Maya Ellison
Panic attacks with increasing avoidance of driving, supermarkets and the underground.
A textbook maintenance cycle — and a patient whose "safety" strategies are the reason it persists.
Referral
Referred by her GP after three attendances at the emergency department in five months. Cardiac workup, thyroid function and ECG all normal. The referral letter reads: "Recurrent episodes of chest tightness, palpitations and derealisation. Extensively investigated, no organic cause identified. Increasingly housebound. Please assess for anxiety."
History
The first attack came fourteen months ago on the M25, in stationary traffic, on the way back from a night shift. She describes a sudden sensation of her heart "going wrong", a rushing in her ears, hands numb, and a conviction that she was about to lose consciousness at the wheel. She pulled onto the hard shoulder and called her partner, who came out to drive her home.
Since then: roughly two to four attacks a month, plus near-daily anticipatory anxiety. She has stopped driving on motorways, then stopped driving alone, then largely stopped driving. She shops online. She has taken the underground twice in a year, both times with her partner. She has moved to day shifts, which cost her about a fifth of her income.
The safety repertoire
- Carries a bottle of water and an unopened packet of diazepam prescribed two years ago; she has never taken one, and describes them as "just in case".
- Sits near exits; will not sit in the middle of a row.
- Checks her pulse — she estimates twenty to forty times a day.
- Will not exercise hard enough to raise her heart rate.
- Avoids coffee entirely, and has recently cut out anything spicy.
- Texts her partner her location when she goes out alone.
Sleep is broken but not severely. Mood is low but she describes it as "because of this, not separate from it" — and on assessment the depressive symptoms are secondary and mild. No alcohol beyond a glass of wine most weekends. No previous psychological treatment. Her mother had "nerves" and did not leave the house much in Maya’s teens; this has never been named as anything.
Formulation notes
This is a clean instance of the Clark panic model, which is precisely why it is a good first case: the mechanism is legible, the treatment is well specified, and the outcome is usually excellent. The learning is in the execution, not in the puzzle.
| Element | In Maya’s case |
|---|---|
| Trigger | Benign bodily sensation — often fatigue, heat, or caffeine |
| Catastrophic misinterpretation | "My heart is going wrong. I am going to pass out and crash." |
| Apprehension | Fear escalates, sympathetic arousal increases |
| Body sensations intensify | Palpitations, numbness, derealisation — confirming the interpretation |
| Safety behaviours | Pulse checking, avoidance, the unopened diazepam, the partner |
| Result | She concludes she survived because of the safety behaviour, so the belief is never disconfirmed |
Her mother’s undiagnosed agoraphobia matters in two ways: as a vulnerability factor, and as a specific fear Maya has not voiced — that this is inherited, fixed, and the beginning of the same life.
Sessions with this person
Cognitive therapy: the maintenance cycle
Structure, socialisation, and a behavioural experiment. The whole session hangs on whether she leaves able to explain her own panic to somebody else.
Cognitive TherapyInteroceptive exposure
The session most therapists dilute. You are going to ask a frightened woman to deliberately produce the sensations she has organised her life around avoiding — and to do it first yourself.
Exposure TherapiesACT: creative hopelessness and values
The same patient as the cognitive session, approached without any attempt to change what she believes. The target is the struggle and what it has cost her.
Acceptance and Commitment Therapy
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