MEQ: CBT formulation and treatment plan for panic with agoraphobia

(i) Cognitive model of panic and safety behaviours (5). Clark’s model: panic is maintained by catastrophic misinterpretation of benign bodily sensations (e.g. palpitations → “I’m dying / heart attack”), which increases anxiety and sensations in a vicious cycle. Safety behaviours prevent disconfirmation of the threat belief. In this case: repeated pulse checking; carrying unused diazepam as a talisman; avoidance of trains/meetings/shopping centres (situational safety via escape/avoidance); possibly alcohol as evening shutdown.[1]

(ii) Five-area formulation (5). Situation: boarding train / staff meeting / shopping centre; noticing heartbeat. Thoughts: “I’m having a heart attack / I’ll collapse / people will see me lose control.” Emotions: panic, fear, shame. Body: palpitations, breathlessness, sweating (normal anxiety physiology misread as danger). Behaviours: leave situation, check pulse, grip diazepam, avoid meetings, evening alcohol. Maintaining cycle: avoidance and checking stop her learning that sensations peak and pass without catastrophe; threat belief stays high.[1][2]

(iii) Session structure and behavioural experiment (5). Structure: bridge/mood-risk check → collaborative agenda → review any homework → active work → specific new homework → summary/feedback. Example experiment: target belief “If my heart races on a train for 10 minutes without checking my pulse or leaving, I will collapse or die.” Prediction: collapse/medical emergency within 10 minutes (rate belief 0–100%). Experiment: brief accompanied interoceptive then in vivo task (e.g. increase heart rate by stair climbing then sit on train one stop without pulse check or diazepam in hand), record outcome, re-rate belief. Emphasise review and learning; homework quality matters for outcome.[1][3]

(iv) Pharmacotherapy and priorities (5). SSRI/SNRI or other guideline-supported agents may be offered based on severity, preference, comorbidity, and access; benzodiazepines as standing “just in case” often become safety behaviours and complicate exposure — plan cautious review rather than reinforce talisman use. Mild–moderate depressive symptoms may improve as panic/avoidance falls; if depression becomes moderate–severe, evidence supports CT/medication pathways depending on context.[4] CBT is not the priority today if acute medical instability, active high suicide risk needing containment, mania, delirium, or severe substance intoxication dominate — stabilise first. Watch therapist drift: do not substitute endless reassurance for exposure and dropping safety behaviours.[5]