Cognitive Behavioral Therapy for Panic Disorder

Cognitive behavior therapy in the treatment of panic disorder

Cognitive Behavioral Therapy for Panic Disorder

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Cognitive Behavioral Therapy for Panic Disorder | Society of Clinical Psychology

Cognitive Behavioral Therapy for Panic Disorder

2015 Criteria
(Tolin et al. Recommendation) Treatment pending re-evaluation 1998 Criteria
(Chambless et al.


  • Basic premise: Thoughts, feelings and behaviors are inter-related, so altering one can help to alleviate problems in another.
  • Essence of therapy: Cognitive therapy aims to help the person identify, challenge, and modify dysfunctional ideas related to panic symptoms (e.g., catastrophic consequences of bodily sensations). Avoidance of panic and panic-cues is targeted through exposure exercises, including both in vivo (e.g., going to crowded places or driving in traffic) and interoceptive (e.g., bodily sensations) exposures.
  • Length: Approx. 12-16 sessions

Editors: Evan Forman, PhD; Joanna Kaye, BA

Note: The resources provided below are intended to supplement not replace foundational training in mental health treatment and evidence-based practice

Treatment Manuals

  • Anxiety and Panic Disorder: Patient Treatment Manual (Andrews et al.)

Self-help Books

Important Note: The books listed above are empirically-supported in-person treatments. They have not necessarily been evaluated empirically either by themselves or in conjunction with in-person treatment. We list them as a resource for clinicians who assign them as an adjunct to conducting in-person treatment.

Smartphone Apps

Important Note: The apps listed above are empirically-supported in-person treatments. They have not necessarily been evaluated empirically either by themselves or in conjunction with in-person treatment. We list them as a resource for clinicians who assign them as an adjunct to conducting in-person treatment.

Clinical Trials

  • Group cognitive-behavioral treatment of panic disorder (Telch et al., 1993)
  • Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial (Barlow, Gorman, Shear, & Woods, 2000)
  • A randomized effectiveness trial of cognitive-behavioral therapy and medication for primary care panic disorder (Roy-Byrne et al., 2005)
  • Behavioral treatment of panic disorder: A two-year follow-up (Craske, Brown, & Barlow, 1991)
  • Alprazolam and exposure alone and combined in panic disorder with agoraphobia (Marks et al., 1993)
  • Brief cognitive-behavioral versus nondirective therapy for panic disorder (Craske, Maidenberg, & Bystritsky, 1995)

Meta-analyses and Systematic Reviews

  • Cognitive-behavioral therapy and the treatment of panic disorder: Efficacy and strategies (Otto & Deveney, 2005)
  • Treatment of panic (Schmidt & Keough, 2010)
  • A meta-analysis of the efficacy of psycho- and pharmacotherapy in panic disorder with and without agoraphobia (Mitte, 2005)
  • A meta-analysis of treatment outcome for panic disorder (Gould, Otto, & Pollack, 1995)
  • Cognitive-behavioral treatment for panic disorder: Current status (Landon & Barlow, 2004)
  • A meta-analysis of the treatment of panic disorder with or without agoraphobia: A comparison of psychopharmacological, cognitive-behavioral and combination treatments (Van Balkom et al., 1997)
  • Psychological treatment of panic disorder with or without agoraphobia: A meta-analysis (Sánchez-Meca, Rosa-Alcázar, Marín-Martínez, & Gómez-Conesa, 2010)

Other Treatment Resources

  • Cognitive-behavioral therapy for panic disorder: A review of treatment elements, strategies, and outcomes (Rayburn & Otto, 2003)
  • The effects of treatment compliance on outcome in cognitive-behavioral therapy for panic disorder: Quality versus quantity (Schmidt & Woolaway-Bickel, 2000)
  • When anxiety symptoms masquerade as physical symptoms: What medical specialists know about panic disorder and available psychological treatments (Teng, Chaison, Hamilton, Bailey, & Dunn, 2008)
  • Treatment of Panic Disorder: A Consensus Development Conference ( Wolfe; Editor: Maser)
  • Panic Disorder and Its Treatment (Editors: Pollack & Rosenbaum)
  • Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic (Barlow)
  • Anxiety Disorders and Phobias: A Cognitive Perspective (Beck, Emery, & Greenberg, 2005)


Cognitive Behavioral Therapy (CBT) for Panic Disorder

Cognitive Behavioral Therapy for Panic Disorder

Cognitive behavioral therapy (CBT) for panic disorder is an effective treatment for sufferers with or without agoraphobia. It may be used in conjunction with medication or independently.

