First Session

Intake and Consent

Discussed limits of confidentiality, explained the Medicare rebate process; Mary provided verbal informed consent to proceed.

Presenting problem(s)

• Experiencing panic attacks in public settings, particularly in crowded shopping centres and public transport (3-4 episodes per week).
• Increasing avoidance behaviours leading to difficulty completing daily tasks and social isolation.
• Sleep disruption due to worry about potential panic episodes the following day.

History of presenting problem(s)

• First panic attack occurred 8 months ago while on a crowded train.
• Symptoms initially occurred once every few weeks but have increased in frequency over the past 3 months.
• Reports most severe episode occurred 2 weeks ago at shopping centre, requiring her to leave immediately.

Current functioning

• Occupation: Works as administrative assistant in legal firm. Currently working 4 days per week, recently reduced from full-time due to anxiety symptoms. Reports supportive workplace but increasing concern about job performance.
• Family: Lives alone in apartment. Parents live interstate but maintain regular phone contact. Has informed mother about anxiety but minimised severity.
• Social: Describes having small circle of close friends who have noticed her withdrawal from social activities. Currently declining most social invitations that involve public transport or crowded venues.
• Sleep: Difficulty falling asleep (30-60 minutes) with racing thoughts about next day’s activities. Wakes 1-2 times nightly, averaging 5-6 hours total sleep.
• Physical health: No significant medical conditions. Previously exercised at gym 3 times weekly but has stopped attending due to anxiety about having panic attack while there.

Current medications

• No current prescribed medications.
• Occasionally takes over-the-counter sleep aid (diphenhydramine) 1-2 times weekly.

Psychiatric history

• Brief counselling during university (4 sessions) for stress management 5 years ago.
• No previous psychiatric diagnoses or medications.
• No history of hospitalisation.

Personal history

• Family of origin: Eldest of two children. Parents divorced when client was 15. Describes mother (54) as supportive but “worries too much.” Father (56) described as emotionally distant. Younger brother (27) lives interstate.
• Relationship history: Currently single for past year. Previous 3-year relationship ended amicably due to career relocation. Reports history of healthy relationships without significant conflict.
• Educational history: Completed bachelor’s degree in business administration. Describes being “academically average” with no significant learning difficulties.

Risk assessment

• Suicidal ideation: Denies current or historical suicidal thoughts, plans, or attempts.
• Self-harm: No history of self-injurious behaviours.
• Risk-taking/impulsivity: No reported impulsive or risk-taking behaviours.

Mental state exam

• Behaviour: Appeared somewhat tense, occasionally fidgeting with hands.
• Mood: “Anxious and frustrated” about impact of symptoms on daily life.
• Affect: Congruent with reported mood, moderately anxious but able to engage appropriately. Range appropriate to content.
• Thought process: Logical and goal-directed, occasional worry-focused rumination.
• Concentration and attention: Good concentration throughout session despite reported anxiety.
• Insight: Demonstrates good awareness of anxiety symptoms and their impact; recognises avoidance is worsening her condition, stating “I know avoiding places isn’t helping in the long run.”

5P formulation

• Presenting problem: Panic disorder with increasing agoraphobic avoidance behaviours impacting daily functioning.
• Predisposing factors: Family history of anxiety (mother described as anxious), perfectionistic tendencies, and high personal expectations.
• Precipitating factors: Initial panic attack coincided with period of increased work stress and responsibility. Recent relationship ending may have reduced social support.
• Perpetuating factors: Avoidance behaviours reinforcing anxiety, catastrophic misinterpretation of bodily sensations, hypervigilance to physical symptoms, reduced exercise and social engagement.
• Protecting factors: Supportive workplace, good insight into condition, motivated for treatment, previous coping success with past stressors.

Biopsychosocial formulation

• Biological: Possible genetic vulnerability to anxiety, reported physiological arousal (racing heart, breathing difficulties), sleep disruption.
• Psychological: Catastrophic misinterpretation of bodily sensations, fear of losing control, anticipatory anxiety, avoidance behaviours.
• Social: Reduced social engagement, supportive but distant family, work environment accommodating symptoms but increasing performance concerns.

Goals

• Reduce frequency and intensity of panic attacks by 50% within 8 weeks.
• Develop effective skills to manage panic symptoms when they occur.
• Gradually increase engagement with currently avoided situations, starting with short trips on public transport.
• Improve sleep quality and reduce anticipatory anxiety.

Next steps

• Begin 10-session Cognitive Behavioural Therapy for panic disorder with weekly appointments.
• Next session scheduled for 12/05/2025 at 3:00 pm.
• Complete panic attack diary and thought record as homework before next session.
• Consider psychoeducational materials about panic cycle and cognitive model.

Other practitioners

• GP: Dr. Sarah Williams at Central Medical Clinic, last seen 3 weeks ago regarding anxiety symptoms.