CBT for Panic disorder


CBT for Panic Disorder

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, different theories explain anxiety in different ways. Treatment then follows from those explanations of anxiety. The CBT model of anxiety suggests:

  1. A stimulus ( sensation, thought, memory situation) happens.
  2. We perceive it as threatening.
  3. The perception leads to reactions of fear and fearful thoughts, for example, “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 get away or avoid the perceived threat.
  5. At the moment, we can have immediate relief by avoiding.
  6. But in the long term, we don’t learn that situations aren’t dangerous, so our anxiety worsens.
  7. The cycle is perpetuated in the manner further driving our anxiety disorder and decreasing our quality of life.

Core Elements of CBT for Panic Disorder


You probably have heard a lot about the magical intervention of CBT so what is it?


CBT consists of a series of therapeutic interventions that target how our thoughts, feelings, and behaviors interact in the above model. This page will explain the core components of CBT for panic disorder.


Psychoeducation and information


Part of CBT focuses on providing psychoeducation and information about how panic works according to CBT theory.


This part of therapy focuses on how your expectations, beliefs, and fearful thoughts about the panic contribute to the attacks. A therapist using CBT will also help you to modify, challenge, and change your thoughts.


First, you will learn information that helps you understand 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, CBT would emphasize fearful catastrophic thoughts such as ” I am going to die,” “I am having a heart attack” or “I am going to faint” and how they drive the panic cycle. In CBT for panic disorder, a therapist helps you see how these thoughts drive the need to escape and avoid.


If you have panic disorder you have behavior of escape and avoidance. A CBT therapist would help you learn how this is contributing to your cycle.

Self Empowerment

CBT therapy for panic disorder emphasizes self-agency. You begin to learn how you are in control and have the tools to heal yourself.

Cognitive Restructuring

Another part of CBT treatment for panic disorder is Cognitive Restructuring. Cognitive restructuring is restructuring your cognitions.


During the cognitive restructuring phase of CBT, you learn:


  • How untrue thoughts drive the panic cycle and how to spot them
  • How to recognize thought biases
  • How to experiment with thought biases that cause the panic cycle
  • About overestimating the probability of death, heart attacks, or fainting!
  • How to be aware of the impact of your thoughts on your panic
  • Learn the skills to challenge your catastrophic beliefs. Will something terrible happen? Will your panic never end?
  • Learn more reality-based thinking, not based on the panic


CBT and Exposure Interventions in Panic

Exposure is a key feature of most good anxiety treatments.

Anxiety and panic occur when we misinterpret certain body sensations as danger when it doesn’t exist. This triggers a fear response in our bodies and emotions. We begin to act as if we are in danger by looking for safety and avoiding the dangerous thing.


Exposure is when you deliberately do or expose yourself to the thing you are afraid of, in this case, have a panic attack. 


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

To do this, you need to face the fear and stop avoiding it. 


Think about this. If you are afraid of all dogs and are never around any that don’t bite, how will you know that all dogs don’t bite?

You have to have experiences with dogs that don’t bite to learn that they are safe. If you avoid all interactions, a phobia of dogs can exist because you have no evidence that any of them are safe.


Avoidance maintains fear. Exposure teaches you that fear is not substantiated.


Panic is the same. If I induce a panic attack and learn to stick with it, I can learn that I don’t die or have a heart attack and see what is happening in my body from a calm place; my fear of panic drops, AND my panic attacks decrease. This is what the research shows.


CBT for Panic disorder might consist of situational or in vivo exposure.   In vivo exposure is exposure to situations that might cause panic. Treatment may also consist of interoceptive exposure or exposure   to the sensations associated with a panic disorder.

In Vivo Exposure

In vivo exposure also includes a survey of the safety behaviors you use to manage and avoid your discomfort. This is a common strategy in people who have anxiety.

Safety Behaviors

Here is a list of common safety behaviors used to avoid and manage discomfort 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 on to rails etc
  • Distracting yourself with music
  • Keeping yourself extra still
  • Moving around


Safety behaviors, like avoidance, strengthen the panic cycle and make you worse. 

The Hierarchy

A CBT therapist is concerned with helping you retrain your fear response!

Establishing a hierarchy of feared situations is often a part of treatment for panic disorder.


There are various ways to do exposure, the most common way is to start from least to most frightening.


A CBT therapist, when doing an exposure, will:


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


• Repeat exposure until fear diminishes


For example


  • A CBT might create an exposure hierarchy of feared places you avoid and help you gradually go to those places until you stop avoiding life. 
  • You also may be asked to do these things with or without your safety, depending on where these things fall on your hierarchy.
  • You will then be asked by your therapist, 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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