CBT empowers the patient with techniques to manage stress and decrease anxiety and correct thinking patterns that potentiate panic. It is the most widely used psychological therapy for treatment of panic disorder.

CBT programs

Cognitive behavioral therapies focus on thinking and making conscious changes in thoughts that are not helpful as well as making behavioral changes.

These therapies focus on the here-and-now; they do not attempt to resolve underlying psychological conflict or trauma. Often programs are short-term, ranging from one to three months.

There are self-help and distance support programs available via the Internet. Group and individual sessions are available.

CBT programs require a high degree of patient motivation and commitment, and the work can be rewarding and exhausting simultaneously. But benefits can reach beyond reducing the panic disorder; therapy can change a patient’s way of relating to him- or herself and others. It may prompt significant lifestyle changes.

CBT addresses thought and belief patterns that cause anxiety and disempower the patient, who learns ways to challenge negative thoughts and replace them with constructive ones. People who suffer from panic may engage in catastrophic thinking, which means believing that the worst possible outcome for an event may happen, even if the lihood is minute.

Participants in CBT programs learn to recognize and refute catastrophic thoughts. They then learn to replace them with more realistic thoughts. CBT programs use a systematic approach.

The participants receive homework to practice skills. Workbooks often are used. Initially, it is very hard work that feels unnatural. In time, confidence grows.

Automatic negative thinking is replaced with more realistic, manageable thoughts that reduce baseline anxiety levels.

CBT can be helpful for people newly diagnosed with panic as well as for people who have had a panic disorder for decades. It works with mild panic and even with patients who have agoraphobia. The tools are helpful for agoraphobics when trying to decrease avoidance behaviors. They learn to break down barriers into smaller components, which increase the lihood of success.

How CBT develops healthier thinking patterns

Here are ways development of healthier thinking patterns may be facilitated:

Participants in a CBT session are provided education that explains panic attacks are not fatal, nor does having a panic attack indicate insanity.

People in the midst of a panic attack often think that they are dying of a heart attack or “going crazy.

” With education about the nature of panic attacks, anxiety that would typically exacerbate fear and heighten the terror of the panic attack is reduced. Baseline anxiety is lessened.

The participant learns to self-assure him- or herself and realizes “I know what this is. It is a panic attack. I feel horrible, but I know what is happening. Panic attacks are self-limiting. I am not losing my mind. I am not having a heart attack. I am not going to die from this. It will pass.”

Basic instructions these offer enormous relief for patients. Knowing that they are essentially okay and not going insane or facing death reduces panic levels monumentally.

CBT may also be beneficial because having a panic attack feels being completely control. This terrifying thought compounds the panicky feelings. Reframing, recognizing self-defeating thoughts, and feeling “more in control” can reduce panic.

Perceiving a higher level of control instead of feeling at the mercy of panic attacks that arise uninvited from anywhere at anyplace or time helps patients feel empowered and less anxious. The less underlying anxiety present, the less frequent and less intense panic attacks may become.

As frequency and intensity are reduced, patients can think clearer, sleep better, and be more realistic. They become optimistic about gaining some power over preventing panic attacks.

CBT skills that are developed

Skills practiced during cognitive-behavioral therapy sessions include recognizing overestimation of the power that panic possesses as well as ways to manage anxiety and panic. Resources are discussed. Realizing that others will assist if panic attacks occur reduces feelings of isolation that dominate during panic attacks.

While these strategies may seem obvious to a person who does not have panic disorder, to a person with it, these acts sometimes seem about as ly for them to achieve as is flying to the moon. A study done in Australia measured the effectiveness of an Internet-based cognitive-behavioral therapy program led by a therapist. It had promising results.

