CBT for Panic disorder

CBT for Panic Disorder


According to the DSM V You have Panic Disorder if you have

  1. Recurrent unexpected panic attacks
  2. Worry about future attacks •
  3. Worry about the consequences of the attack
  4. Change your behavior in response to the attack ( avoid going places or doing things for fear of the attack, have safety behaviors etc.)

CBT Theory

In psychology, various theories explain anxiety in different ways, and treatment follows from these explanations.

The cognitive-behavioral therapy (CBT) model of anxiety suggests the following steps:

  1. A stimulus (sensation, thought, memory, or situation) occurs.
  2. We perceive it as a threat.
  3. This perception leads to fear reactions and fearful thoughts, such as “I need to get out of here,” “I am going to die,” “I am having a heart attack,” or “I am going to faint.”
  4. These thoughts and sensations cause us to want to avoid or get away from the perceived threat.
  5. Avoiding the situation can provide immediate relief.
  6. However, in the long term, we do not learn that situations are not dangerous, and our anxiety worsens.
  7. The cycle is perpetuated, further driving our anxiety disorder and decreasing our quality of life.

Core Elements of CBT for Panic Disorder

You may have heard about the remarkable effectiveness of cognitive-behavioral therapy (CBT). But what exactly is it?

CBT is a type of therapy that focuses on how our thoughts, feelings, and behaviors interact with each other. This approach can be highly effective in treating panic disorder. In this document, we’ll explain the core components of CBT for panic disorder.

Psychoeducation and information

Part of cognitive-behavioral therapy (CBT) involves providing psychoeducation and information about how panic works according to CBT theory. This aspect of therapy focuses on how your expectations, beliefs, and fearful thoughts about panic contribute to attacks. A therapist using CBT will also help you modify, challenge, and change your thoughts.

Initially, you will learn about how your thoughts, behaviors, and physiological symptoms interact to produce panic. CBT heavily emphasizes how your thinking influences the panic cycle.

Catastrophic Thoughts

For panic disorder, cognitive-behavioral therapy (CBT) focuses on identifying and challenging catastrophic thoughts such as “I am going to die,” “I am having a heart attack,” or “I am going to faint,” and how they contribute to the panic cycle. A therapist will work with you to recognize how these thoughts lead to the need to escape and avoid situations.


If you have panic disorder, you may exhibit behaviors of escape and avoidance. A cognitive-behavioral therapist can help you understand how these behaviors contribute to your condition and how to break that cycle.

Self Empowerment

CBT therapy for panic disorder emphasizes self-agency. It teaches you that you are in control and provides you with the tools to heal yourself.

Cognitive Restructuring

Another aspect of CBT treatment for panic disorder is Cognitive Restructuring. This involves restructuring your thoughts.

During the cognitive restructuring phase of CBT, you will learn:

  • How false thoughts trigger the panic cycle and how to identify them
  • How to recognize thinking biases
  • How to experiment with thinking biases that contribute to the panic cycle
  • About overestimating the likelihood of death, heart attacks, or fainting!
  • How to be mindful of the impact of your thoughts on your panic
  • Techniques to challenge your catastrophic beliefs. Will something terrible happen? Will your panic never end?
  • Strategies for developing more reality-based thinking, not based on panic.

CBT and Exposure Interventions in Panic

Exposure is a key feature of most effective anxiety treatments.

Note: Exposure may be harmful to autistic individuals and may need to be modified for people with ADHD.

Anxiety and panic occur when we misinterpret certain body sensations as danger when they don’t actually pose a threat. This triggers a fear response in our bodies and emotions, causing us to act as if we are in danger by seeking safety and avoiding the “dangerous” thing.

Exposure is deliberately doing or exposing oneself to the thing that one is afraid of, in this case, having a panic attack.

Part of anxiety treatment is learning that the thing you are afraid of is not actually scary.

To achieve this, you must face the fear and stop avoiding it. Consider this: if you are afraid of all dogs and never come into contact with any that don’t bite, how will you know that all dogs don’t bite?

You need to have experiences with non-threatening dogs to learn that they are safe. If you avoid all interactions, you may develop a phobia of dogs because you have no evidence that any of them are safe.

Avoidance perpetuates fear, while exposure teaches you that your fear is unwarranted.

Panic works the same way. By inducing a panic attack and learning to stick with it, I can discover that I won’t die or have a heart attack, and I can observe what’s happening in my body from a calm place. My fear of panic decreases, and my panic attacks become less frequent. This is supported by research.

CBT for panic disorder may involve situational or in vivo exposure, which refers to exposure to situations that might cause panic. Treatment may also involve interoceptive exposure or exposure to the sensations associated with a panic disorder.

In Vivo Exposure

In vivo exposure involves identifying and working through the safety behaviors you use to manage and avoid anxiety. This is a common strategy for people with anxiety disorders.

Common Safety Behaviors

Here are some common safety behaviors used to manage anxiety in people with panic disorders:

  • Carrying medication to stop panic
  • Looking for exits
  • Having a cell phone to call for help
  • Sitting close to exits
  • Holding onto rails or other objects
  • Distracting oneself with music
  • Keeping oneself extra still
  • Moving around

However, it’s important to note that safety behaviors, like avoidance, can actually strengthen the cycle of panic and make symptoms worse.

The Hierarchy

A CBT therapist’s goal is to help you retrain your fear response. In treating panic disorder, establishing a hierarchy of feared situations is often necessary.

Exposure therapy is one of the most common ways to do this, starting from the least to the most frightening situation. When conducting an exposure therapy, a CBT therapist will:

  • Provide accurate expectations for what will happen during the exposure (your fear will likely increase and then drop)
  • Repeat the exposure until fear diminishes

For example, a CBT therapist might create an exposure hierarchy of feared places that you avoid, and help you gradually go to those places until you stop avoiding life. Depending on where these things fall on your hierarchy, you may be asked to do them with or without your safety.

Then, your therapist will ask you what changed, and you can watch your fear levels and panic improve.

Interoceptive exposure

CBT for panic disorder will often consist of a certain kind of exposure called Interoceptive Exposures or exposures to internal sensations.

Internal sensations are what kicks off the fight or flight cycle.

This provides you with opportunities to examine negative ideas about what terrible things your internal sensations mean.

In CBT this will repeatedly happen until you feel comfortable and accept the internal sensations without fear, so they don’t scare you and drive your panic!

Relaxing around these internal sensations will drop your resistance and decrease your panic attacks.

How do we do this?

A therapist will create exercises that induce panic by mimicking sensations that initiate the danger response (i.e., dizziness, increased heart rate).

Standard Interoceptive Exposure Procedures •

  • If you have dizziness during your panic attacks, dizziness might be induced by spinning around
  • If you have a racing heart during your panic attacks, your therapist might have you run in place vigorously until your heart pounds.
  • Your therapist might have you drink caffeine and gradually expose you to the symptoms induced by caffeine if you notice that caffeine is a trigger for your panic attacks.

This article highlighted some main features of CBT for panic disorder. I hope this has been helpful for you if you have been trying to learn about CBT for panic disorder.

Here are some other pages on this website on panic:


Medical information obtained from this website is not intended as a substitute for professional care. If you have or suspect you have a problem, you should consult a healthcare provider.

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