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
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.
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
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.