While the Internet is not a substitute for direct face-to-face contact, this offers an affordable, accessible option for people who are far from services, too embarrassed to obtain services, or agoraphobic. For some it may be sufficient help; for others it may be a much-needed lifeline when other options are not available.

Some cognitive-behavioral therapy programs include instruction about progressive muscle relaxation techniques. To do progressive muscle relaxation, clients sit or lie in a comfortable position with their eyes closed.

Starting at the toes, the person contracts then release the muscles in the toes, then feet, followed by the ankles and so forth until his or her entire body is relaxed. The exercise provides immediate relaxation and body awareness skills.

Numbness and not being able to feel grounded is terrifying during panic. Being able to feel, concentrating on an activity that can be performed anywhere, and having to think about something other than the panicky feelings can be useful during a panic attack.

Participants are encouraged to use this strategy on a regular basis as a healthy exercise as well.

Hyperventilation causes many of the frightening symptoms of panic. Often, people with panic disorder hyperventilate under stress so frequently that they are not even aware of it until it becomes extreme.

Learning breath awareness and practicing breathing techniques for 10 minutes twice daily can be beneficial. It is relaxing and helps people realize they can control their breathing. During a panic attack, people commonly say that they feel they are suffocating and can’t breathe.

By practicing breathing techniques, people reduce the lihood of hyperventilation precipitating a panic attack.

If a panic attack does occur, the person has another tool to calm him- or herself. Of all the behavioral skills, breath awareness is probably the most powerful.

Education about panic disorder

Another component of CBT is education about the disorder. As participants learn its physiology, it may help to reduce feelings of shame that are common.

People with panic disorder often feel embarrassed by their limitations and “odd” behaviors. To know that panic is a physical disorder and not a weakness goes a long way in stress reduction.

By learning about the condition, participants feel more in control.

This is critical for people who have a panic disorder because they feel extremely vulnerable and control when panic attacks occur. In addition, the more information that sufferers have, the more choices they can make to minimize panic.

Participants in cognitive-behavioral therapy programs learn to identify what makes them feel anxious. Learning to avoid caffeine and nicotine, being aware that panic may increase at certain times of a menstrual cycle, or finding that exercise may help prevent panic are just some of the topics that may be addressed.

Participants learn to make lifestyle choices that reduce stress and panic and frequency of panic attacks.

Examining thought patterns in CBT

A great deal of time in CBT is spent examining thought patterns. Automatic thoughts can trigger and intensify panic attacks. Participants learn to recognize their negative thoughts and refute them. They learn to distinguish between thoughts and feelings. There are several common, automatic thought patterns that panic sufferers have that increase their distress. These include:

  • Viewing situations as black and white; perfectionism; feeling “ I am weak.”
  • Catastrophic thinking: “If I have a panic attack, I might die from a heart attack.”
  • Exaggerating risk: “If I have a panic attack, no one will want to go out with me ever again.”
  • Giving up: “I will have a panic attack and get fired, so I am not even going to apply for a job.”
  • Thinking that they are weak: “There is something wrong with me, I am too sensitive; it’s just the way I am, and that won’t change.”
  • Thinking too many “shoulds”: “I should be able to drive on the interstate, everyone else does.”
  • Confusing body feelings with facts that imply danger: “When I run, my heart beats fast” or “That will give me a panic attack.”

Recognizing, examining, refuting, and replacing unhelpful thinking patterns is tough work. People who have panic disorder may have thousands of these kinds of thoughts each day.

Fortunately, most people have a few patterns that tend to repeat themselves over and over, so a process does not have to be developed for everyone.

Participants are instructed to write down their thought patterns and substitute new, realistic ones instead.

Here is an example of how to challenge an automatic negative thought pattern:

Jane has a panic disorder. Her biggest fear is that she will not be able to breathe during a panic. She believes that she will die a horrible, suffocating death and no one will care for her children. The children will end up in foster care and lead terrible lives because she is unable to “get a grip.”

