Complex interaction and panic disorder: emergent phenomena and therapeutic implication. (Adapted from Lambert R (2007) Complexity, panic and primary care. In: Bogg J, Geyer R (eds) Complexity science and society. Radcliffe, Oxford, with permission of the copyright holder)
Another point of entry may be through environmental influences such as work or other occupational behaviors. Therefore, through applying the LMI, the OT increases client awareness of individual sensitivities within their physiological system, and considers possible remedial action to regain control over associated symptomatic responses. Lifestyle review increases understanding of how habitual lifestyle behaviors may affect symptoms of anxiety and panic. Through modifying lifestyle behavior and learning how to monitor the outcome of change, clients can learn what actions assist them in regaining control over symptoms and to regain control over their routine occupational behaviors. This places them in a better position to fulfill desired occupational roles and achieve an improved occupational balance.
The LMI provides up to ten intervention sessions over a 16-week period (three 1-h appointments at weekly intervals, three half-hour appointments at weekly intervals, three half-hour appointments at two-weekly intervals, and one 1-h appointment at a monthly interval). The intervention should be delivered in four distinct but largely concurrent stages:
Lifestyle review using self-report “lifestyle” and “mood and sleep” diaries. The lifestyle diary provides detail of (a) fluid intake including water, caffeinated/decaffeinated, soft, and alcoholic drinks, (b) diet content and pattern, (c) exercise, and (d) smoking. Behaviors are rated by volume at three daily time points (am, pm, and evening). Weekly totals are used to correlate with results from the mood diary. The mood and sleep diary also provides a daily record at the same three time points, for sleep quality, and anxiety ratings based on the potential symptoms of a panic attack, along with a record of situational influences. Correlations between evidence from both diaries are used to identify potential lifestyle behaviors that appear to influence anxiety reactions. It is the correlations that focus discussion, rather than firm cut-off values. The diary sheets are given to clients during the first session and they are asked to complete them daily, and these are reviewed in the second and subsequent sessions.
Education to increase client awareness of the potential negative health effects of some lifestyle behaviors (such as smoking and poor diet) and the health benefits of other lifestyle behaviors (such as sufficient exercise and sufficient fluid intake). The level and amount of information needs to be tailored to each individual client, but it is vitally important that the therapists themselves are familiar with, and regularly update, their own evidence base.
Specific lifestyle changes (in diet, fluid intake, exercise, habitual lifestyle drug use, or sleep) should be negotiated between the client and the OT. The focus of attention should be guided by the lifestyle review, and changes in the behaviors that appear to represent the highest risk behaviors should be targeted at the earliest stages if possible. The approach should be motivational and positive, discussing how to overcome practicalities and recognizing the fluctuating nature of any lifestyle change program.
Monitoring and review between therapist and client of the agreed lifestyle changes and any subsequent symptom change. It is vitally important that positive feedback is provided during each session, to recognize not only the impact on symptoms of any changes made but also the effort required to effect and maintain those changes. If lifestyle change in one area has limited impact, then move to the next.
A final review session is needed after a longer period (of around a month) at the end of the intervention. This reviews progress made during the series of sessions, in both lifestyle behavior change and symptom experience. This also provides an opportunity to consider future changes in areas that have been identified as potential risks, but have not been attempted during the intervention. This again focuses attention onto the patient regaining control.
It is important that OTs are familiar with the literature relating to habitual lifestyle behaviors and health. Key works are those associated with diet (Benton and Nabb 2003), fluid intake (Wilson and Morley 2003), exercise (Broman-Fulks et al. 2004), and habitual lifestyle drug use, including alcohol (Marquenie et al. 2007), nicotine (McLeish et al. 2009), and caffeine (Masdrakis et al. 2007). These behaviors should not be considered in isolation; however, as evidence suggests high levels of interaction among these habitual lifestyle behaviors (Poitras and Pyke 2013).
Results from a randomized controlled trial have been published in which the lifestyle intervention was compared with routine general practitioner (GP) care (Lambert et al. 2007). This showed a significant short-term benefit using the Beck Anxiety Inventory (BAI) as the primary outcome measure, assessed at 20 weeks. However, between-group differences were not significant at the 10-month follow-up. The conclusion was that the lifestyle intervention was at least as cost-effective as routine GP care (Lambert et al. 2010). It also produced improved results when compared with a broad range of prescribed medications, including benzodiazepines and selective serotonin reuptake inhibitors or serotonin-specific reuptake inhibitor (SSRI; Lambert 2012). The LMI was equivalent in efficacy to the use of cognitive behavioral therapy (Lambert et al. 2007). This trial has shown that when symptom profiles are similar at baseline, lifestyle review provides a rational explanation for experienced symptoms, along with a strategy for regaining control, that the fear of the previously misinterpreted symptoms reduces dramatically (Lambert et al. 2008).
Many interventions in mental health are focused either on a purely neurobiological approach through the use of medication or on mainly cognitive approaches through the use of differing forms of cognitive behavioral therapy, either alone or in combination. The proposed LMI provides the patient with increased awareness of their own specific neurobiological sensitivities and also their physical and cognitive responses. It also provides positive strategies through which the patient can regain control over these. The evidence base is increasingly in support of this focus of intervention. The LMI provides a specific, patient-focused, occupational therapy intervention based on occupational behavior. It has been shown to provide both a clinically effective and cost-effective intervention with evidence of longer-term benefits. There is an ongoing need to evaluate its use with different patient groups (such as psychosis and depression) , and in different settings (such as inpatient care) and formats (such as group work). The author would be very happy to work with anyone wishing to develop the work further.
The main trial results from the wider study were presented at the 33rd North American Primary Care Research Group meeting held in Quebec City on October 15–18, 2005. This research was supported by a National Health Service (NHS) Research and Development (R&D) National Primary Care Researcher Development Award Fellowship (grant RDA99/062) and by a NHS R&D Eastern Region Health Services and Public Health Research Scheme Grant (HSR/0500/1).
I am indebted to the grant-awarding bodies whose financial support made the research possible. The long-term support of the patients, the GP practices, and occupational therapists who participated in the research enabled completion of the research.
The Case Study of Mister C: Change of Lifestyle Influence on Panic Attacks and Outcome
Dizziness, lifestyle, panic attacks
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