Midwifery: Psychosocial Factors and Theories Applied - Case Study Example

Introduction Primary health care refers to the practice of health professionals acting as the first point of consultation to patients with a variety of problems. The approaches involved for mentally disturbed patients include Social Psychology and treatment of Psychological Anxiety Disorders (Craske, 2003, 48). Social Psychology is the study of the relations between individual persons and groups. It focuses on how relating to given social setting influences the behavior of an individual (Myers, 1993, 3). A Psychological Anxiety Disorder is a condition in which an individual experiences excessive anxiety that manifests itself in seemingly exaggerated and unreasonable behaviour (Herring et al, 2010, 231). This paper sets out to explain how a session with a patient involving these two approaches to therapy is carried out. A case study of the therapy offered to Angel, a 33 year old mother of 3 is used to elaborate this point. The Client Angel is a 33 year old single mother of 4 children living in Boston, Massachusetts. She works as a bank teller at a local branch of a bank. Three of her children are in elementary school. Her youngest child is 6 months old and during day is taken care of by a nanny. The problem for which she was referred to me is that she experienced occasional bouts of trauma attacks that made her scream, shake uncontrollably or in extreme cases lose her consciousness. She was wondering what caused these attacks and how she could solve or cope with the problem. Revelations during Therapy Taking the social model of health as proposed by Dahlgren and Whitehead (1991) into consideration I tried to identify the possible social and psychological causes for the problem of my client. Dahlgren and Whitehead (1991) had divided the causes affecting an individual’s health in form of layers. The first layer is personal behaviour and way of living. Angel led a solitary life, even though she did not prefer it that way, but she was reticent and was not able to open up with people that easily. Being a single mother she was the only support system of her family and this had pressured her to work extra hard. So while she would work till late at night occasionally she had to also take care of her youngest child and this disturbed her sleep cycle. She mentioned that the bouts had not happened when she was at work or out on visits with friends, but only at home occasionally late at night. When I inquired how she felt immediately before each bout, she explained that she would suddenly feel very scared as if someone was sneaking around the house trying to harm her. She would then feel her skin creep and her hair rise on the nape of the neck, and then the shaking would begin. Her imagination could be a result of sleep deprivation. She usually woke up till 2-3 a.m. but had to wake up early by 7 a.m., so she hardly ever got any time to rest. Sleep deprivation is associated with conditions like agitated depression, paranoia, and hallucinations (Sacker et al., 1995, 164-171). Sleep deprivation also aggravates the condition of postnatal depression. She said that she had first experienced the bout when she was 27 years old; six months after her husband had died in a serious traffic accident. He had been a railway engineer but had died one day on his way to work when his car rammed into a stationary lorry. Her condition can also be a result of trauma she must have suffered because of her husband’s accident. The psychological trauma occurring due to the suddenness and freak nature of the accident may have seriously disillusioned her. This kind of situation is termed as post traumatic disorder and was postulated by psychologist Jean-Martin Charcot (Laplanche & Pontalis, 1967, 465). She further informed me that she had been raised by a single mother, after her father had abandoned them when she was still a toddler. She said that being the only child she was always scared when left alone in the house. Her mother had to go do odd jobs every afternoon to make ends meet. This meant she was left alone most of the time. According to Erickson’s theory of Psychosocial Development at infancy and pre-school stage the child mainly relies on the parents for protection and feels exposed when they are not there for long periods of time. Due to this the child grows up feeling vulnerable. This makes them grow up in fear and uncertainty. Some of this fear may be carried into adulthood (Wright, 1982, 73). The situation changed with the birth of her younger brothers. She had not experienced anything traumatic as a child. She also mentioned that she never really wished to see her father, growing up with her mother her world remain limited to her mother and brothers. Though she had really wished to know what his face looked like when she was younger, but with time she had outgrown the desire. As a child she would also occasionally wonder if having a father would have meant that she wouldn’t have to stay alone