In this example, it is clear that Jane is not being kind to herself and sees herself as defective. She is using catastrophic thinking, assuming she will be dead and her children’s lives will be ruined. She is exaggerating the risk associated with panic.

People do not die from panic attacks. People do not stop breathing with panic, even if it feels that they are not getting air. She is associating the feeling of suffocation with death, when in reality, it is the panic that makes her feel unable to breathe.

She is hyperventilating and causing the sensation.

So how can Jane help herself?

She can learn the physiology of panic so she can separate feelings from thoughts. Jane would initially be asked to write down the following procedure, shown below in bold type. Several workbooks are available to guide clients through this process, but they can also use a simple notebook. (Download the Automatic Thoughts worksheet at the end of this article.)

First, Jane needs to (1) identify the feelings that make her feel she is going to die. She believes that when she feels short of breath, it means she is dying. Thus, in this case, the feelings of shortness of breath are the trigger for the panic. Jane then must (2) identify the automatic thought she gets in this situation: “I am suffocating to death.

” She then must learn to (3) challenge that thought. She should ask herself what the lihood of her dying during a panic attack realistically is.

Because she has received information about the physiology of panic, even though Jane feels it’s 100 percent ly when in the throes of panic, her rational thought might tell her that it is a 40 percent probability (which is still an exaggeration but also is markedly less than 100 percent.)

She then must (4) write down the change in her feelings, in this case, the percentage she now estimates is her lihood of dying from suffocation during a panic attack.

Jane needs to (5) write down her revised rationale for believing the new estimate that there is a 40 percent chance of dying. She might write something this: “It gets so hard to breathe when I am having a panic attack.

I try hard to take a deep breath, but I just can’t. My throat feels so tight. It will just block off my airway completely one day.”

She needs to write down why that is not what is really happening and (6) state what actually is occurring: “I know that I am breathing. Throats do not close up during panic attacks. I feel short of breath because I am hyperventilating.”

Jane then should be asked to (7) consider other ways of thinking about the feeling of suffocating and (8) rate the probability that the new thoughts are true: People do not just suffocate to death.

Most people who have trouble breathing suffer from emphysema or have bad hearts or something that. I had a physical. I have a healthy heart and lungs.

The lihood of this being a fact is 75 percent,” Jane might write.

She also should consider another explanation for her symptom: “My throat feels terrible because my neck muscles are tense because of the anxiety. The lihood of this being true is 50 percent.

” Finally, Jane should (9) write down what she now thinks is the lihood of that original automatic thought, that she is going to suffocate to death during a panic.

When she faces facts, Jan should realize that the true lihood of suffocating to death in a panic is much less than she thought. So she might at this point rate the lihood of dying from suffocation during a panic at a much-reduced level of 2 percent.

She might write that it is less ly because if she were going to die during a panic because of suffocation, “I would have already died because I’ve had that feeling many times and I am still alive.”

Unlearning and challenging automatic thoughts reduces anxiety about future panic attacks and improves coping abilities should one occur. It is productive work, but exhausting and time-consuming. Cognitive-behavioral therapies offer people with panic disorder a well-rounded treatment plan that reduces panic and empowers them with skills that they can use to live fuller, healthier lives.


Self Help – Cognitive-Behavioural Therapy (CBT)

Cognitive Behavioral Therapy for Panic Disorder

An important first step in overcoming a psychological problem is to learn more about it, otherwise known as “psychoeducation.”

Learning about your problem can give you the comfort of knowing that you’re not alone and that others have found helpful strategies to overcome it. You may even find it helpful for family members and friends to learn more about your problem as well. Some people find that just having a better understanding of their problems is a huge step towards recovery.

For example, an individual suffering from frequent panic attacks would begin by learning what a panic attack is (see Panic Disorder). In learning about panic, one would discover that although a panic attack is an uncomfortable experience, it’s temporary and not dangerous.

A CBT therapist is able to provide helpful information on your particular problem, but you can also find information on your own through reputable sources at bookstores and on the Internet.

Psychoeducation is a vital first step, but it’s important to remember that this is only one part of a complete treatment plan.

