CASC: Explaining cognitive maintenance of panic and setting a behavioural experiment

Candidate instructions

You are the psychiatry registrar in outpatient clinic. Alex, 27, has panic attacks with racing heart. Always sits down and checks pulse; carries unused lorazepam “just in case.” Also says “I can’t remember anything you say in appointments — my brain is broken.” Your tasks in 10 minutes:[9]

1. Engage collaboratively; set agenda; validate distress without agreeing the heart will stop.
2. Explain in plain language catastrophic misinterpretation of sensations and how safety behaviours keep the fear belief alive.
3. Rate a specific prediction (0–100%) for a planned mild interoceptive or real-world test.
4. Negotiate one behavioural experiment with a plan to partially fade a safety behaviour.
5. Address “broken brain” with a brief working-memory load explanation and one compensatory strategy (written single-step plan).
6. Brief risk screen (SI, benzo misuse, avoidance of medical care) without abandoning the cognitive-education task. Station prioritises Clark-model teaching, collaborative empiricism, and capacity-aware communication.[2][9]

Actor brief (Alex)

• Frightened; equates tachycardia with dying.
• Defends safety behaviours: “If I don’t check my pulse, something bad will happen.”
• Softens with collaborative “let’s test the idea” framing; hardens if called silly or ordered to stop all safety today.
• Worries cognition is permanently damaged; accepts written plan if you normalise limited working-memory capacity under anxiety load.
• Will try a 2-minute stand-and-notice-heart trial with phone face-down if prediction is rated first. Actor tracks Clark safety-behaviour maintenance and anxiety-related efficiency costs under load.[9][10]

Marking grid (domains)

Exemplar phrases

• “Your brain is treating a racing heart as a catastrophe signal — checking and sitting teach ‘I only survived because I did that.’”[9]
• “We’ll rate how sure you are the disaster will happen, then gently test that prediction.”[9]
• “Anxiety also loads the mental notepad we use for instructions — we’ll write one clear step so it’s not all held in working memory.”[2][10]
• “Thoughts about self and danger can be treated as hypotheses, not final facts — that’s the cognitive therapy idea.”[8]