Understanding a Client’s Panic Attacks


The first client of the day was a young woman, just out of university who was experiencing severe panic attacks with the physical symptoms sometimes casing her to faint. I had seen her for her first appointment last week and she had described how this had started a few years ago and although she had been prescribed anti-depressants by her GP, this had had no effect.

I had spoken to her GP on the telephone after obtaining the client's written permission to

do so and he had spoken about how she had repeatedly attended appointments with

regards to her panic attacks but that no medications had seemed to work in reducing the

distressing symptoms.

On speaking with the client, she had described the panic attacks and how they affected her

every day. I am always keen to understand why the panic is present and what thoughts are

causing these feelings.

To enable the client to pin-point her thoughts, we discussed how she might record them on

a worksheet. As soon as she was conscious of having a negative thought, she would record

it on the worksheet along with the resulting feeling that the thought produced. She agreed

to take this worksheet home with her and fill it in during the week before her next

counselling session which was today.

Relaxation exercises

We had also talked about relaxation exercises and how they can be of benefit and after

coaching her in these and giving her an audio CD with guided relaxation exercises on it, we

had scheduled a meeting for today.

It struck me during the session last week that this client was not presenting as typically

anxious and although she was understandably upset about the panic attacks and worried

about their recurrence, she didn't talk about any issues that would normally be associated

with panic disorder.

Medical case history

I always take a complete medical case history during the initial consultation and I read

through this again to see if there were any clues or anything that I had missed. Excessive

caffeine or stimulant consumption can mimic panic disorder as can the intake of some

prescribed and non-prescribed medications. There was nothing at all that indicated this

was the case with this client. In fact she had mentioned that she didn't tolerate caffeine

well so drank water and fruit tea rather than caffeinated drinks.

What she mentioned most about the panic attacks was a 'fluttering' sensation in her chest

which she thought was a palpitation. This 'fluttering' would happen when she was relaxed

and not thinking of stressful things, which was what intrigued me.

It can be that clients are just not aware of their negative thoughts and that counselling can

bring them into their consciousness. Being able to tune into their 'inner voice' allows them

to address the negative thoughts and replace them with more realistic ones resulting in

appropriate responses rather than negative ones. It would be interesting to see whether she

had been able to record any negative thoughts on the sheet she would be bringing back



On arrival, we sat down and began the session. She spoke about feeling quite down as she

had had a few episodes of the 'fluttering' in the last week and once when she had been

carrying out the relaxation exercises. Other than being worried about the palpitations,

there were only a few other negative thoughts recorded and I was beginning to feel that

this issue may have a physical cause.

We went through the worksheet during the session and agreed that she would start to

rationalise her thoughts as they arose. I coached her in how she might go about doing this

and after checking her understanding, we concluded the session and scheduled for the

following week.

Contacting the GP

Once the client had left, I did some research online about her symptoms and treatment

resistant panic disorder. After much reading, I came across a condition called Mitral Valve

Prolapse (MVP) which affects the pumping of blood through the heart and causes a

'fluttering' sensation in the chest as the valve opens and shuts.

I called the client's GP and discussed her counselling (I already had the client's permission)

and that I was wondering whether the symptoms could be physical rather than

psychological in nature.

After a long conversation, the GP said he would call the patient with regard to referring her

to a cardiologist as he thought that MVP was a possibility but that he had recommended

therapy in the first instance to rule out psychological causes.

The client called me later in the day to say that she had spoken with her GP and that she

was delighted that she was being taken seriously at last. We agreed to keep the scheduled

meeting for next week and she would wait to hear about an appointment with the


As a counsellor, I am not permitted to diagnose clients and I would never attempt to do so.

If I have any concerns about a client's medical health, after gaining written permission

from them, I always contact their GP to discuss any concerns and possible treatments.

I will eagerly await the outcome of this client's appointment with her consultant and in the

meantime, continue to work with her on managing her symptoms.


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