Relaxation Strategies

Learning how to relax your body can be a helpful part of therapy. Muscle tension and shallow breathing are both linked to stress and anxiety (and sometimes depression). So, it’s important to become aware of these bodily sensations and to regularly practice exercises to help you learn to relax.

Two strategies often used in CBT are Calm Breathing, which involves consciously slowing down the breath, and Progressive Muscle Relaxation, which involves systematically tensing and relaxing different muscle groups.

As with any other skill, the more these relaxation strategies are practiced, the more effectively and quickly they will work.

Other helpful relaxation strategies include listening to calm music, meditation, yoga and massage.

It’s important to realize, however, that the goal of relaxation is not to avoid or eliminate anxiety (because anxiety is not dangerous), but to make it a little easier to ride out these feelings.

Realistic Thinking

Effectively managing negative emotions involves identifying negative thinking and replacing it with realistic and balanced thinking.

Because our thoughts have a big impact on the way we feel, changing our unhelpful thoughts to realistic or helpful ones is a key to feeling better.

“Realistic thinking” means looking at yourself, others, and the world in a balanced and fair way, without being overly negative or positive. For example:

Unhelpful and unrealistic thoughtMore realistic and balanced thought
I always screw things up, I’m such a loser. What’s wrong with me?Everyone makes mistakes, including me – I’m only human. All I can do now is try my best to fix the situation and learn from this experience.
I can’t do it. I feel way too anxious. Why can’t I control my anxiety?It’s OK and normal to feel anxious. It’s not dangerous, and it doesn’t have to stop me. I can feel anxious and STILL go to the party.

Steps to Realistic Thinking

Know what you’re thinking or telling yourself. Most of us are not used to paying attention to the way we think, even though we are constantly affected by our thoughts. Paying attention to your thoughts (or self-talk) can help you keep track of the kind of thoughts you typically have.

Once you’re more aware of your thoughts, try to identify the thoughts that make you feel bad, and determine if they’re problematic thoughts that need to be challenged.

For example, if you feel sad thinking about your grandmother who’s been battling cancer, this thought doesn’t need to be challenged because it’s absolutely normal to feel sad when thinking about a loved one suffering.

But, if you feel sad after a friend cancels your lunch plans and you begin to think there’s obviously something seriously wrong with you and no one s you, this is problematic because this thought is extreme and not reality.

Pay attention to the shift in your emotion, no matter how small. When you notice yourself getting more upset or distressed, ask yourself, “What am I telling myself right now?” or “What is making me feel upset?”

When you’re accustomed to identifying thoughts that lead to negative emotions, start to examine these thoughts to see if they’re unrealistic and unhelpful. One of the first things to do is to see if you’ve fallen into Thinking Traps (e.g.

, catastrophizing or overestimating danger), which are overly negative ways of seeing things.

You can also ask yourself a range of questions to challenge your negative thoughts (see Challenge Negative Thinking), such as “What is the evidence that this thought is true?” and “Am I confusing a possibility with a probability? It may be possible, but is it ly?”

Finally, after challenging a negative thought and evaluating it more objectively, try to come up with an alternative thought that is more balanced and realistic. Doing this can help lower your distress.

In addition to coming up with realistic statements, try to come up with some quick and easy-to-remember coping statements (e.g., “This has happened before and I know how to handle it”) and positive self-statements (e.g.

, “It takes courage to face the things that scare me”).

It can also be particularly helpful to write down your realistic thoughts or helpful coping statements on an index card or piece of paper. Then, keep this coping card with you to help remind you of these statements when you are feeling too distressed to think clearly.

Facing Fears: Exposure

It’s normal to want to avoid the things you fear because this reduces your anxiety in the short term.

For example, if you’re afraid of small, enclosed places elevators, taking the stairs instead will make you less anxious. However, avoidance prevents you from learning that the things you fear aren’t as dangerous as you think.

So, in this case, taking the stairs prevents you from learning that nothing bad happens when you do take the elevator.

In CBT, the process of facing fears is called exposure – and it’s the most important step in learning to effectively manage your anxiety.

