Stepped Care for Panic Disorder With Agoraphobic Avoidance
A 34-year-old woman has panic disorder with agoraphobic avoidance. She has had three emergency department visits in four months, all medically cleared. She avoids public transport, supermarkets, and driving more than a few kilometers. She works remotely and has stopped most social contact. She completed six sessions of supportive counseling with no change and is skeptical of 'breathing exercises.' She wants to 'just feel normal' and asks for medication because a friend was helped by it. She has no current substance misuse, no self-harm, and a supportive partner. The clinic offers 12 sessions of CBT, a psychiatrist for medication evaluation, and a group program.
1. What case formulation explains the maintenance of her panic and avoidance, and how does it guide treatment selection?
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The formulation is a fear-of-fear cycle. Bodily sensations are catastrophically misinterpreted (for example, a racing heart means a heart attack or losing control), which raises anxiety and produces more sensations, confirming the misinterpretation. Avoidance and safety behaviors reduce anxiety in the short term but prevent disconfirmation, so the belief survives. The emergency visits function as reassurance-seeking safety behavior, and the remote work and social withdrawal narrow her world further.
This formulation points to interoceptive exposure (deliberately eliciting sensations to test the catastrophe predictions), cognitive restructuring of the misinterpretations, and graded in vivo exposure to avoided situations, with response prevention of safety behaviors. It also explains why supportive counseling did not work: it offered reassurance without disconfirmation. Her skepticism about breathing exercises is reasonable if they were presented as anxiety reduction rather than as a test of her beliefs; the therapist should reframe them as experiments.
The formulation also predicts that reassurance from the therapist will feel helpful and maintain the disorder, so the therapist must plan for that pull.
2. She asks for medication. How do you integrate that request with the psychological plan and the stepped-care options?
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I would take the request seriously rather than treat it as resistance. Wanting relief is legitimate, and her friend's experience is meaningful to her. I would provide psychoeducation that both SSRIs and CBT have good evidence for panic disorder, that combined treatment is often used, and that medication can reduce the intensity of sensations enough to make exposure work feasible for some people. I would also be honest about trade-offs: time to onset, side effects, discontinuation considerations, and the risk that medication alone can become another safety behavior if she attributes all gains to the pill.
I would arrange a psychiatric consultation for a medication evaluation while starting CBT, so the decision is informed and not a substitute for the exposure work. Given her avoidance severity, I would recommend individual CBT rather than group as the first step, with group as an option later for generalization and social re-engagement.
I would agree on measurable targets (rides the bus, enters a supermarket, one social contact weekly) and review progress at session four, adjusting the step if she is not engaging.
3. At session five she has done no exposure homework and says she is waiting to feel ready. What is your next move?
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Readiness is often the avoidance talking. I would not lecture or abandon the plan; I would explore what 'ready' would look like and what she fears would happen if she tried now. This often surfaces a specific catastrophic belief that can be tested.
I would then shrink the step until it is genuinely doable, for example standing outside the supermarket for two minutes rather than shopping, or riding one stop. The principle is to keep the exposure but lower the dose so success is likely, then build. I would also check for unspoken barriers (time, partner's role, fear of panic in public, shame) and for therapist behaviors that may have reinforced waiting, such as over-explaining.
I would be transparent that avoidance, not lack of readiness, maintains the disorder, and that the goal is to act with anxiety present, not without it. I would set a small, specific, scheduled task for before the next session and rehearse it in session, including a plan for what she will do if panic rises. If she still cannot engage, I would revisit the formulation, consider a motivational interviewing approach, and consult.