at home but after birth of her younger brother she hardly ever thought about him. So her real problem was hallucination which is another effect of anxiety disorders (Wright, 1982, 73). When she finally got married, she had a loving caring husband with whom she felt secure. Her mother passed away shortly after Angel got her first daughter while her two younger brothers left the country as international volunteers. So when her husband died she was once again left alone with the children. It was shortly after that when her visions, shaking and fainting began, which are prominent signs of a neural disorder ((Laplanche & Pontalis, 1967, 465). The second layer that affects an individual is social and community influences. Since Angel had limited communication with her neighbours as well as her colleagues, there wasn’t much that can be said to have influenced her in a negative way. The third layer includes structural factors. Her living and working conditions were fairly comfortable in that she had been working at the place for almost 6 years and knew the people around so was never uncomfortable around them; also people sympathized with her and were generally helpful. She had no debts or other financial worries; she managed to make ends meet with her salary. In spite of that she was under substantial pressure. She said that she felt being single mother of 4 children is really difficult. In a nutshell, this is all she said and any further sessions just resulted in repetition or elaboration of this information. She did point out that there was no disease she had that would make her faint. Psychological Interpretation The main causes that seemed to be the reason for Angel’s condition were her husband’s death, the pressure of raising a family on her own, postnatal depression aggravated by sleep deprivation. Taking the reasons into consideration and the problem she had been suffering from I came to the conclusion that she was suffering mainly from an anxiety disorder. Anxiety disorders are defined as several different forms of abnormal and pathological forms of fear that affect an individual from time to time (Craske, 2003, 48). This was my interpretation, but it is always very easy to be wrong especially with psychological situations. So I decided to countercheck with the chief psychiatrist who agreed with my assessment. There are anxiety disorders of different types such as general anxiety, phobic and panic disorders. Each of the types either happens regularly or episodically (Stein, 2004, 7). The kind of disorder that Angel was describing was most definitely the episodic panic type. It would attack unexpectedly and without any particular pattern (Stein, 2004, 7). Common Signs of a Panic Disorder Common signs of a panic disorder are: episodic attacks of intense terror and apprehension, trembling, shaking, nausea, dizziness and short breath. The attacks occur abruptly, peak in ten minutes or less. Often they are triggered by stress, fear, or exercise. However it is not clear what the exact causes of these attacks are. These attacks make the sufferer be highly sensitive and anxious of the consequences of their traumatizing experiences (Vanin & Helsley, 2007, 14). Causes The causes of these disorders are even more varied than the types of disorders. The first category is the biological causes. Chief of these is low levels of Gamma Aminobutyric Acid [GABA] which is a neurotransmitter responsible for reducing activity in the central nervous system. This situation can be further aggravated by the intensive intake of alcohol, caffeine and benzodiazepines. The latter come from drugs which are ironically used to control anxiety, but excessive use of them can have the opposite effect (Nemeroff, 2003, 133). Another biological cause of anxiety is when the function of the Amygdala is affected. The Amygdala is the central processing unit of fear and anxiety in the brain. It interprets the extent of threat to memory in the brain. When it malfunctions, the Amygdala can send impulses of excessive threat even when only a mild threat is involved. Its regulatory function of the amount of threat is also impaired Etkin et al, 2009, 1362). Another major cause of anxiety disorders is excessive stress. This may arise out of worries about money, safety, or as in the case of Angel, loss of close relations who define one’s world. Stress impairs normal brain function as anxiety related adrenalin builds up. It is always advisable to avoid excessive stress since a continuous build up is likely to result in anxiety disorders even of a mild nature (Lindsay & Powell, 1998, 152). Social Psychological Factors From a social perspective, what emerged from the sessions is that Angel was a bit of a recluse who kept to herself most of the time. She therefore did not develop strong social bonds that helped to regulate her behavior. She also developed unusually strong attachment s to the people around her and kind of felt lost without them. Habitually, the thoughts, feelings and behavior of