Exposure involves gradually and repeatedly entering feared situations until you feel less anxious.

You start with situations that only cause you a little bit of anxiety, and you work your way up to facing things that cause you a greater deal of anxiety (See Facing Fears: Exposure).

The first step involves making a list of the situations, places or objects that you fear.

For example, if you’re afraid of spiders and want to overcome this fear so you can enjoy camping with friends, the list may include: looking at pictures of spiders, watching videos of spiders, observing a spider in an aquarium, and standing across the room from someone holding a spider. Once you have a list, order it from the least scary to the scariest.

Starting with the situation that causes you the least anxiety, repeatedly take part in that activity or face that situation (e.g., looking at pictures of spiders) until you start to feel less anxious doing it. Once you can face that specific situation many different times without experiencing much anxiety, you’re ready to move on to the next step on your list.

CBT stresses the importance of facing fears on a regular basis. The more you practice, the faster your fears will fade! Having successes and feeling good about your progress is a powerful motivator to keep going.

How to Prevent a Relapse

Managing your problem effectively is a lot exercise – you need to “keep in shape” and make practicing the helpful skills a daily habit. However, sometimes people slip back into old habits, lose the improvements they’ve made and have a relapse.

A relapse is a complete return to all of your old ways of thinking and behaving before you learned new strategies for managing your problem.

While it’s normal for people to experience lapses (a brief return to old habits) during times of stress, low mood or fatigue, a relapse certainly does not have to take place. Here are some tips on how to prevent lapses and relapses:

Keep practicing your CBT skills! This is the best way to prevent a relapse. If you’re practicing regularly, you’ll be in good shape to handle whatever situations you’re faced with.

Tip: Make a schedule for yourself of what skills you’re going to work on every week.

Know when you are more vulnerable to having a lapse (e.g., during times of stress or change), and you’ll be less ly to have one. It also helps to make a list of warning signs (e.g.

, more anxious thoughts, frequent arguments with loved ones) that tell you your anxiety might be increasing. Once you know what your warning signs or “red flags” are, you can then make an action plan to cope with them.

This might involve, for example, practicing some CBT skills calm breathing or challenging your negative thinking.

Remember that, everyone else on earth, you are a work in progress! A good way to prevent future lapses is to continue working on new challenges. You’re less ly to slide back into old habits if you’re continually working on new and different ways of overcoming your anxiety.

If you have had a lapse, try to figure out what situation led you to it. This can help you make a plan to cope with difficult situations in the future. Keep in mind that it’s normal to occasionally have lapses and that you can learn a lot from them.

How you think about your lapse has a huge impact on your later behaviour. If you think that you’re a failure and have undone all your hard work, you’re more ly to stop trying and end up relapsing.

Instead, it’s important to keep in mind that it’s impossible to unlearn all the skills and go back to square one (i.e., having anxiety and not knowing how to handle it) because you do know how to handle your anxiety. If you have a lapse, you can get back on track.

It’s riding a bike: once you know how to ride one, you don’t forget it! You might become a bit rusty, but it won’t be long until you’re as good as before.

Remember that lapses are normal and can be overcome. Don’t beat yourself up or call yourself names “idiot” or “loser,” because this doesn’t help. Be kind to yourself, and realize that we all make mistakes sometimes!

Finally, make sure to reward yourself for all the hard work you’re doing. A reward might be going out for a nice meal or buying yourself a little treat. Managing anxiety is not always easy or fun, and you deserve a reward for your hard work!


How Cognitive Behavioral Therapy Can Help Relieve Panic Disorder

Cognitive Behavioral Therapy for Panic Disorder

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If you've decided to go to psychotherapy for panic disorder, you may be wondering what your therapeutic treatment options are. Numerous types of therapy are available, depending on your therapist’s approach and training background.

Panic-focused psychodynamic psychotherapy (PFPP) is one such option that's been shown to be effective in treating panic disorder; another effective psychotherapy—often considered to be the most popular type of therapy for anxiety disorders—is cognitive-behavioral therapy (CBT).

