sense. – Well, if we are starting to tackle this as
if it were an anxiety problem, there are a number of approaches. We can think about tablets,
we can think about other kinda talking approaches. There are pros and cons to those, and side
effects that we need to discuss.
– Ok – So I’m just slightly watchful of the time, we seem to be coming to the end of today’s session for the appointment,
– Oh right, OK.
– but what I wonder is whether we should meet again, perhaps next week, and look again more carefully at some of the treatment
options, and think together about which might suit you best. How would that sound, Julie? – Oh that’s fine, that’s fine. – Any other questions before we finish? – No, I’ll make an appointment to see you
next week. – That’s fine, and I’ll see you next week. – Ok, thank you Doctor. – It’s a pleasure, bye. – Bye.