The following is a sampling of some questions (Q) we received and Dr. Christine Padesky’s answers (A) to them.
Correspondents consented to publication of their question and follow-up response for educational purposes
- Highlights the importance of understanding principles of anxiety treatment so you can troubleshoot the unexpected when using treatment protocols
- Please note that the follow-up response at the end of Padesky’s reply provides critical corrective information
Q: DEAR DR. PADESKY Hi, could you clarify something please? I’ve been telling clients for years, following your workshops, that they cannot faint in a panic attack, and explaining why. Then the other day I had a client tell me he frequently did faint in a panic attack. I checked with his doctor who said nothing else [medically] was going on and the doctor assured me that hyperventilating in a panic attack can cause fainting – ??? Hope you can help with this.
— Thanks Julia
A: FROM CHRISTINE A. PADESKY, PhD
Dear Julia,
It was a good idea to consult with your client’s physician first to see if there might be a medical cause of the fainting. Unfortunately, what the physician told you is not consistent with what I’ve been told by physicians over the years. As the Freedom From Fear website (www.FreedomFromFear.org) states:
Panic will not make you faint; While you faint for a variety of reasons that may have nothing to do with panic attacks, (heat, exhaustion, dehydration, poor nutrition, etc.) panic WILL NOT make you faint. When you faint your blood pressure must go down, when you’re having a panic attack your blood pressure is going sagely up, not down. (reference: www.freedomfromfear.org/aanx_factsheet.asp?id=10)
There are several issues raised by your client’s experience:
First, people often say they “fainted” when they felt faint and “needed to sit down.” It is necessary to interview carefully to find out if the person actually lost consciousness as occurs in actual fainting. People do often feel faint when hyperventilating or having a panic attack. While feelings of lightheadedness can be so intense they are labeled “fainting,” the person does not lose consciousness during a panic attack which is part of panic disorder.
Fainting can occur under a variety of situations that can co-occur with panic attacks such as hunger, viral infection, allergy, vertigo from an inner ear disorder, anemia, sinusitis, heat exhaustion, poor eating habits, low blood sugar, salt depletion, standing up quickly, pressure on the vasovagal nerve (e.g., in pregnancy), etc. If fainting is verified, interview to find out if any of these were present when the client fainted. As I may have mentioned in my workshop, one man had been thoroughly tested by a neurologist who ruled out any physical cause for his fainting. Later tests found a small tumor in his brain that was pressing on a nerve and was missed in earlier tests.
As a third point, panic attacks can occur within any anxiety disorder not just panic disorder. It is important to interview and find out what thoughts and images were going through the person’s mind in the middle of the panic attack. With panic disorder you get beliefs such as “I’m having a heart attack.” “If I faint, I will stop breathing and die.” In social anxiety you get thoughts during panic such as “if others see how anxious I am, they will think I am a mental case.” In blood phobia you get thoughts such as “if I see blood I will faint” (which may be true for the reasons in the next paragraph).
If the panic attack is a symptom of severe anxiety when the person has a blood phobia, they would indeed be likely to faint. In blood phobia there is a rapid DROP in blood pressure which leads to fainting. Over time, a person can become so anxious when the anticipate seeing blood or an injury that they become anxious to the point of panic and simultaneously have the drop in blood pressure associated with blood phobia. This would not be diagnosed as panic disorder (and so you would not use hyperventilation as part of treatment) but instead as a blood phobia. Interestingly, the treatment for blood phobia involves teaching the client to raise their blood pressure in the presence of blood or injury through various muscle tightening exercises.
Thus, you need to be a bit of a detective when the client reports fainting during a panic attack. It is important to question with compassionate curiosity (expressing concern for your client) because the client can otherwise think you doubt their veracity.
Please let me know what you learn from your client.
— Christine A. Padesky, PhD
Q: FOLLOW-UP RESPONSE FROM JULIA
Dear Dr Padesky,
Thank you so much for taking the time to answer personally.
I think the client does indeed have blood/injury phobia – which I had never heard of. He does actually faint, and all his triggers are related to blood tests, injuries, hospitals etc. It would also be consistent with a traumatic hospitalization when he was a toddler.
I’m fascinated that the effect of this on blood pressure is the opposite to what happens in panic disorder! I now need to learn more about my interventions.