an individual are greatly influenced by the people around them (Sun, 2008, 12). These extremely strong bonds to close relations grew into a dependency on them that left her feeling exposed when left without her mother and husband. The absence of a father figure in earlier life also made her regard her husband more like a father figure than just a mere spouse. Unresonable bonds such as this are developed when one feels too attached to certain individuals (Miles & Wolfgang, 2004, 24). It is quite obvious that the death of these close relations seriously affected her sense of security. Moreover, she felt that her children were exposed when left with her alone in this world. Another cause of worry was the way in which her panic attacks might affect her children. This was a legitimate concern since the parent is the most influential role model in child’s life and thus her anxieties were likely to be highly magnified by them and thus affect them too (Miles & Wolfgang, 2004, 26). Government Regulations and Treatment The Food and Drug Administration [FDA] is the government arm that is charged with regulating the use of medication and treatment, promotion of public health and control of electromagnetic emission devices among other duties (FDA, 2010). Under the 1906 Food and Drugs Act, which has been revised a number of times, the FDA strictly regulates the use of Selective Serotonin Reuptake Inhibitors (SSRIs) which are drugs used by psychiatrists to control anxiety levels. However, they did approve Peroxetin which is sold as Paxil in the US and Seroxat in the UK. The rational for this approval was that the drug was very useful in controlling anxiety and had no known side effects (FDA, 2010). Since Angel’s case was a mixture of anxiety disorder and social isolation in my diagnosis, which was backed by the resident psychiatrist, we recommended that she undergoes a three tier treatment. The Paxil drugs would be used by her in mild dosage especially after she had a particular attack. The drug is useful in calming the nerves and preventing any further attacks (Dunlop & Davis, 2008, 22). Another mode of treatment we recommended was Psychotherapy. This is the use of personal counseling sessions with the patient to help her face up to the realities of life. The sessions would also help her overcome her hallucinations and realize that her fears were without any real foundation (Strupp & Binder, 1984, 3). A method that would come in handy during the sessions is Cognitive Behavioral Therapy [CBT]. The cognitive part of the therapy would enable the patient to interrogate her fears in a realistic manner so as to help overcome them (Stein, 2004, 7). In Angel’s case she would be confronted with the reality that her uncontrolled fears have never really resulted in any personal harm to her which makes them pointless. The behavioral part would help shape her behavior and assist her in overcoming the social phobia that was inhibiting her socialization. To help strengthen this, she would be encouraged to explore social clubs, church communities and neighborhood associations to help her acquire friends (Stein, 2004, 7). However, at the end of the day she would also need another husband or at least a trusted male companion. This would not be easy since it is not always a guarantee that one gets a reliable trusted partner (Westenberg, 1999, 93). All the same, through constant interaction chances were that she might just end up with the right companion. Conclusion Angel’s case helped me to understand the procedure required in dealing with a patient. As was clear from the psychological disorders have a close relation with both the patient’s history and his present, so it important to know both. Angel improved dramatically over time and has become more enthusiastic in life. Her number of friends is growing constantly and she confesses to have overcome the little fears that were plaguing her life on a daily basis which she did not even mention during the fact finding sessions. We can only hope that there won’t be any relapses in future. 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Archives of Internal Medicine (American Medical Association), pp 231. Sun, Ronald, 2008, The Cambridge Handbook of Computational Psychology. Cambridge University Press, p 12. Miles, Hewstone & Wolfgang Stroebe, 2004, Introduction to social psychology: a European perspective (3rd ed.), Boston: Blackwell, pp 24-26. Food and Drug Administration (FDA), 2010, December 12, Retrieved on 12/12/2010 from: Nemeroff, CB, 2003, "The role of GABA in the pathophysiology and treatment of anxiety disorders," Psychopharmacol Bull 37 (4): p 133. Dunlop BW & Davis PG, 2008, "Combination treatment with benzodiazepines and SSRIs for comorbid anxiety and depression: a review". Prim Care Companion J Clin Psychiatry 10, p 22. Lindsay, S.J.E. & Powell, Graham E., eds, 1998, 28 July, The Handbook of Clinical Adult Psychology (2nd ed.), New York: Routledge, p. 152. 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