Case laboratory · fictional case
Meera: chest pain, emergency visits and fear of dying
A 34-year-old nurse has repeated emergency visits for chest pain with normal cardiac tests. Panic, health anxiety, stimulants, sleep and life stress interact — and collaboration with physicians is essential.
Stage 1 of 7
1 Observe
Presenting concerns
Meera describes sudden episodes of pounding heart, breathlessness, tingling and terror that she is having a heart attack. Episodes peak within minutes. She now avoids climbing stairs quickly and checks her pulse often.
Observations
- Articulate and slightly embarrassed: 'I'm a nurse, I should know better.'
- Rubs her chest when describing episodes.
- Asks whether the tests could have missed something.
Your turn: What features suggest panic? What must not be assumed?
Teaching discussion for this stage
Sudden peaks of physical symptoms with catastrophic fear are characteristic of panic attacks. However, medical causes must be ruled out by physicians — here, cardiac tests are reported normal, but the psychologist should not make medical judgements. Her embarrassment suggests stigma to address with normalising psychoeducation.
2 Gather information
History
The first episode occurred after a run of night shifts. Her father has heart disease. She has no history of anxiety treatment.
Self-monitoring (two weeks)
- Five episodes, four after night shifts.
- Most began with palpitations after several cups of tea.
- Peak thought: 'My heart is failing.'
- Each ended after she left the ward and sat down.
Your turn: What patterns appear in the self-monitoring data?
Teaching discussion for this stage
The diary links episodes to shift work, caffeine and catastrophic interpretation of palpitations, and shows escape as a safety behaviour that prevents disconfirmation. Her father's heart disease may make cardiac fears especially salient.
Missing information
- Avoidance and safety behaviours outside work.
- Mood and any depression.
- Alcohol or other substance use.
- Sleep duration.
- Her beliefs about what would happen if she stayed in the situation.
3 Generate hypotheses
Your turn: What are your main hypotheses and differentials?
Teaching discussion for this stage
Consider how physical and psychological processes interact rather than choosing one.
Hypotheses and differentials
- Panic disorder with developing avoidance.
- Health anxiety focused on cardiac illness.
- Caffeine and sleep loss increasing physiological arousal.
- Situational stress (finances, husband abroad).
- Medical conditions (for physicians to evaluate) such as thyroid problems or arrhythmias.
4 Formulate
Your turn: Write a biopsychosocial formulation that explains the vicious cycle.
Teaching discussion for this stage
Shift work, sleep loss and high caffeine intake increase arousal; she notices palpitations and interprets them catastrophically, heightened by her father's illness; fear increases sensations, producing panic; escape and pulse-checking bring relief but prevent learning that sensations are harmless; worry about work and finances adds to arousal.
| Factor | Biological | Psychological | Social / cultural |
|---|---|---|---|
| Predisposing | Family history of heart disease | Health-focused vigilance (professional and personal) | Financial responsibility for parents |
| Precipitating | Run of night shifts; high caffeine | First frightening episode | Husband's move abroad |
| Perpetuating | Ongoing sleep disruption | Catastrophic interpretations; safety behaviours; avoidance | Embarrassment about seeking help as a nurse |
| Protective | Normal cardiac findings | Psychologically minded; motivated | Supportive colleagues; regular calls with husband |
5 Plan assessment
Your turn: What assessment would guide and monitor treatment?
Teaching discussion for this stage
Assessment should both confirm the formulation and provide baseline measures.
Possible next steps
- Diagnostic interview for panic disorder and related conditions.
- Continued panic diary as a baseline and progress measure.
- Brief standardised anxiety and depression measures repeated over treatment.
- Liaison with the physician (with consent) about medical findings and caffeine.
- Assessment of avoidance hierarchy.
6 Consider interventions
Your turn: Which evidence-informed treatment would you propose and how would you explain it?
Teaching discussion for this stage
CBT for panic has strong research support. It would be presented collaboratively, using her diary data.
Evidence-informed options
- Psychoeducation about the panic cycle, using her own diary.
- Cognitive work on catastrophic interpretations.
- Interoceptive exposure (deliberately bringing on harmless sensations) and situational exposure, after medical clearance.
- Dropping safety behaviours such as pulse-checking.
- Reducing caffeine and improving sleep where shifts allow.
- Problem solving for financial and family stress.
- Physician involvement regarding any medication options.
7 Review outcomes
Fictional follow-up
After ten sessions, panic attacks have reduced to one mild episode in four weeks, she has stopped emergency visits, and she climbs stairs normally. She still feels uneasy after night shifts.
Your turn: How would you plan the end of treatment?
Teaching discussion for this stage
Plan termination with relapse prevention: a written summary of the panic model, signs of early relapse, what to do if sensations return, continued exposure practice and a follow-up session. Collaboration with occupational health about shift patterns may help.
Ethical questions and references
Ethical questions to discuss
- How should a psychologist work with physicians without overstepping into medical judgement?
- How would you address the stigma Meera feels as a health professional seeking help?
- What information should be shared with her employer, and with what consent?
References and resources
- Plante, T. G. (2005). Contemporary clinical psychology (2nd ed.). John Wiley & Sons.
- Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129–136.