SOAP Note

Subjective

The client reported three episodes of sudden racing heart, breathlessness and fear of losing control while travelling on crowded trains during the previous week. They left the train early on two occasions and described increasing anticipatory anxiety before commuting, which had begun to affect office attendance. Paced breathing learned previously had reduced the intensity of one episode but had not prevented the client from leaving. The client wanted to regain confidence using public transport and denied current suicidal thoughts, self-harm thoughts or thoughts of harming others when asked directly.

Objective

The therapist completed a structured review of the episodes, including onset, physical sensations, feared outcome, avoidance and recovery time. The therapist mapped a cycle linking bodily sensations with catastrophic interpretation, escalating anxiety and escape, then led a two-minute paced-breathing exercise while the client recalled a lower-intensity travel cue. The client completed the exercise and reported a reduction in distress from 6/10 to 4/10. The therapist documented the client’s speech as clear and at a normal rate during the review.

Assessment

The current difficulty was understood through a supported panic-maintenance cycle in which fear of bodily sensations increased arousal and leaving the train provided immediate relief while strengthening anticipatory anxiety. Avoidance had begun to affect work attendance, while the client’s previous use of paced breathing and ability to identify the cycle provided a basis for graded behavioural work. The in-session reduction in distress suggested that paced breathing was usable as a regulation strategy, without establishing that it would be sufficient on its own during travel. Direct risk assessment did not indicate a current suicide, self-harm or harm-to-others concern in this session.

Plan

• Treatment direction / next-session focus: Continue CBT-oriented work on catastrophic interpretations of bodily sensations and review a graded travel experiment.

• Client between-session therapeutic work: The client agreed to record the trigger, bodily sensations, feared outcome, response and recovery for any further episodes, and to practise paced breathing once daily outside periods of high anxiety.

• Monitoring, assessment, referral or coordination: Review functional impact on commuting and whether avoidance is increasing.

• Booking, timing or frequency arrangements: The next appointment was retained for the usual fortnightly time.