CASC: Explaining exposure and dropping safety behaviours in panic · Psych CASC / OSCE

Prompt

CASC: Explaining exposure and dropping safety behaviours in panic

Candidate instructions

You are the psychiatry registrar in outpatient clinic. Sam, 31, has panic attacks in supermarkets. Leaves when heart races, feels better, now only shops with partner and always carries lorazepam “just in case” (rarely takes it). Wants help but fears exposure will “give me a heart attack.” Your tasks in 10 minutes:[6][9]

Engage collaboratively; set agenda.
Explain in plain language how panic cues and escape maintain the problem (classical + operant / safety behaviours).
Outline exposure that tests predictions (expectancy violation), not “scare me until I calm.”
Negotiate a plan to fade partner/lorazepam-as-talisman carefully.
Agree one specific next-step behavioural experiment with a prediction to rate.
Briefly screen risk (avoidance of care, substance misuse of benzo, suicidal ideation) without abandoning the educational task. Station tasks prioritise inhibitory-learning teaching and safety-behaviour work over advice stacks.[5][6][9]

Actor brief (Sam)

Motivated but frightened; catastrophises palpitations as heart attack.
Defends safety behaviours: “The lorazepam in my bag is the only reason I can leave the house.”
Softens if you use collaborative empiricism and do not force cold-turkey abandonment of all safety at once.
Will accept a small supermarket aisle trial with partner waiting outside (not inside) if self-efficacy is supported.
Becomes defensive if lectured or told safety behaviours are “stupid.” Actor responses track Clark safety-behaviour maintenance and Bandura self-efficacy levers.[1][9]

Marking grid (domains)

Domain	Pass behaviours	Fail behaviours
Engagement	Warmth, agenda, permission	Interrogation, jargon dump
Mechanism teaching	CS/panic cues + escape negative reinforcement + safety blocks learning	Only “chemical imbalance” or only secondary gain
Exposure model	Expectancy test / new learning; not pure SUDS chase	“Stay until panic is zero every time” as only goal
Safety behaviours	Collaborative fade plan, not abrupt shaming	Order “throw away lorazepam today” with no plan
Behavioural experiment	Specific prediction, task, review time	Vague “try to go out more”
Risk	Brief benzo misuse / mood / SI screen	Ignores risk entirely or only risk-lectures
Evidence anchors	Names expectancy violation / multi-context practice	Pure habituation or coercion framing
Marking rewards inhibitory-learning language, safety-behaviour fade, and risk screening without abandoning MI-style collaboration.[1][5][6][9]

Exemplar phrases

“Part of your brain has learned that heart racing means danger; leaving and the pill-in-the-bag both teach ‘I only survived because I escaped.’”[9]
“We’ll rate how likely the catastrophe feels before and after a planned test — success is learning the prediction was wrong or tolerable, not that anxiety never showed up.”[5][6]
“We’ll build confidence in steps so you believe you can do this — that belief matters.”[1]
“Gains only in the clinic can fade in a new shop — we’ll practise across places.”[3]

References

[5]Craske MG, Kircanski K, Zelikowsky M, et al. Optimizing inhibitory learning during exposure therapy Behav Res Ther, 2008.PMID 18005936
[6]Craske MG, Treanor M, Conway CC, et al. Maximizing exposure therapy: an inhibitory learning approach Behav Res Ther, 2014.PMID 24864005
[9]Clark DM A cognitive approach to panic Behav Res Ther, 1986.PMID 3741311
[1]Bandura A Self-efficacy: toward a unifying theory of behavioral change Psychol Rev, 1977.PMID 847061
[3]Bouton ME Context, ambiguity, and unlearning: sources of relapse after behavioral extinction Biol Psychiatry, 2002.PMID 12437938

Candidate instructions

Engage collaboratively; set agenda.

Explain in plain language how panic cues and escape maintain the problem (classical + operant / safety behaviours).

Outline exposure that tests predictions (expectancy violation), not “scare me until I calm.”

Negotiate a plan to fade partner/lorazepam-as-talisman carefully.

Agree one specific next-step behavioural experiment with a prediction to rate.

Briefly screen risk (avoidance of care, substance misuse of benzo, suicidal ideation) without abandoning the educational task. Station tasks prioritise inhibitory-learning teaching and safety-behaviour work over advice stacks.[5][6][9]

Actor brief (Sam)

Motivated but frightened; catastrophises palpitations as heart attack.

Defends safety behaviours: “The lorazepam in my bag is the only reason I can leave the house.”

Softens if you use collaborative empiricism and do not force cold-turkey abandonment of all safety at once.

Will accept a small supermarket aisle trial with partner waiting outside (not inside) if self-efficacy is supported.

Becomes defensive if lectured or told safety behaviours are “stupid.” Actor responses track Clark safety-behaviour maintenance and Bandura self-efficacy levers.[1][9]

Marking grid (domains)

Domain	Pass behaviours	Fail behaviours
Engagement	Warmth, agenda, permission	Interrogation, jargon dump
Mechanism teaching	CS/panic cues + escape negative reinforcement + safety blocks learning	Only “chemical imbalance” or only secondary gain
Exposure model	Expectancy test / new learning; not pure SUDS chase	“Stay until panic is zero every time” as only goal
Safety behaviours	Collaborative fade plan, not abrupt shaming	Order “throw away lorazepam today” with no plan
Behavioural experiment	Specific prediction, task, review time	Vague “try to go out more”
Risk	Brief benzo misuse / mood / SI screen	Ignores risk entirely or only risk-lectures
Evidence anchors	Names expectancy violation / multi-context practice	Pure habituation or coercion framing
Marking rewards inhibitory-learning language, safety-behaviour fade, and risk screening without abandoning MI-style collaboration.[1][5][6][9]

Exemplar phrases

“Part of your brain has learned that heart racing means danger; leaving and the pill-in-the-bag both teach ‘I only survived because I escaped.’”[9]

“We’ll rate how likely the catastrophe feels before and after a planned test — success is learning the prediction was wrong or tolerable, not that anxiety never showed up.”[5][6]

“We’ll build confidence in steps so you believe you can do this — that belief matters.”[1]

“Gains only in the clinic can fade in a new shop — we’ll practise across places.”[3]

References

[5]Craske MG, Kircanski K, Zelikowsky M, et al. Optimizing inhibitory learning during exposure therapy Behav Res Ther, 2008.PMID 18005936
[6]Craske MG, Treanor M, Conway CC, et al. Maximizing exposure therapy: an inhibitory learning approach Behav Res Ther, 2014.PMID 24864005
[9]Clark DM A cognitive approach to panic Behav Res Ther, 1986.PMID 3741311
[1]Bandura A Self-efficacy: toward a unifying theory of behavioral change Psychol Rev, 1977.PMID 847061
[3]Bouton ME Context, ambiguity, and unlearning: sources of relapse after behavioral extinction Biol Psychiatry, 2002.PMID 12437938