Thank you for clearing up my mystery and pointing me in the right direction.
— Best Regards, Julia
Q: IS IT POSSIBLE TO OBTAIN A LIST OF GOOD SOCRATIC QUESTIONS? I’m a trainee clinical psychologist and it would be incredibly useful as I’m just starting out and would like to get a real idea of how questions are phrased and to see what is considered a ‘good’ socratic question. I have been reading through your website in order to understand how to use Socratic questioning in therapeutic interviews. I came across the article: ‘Socratic questioning: changing minds or guided discovery’ where Dr Padesky wrote that she had given out lists of ‘good’ socratic questions to students. We were shown a clip of your dvd on Socratic questioning during our current induction block of lectures which just filled me with a lot of questions of how you were able to pose such good questions. Thanks so much for your help and look forward to hearing from you soon. A: FROM CHRISTINE A. PADESKY, PhD Two years after I gave that keynote address you read on my website, those “good Socratic questions” were published in Mind Over Mood (Greenberger & Padesky, 1995). If you look at the summary boxes throughout that book you will find several collections of questions (pages 51 & 70). The questions referred to most directly in my talk were the “questions to look for evidence that doesn’t support hot thoughts.” There is additional information on use of Socratic questions in the Clinician’s Guide to Mind Over Mood (chapter one). Also, I have a Socratic questioning clinical workshop on Audio CD (Guided Discovery) and a clinical demonstration on DVD of the 4 stages of Socratic dialogue (Socratic Dialogue). The CD and DVD programs are available from www.Store.Padesky.com In my CBT Boot Camp workshop, I teach the principles of Socratic questioning and include other topics essential to developing skills as a cognitive therapist. I hope you find this information helpful. I wish you good success in your development as a CBT therapist. FOLLOW-UP RESPONSE Thanks so much for your reply! This has been really helpful and informative. I will definitely get hold of the books that you mentioned as at the present moment I feel there is so much that I could improve. But you’ve pointed me in the right direction.
Subject: Changing minds or guided discovery
DEAR KATHLEEN & CHRISTINE
Presently I am preparing a presentation on Socratic Questioning and have been using Christine’s keynote address to the ECBCT, London 1993 as a reference (Socratic Questioning: Changing Minds or Guiding Discovery).
Whilst I am in agreement that the guiding discovery route is superior to changing minds I see the following potential problems. I was wondering what your latest thinking is on this?
Yours Sincerely,
Colleague in Scotland
POTENTIAL PROBLEM 1
There may not be enough therapy time to explore the pathways the client chooses.
Answer 1: Of course, guided discovery must be balanced to match the time available. This is why it is important to only use guided discovery in the session to test out really central beliefs, not everything discussed. To be clear, there is lots of straightforward discussion and teaching in a CBT session. Guided discovery is only used when testing beliefs or evaluating emotional responses/behavioral choices.
POTENTIAL PROBLEM 2
The clients condition [ i.e. Depression ] may significantly reduce his capacity to access pathways that lead to therapeutic change.
Answer 2: With depression or other specific diagnoses, we have hypotheses which give us ideas as to where to begin our guided discovery. We also use information we have about the client, common human experiences, and “standard” questions that often yield helpful information. Of course these all give us suggestions about a possible therapeutic destination. But I think it is important to hold this imagined destination at arm’s length so one is truly open to hearing what the client has to say.
POTENTIAL PROBLEM 3
Is it not preferable for the therapist to have some idea of where he may be going in terms of a therapeutic destination , but at the same time be flexible enough to embark upon alternative routes suggested by the client?
Answer 3: I don’t disagree with what you say. I also think these points are consistent with what I said in my ’93 keynote. I think of guided discovery along a continuum from pure guided DISCOVERY (for both therapist and client) to GUIDED discovery (in which the therapist is pretty sure about preferred destinations — e.g., client to loosen convictions in favor of suicide). All points on this continuum occur in good CBT and have their place. My keynote was meant to counter a bias I see in the field to Guide rather than Discover.
Hope this is clarifying.
— Christine Padesky
REFERENCES
- Keynote address: Padesky: Socratic questioning: Changing minds or guiding discovery? – listed under Fundamentals