Due to its proven effectiveness, goal-oriented focus, and quick results, professionals who treat panic disorder often prefer CBT to other forms of therapy. The following describes the CBT approach and explains how it's used to treat panic disorder, panic attacks, and agoraphobia.

Cognitive-behavioral therapy, or simply CBT, is a form of psychotherapy used in the treatment of mental health conditions. The underlying concepts of CBT are the notion that a person’s thoughts, feelings, and perceptions influence her actions and behaviors.

According to the tenets of CBT, a person may not always be able to change her life circumstances, but she can choose how she perceives and acts upon life’s ups and downs.

CBT works to help change a person’s faulty or negative thinking, and assists in shifting unhealthy behaviors.

CBT is currently used for the treatment of numerous mental health disorders, including major depressive disorder, phobias, post-traumatic stress disorder (PTSD), and addiction.

 CBT has also been found to be an effective treatment option for some medical conditions, such as irritable bowel syndrome (IBS), fibromyalgia, and chronic fatigue.

Get our printable guide to help you ask the right questions at your next doctor's appointment.

One of the main goals of CBT is to help a client overcome negative thinking patterns so that he may be able to make better choices in his actions and behaviors.

In general, people with panic disorder are often more susceptible to negative thoughts and self-defeating beliefs, which can result in lowered self-esteem and increased anxiety.

 Fearful and negative thinking is often associated with panic attacks, the main symptom of panic disorder.

Panic attacks are frequently experienced through a mix of physical and cognitive symptoms. Typical somatic symptoms include shortness of breath, heart palpitations, chest pain, and excessive sweating. These symptoms are often perceived as frightening and can lead to distressing thoughts, such as a fear of losing control, going crazy or dying.

Fears associated with panic attacks can become so intense that they begin to negatively impact a person’s behaviors. For example, a person may begin to fear having an attack while driving or in front of other people (thoughts).

The person will then avoid driving or being in crowded areas (behaviors). Such behaviors lead to a separate condition known as agoraphobia.

 With agoraphobia, fearful thoughts become instilled over time, and avoidance behaviors only serve to reinforce these fears.

CBT can assist people with panic disorder and/or agoraphobia in developing ways to manage their symptoms. A person may not be able to control when he has a panic attack, but he can learn how to effectively cope with his symptoms. CBT assists the client in achieving lasting change through a two-part process.

  1. Recognize and Replace Negative Thoughts. The CBT therapist will first assist the client in identifying his negative cognitions or thinking patterns. For instance, a person may be directed to contemplate how he perceives himself, views the world or feels during a panic attack. By focusing on the thought process, a person can begin to recognize his typical thought patterns and how it influences his behaviors.
  2. The therapist may use a wide range of activities and exercises to help the client become aware of his negative thoughts, and learn to replace them with healthier ways of thinking. Additionally, homework activities are often assigned between sessions to help the client in continually identifying and eliminating faulty thinking.
  3. Writing exercises can be a powerful way to conquer faulty thinking patterns. These exercises may be used to increase awareness of and replace negative thoughts. Some common CBT writing exercises include journal writing, keeping a gratitude journal, using affirmations, and maintaining a panic diary.
  4. Skill Building and Behavioral Changes. The next step of CBT involves building on healthy coping strategies to change maladaptive behaviors. During this phase, the client will learn to develop skills to help in reducing stress, managing anxiety, and getting through panic attacks. These skills may be rehearsed in session, but it's also important that the client practices new behaviors outside of therapy, too.
  5. Desensitization is a common CBT technique that is used to help the client get past avoidance behaviors. Through systematic desensitization, the CBT therapist gradually introduces the client to anxiety-producing stimuli while teaching him how to manage his feelings of anxiety. The person is slowly introduced to more fear-inducing situations, developing ways to cope with panic symptoms through each feared circumstance.
  6. To help remain calm through anxiety-provoking circumstances, relaxation techniques are also learned. These skills assist in managing fears, lowering heart rate, reducing tension, and improving problem-solving skills. Some common relaxation techniques include deep breathing exercises, progressive muscle relaxation (PMR), yoga, and meditation.

Being one of the most widely used forms of therapy, CBT may be part of your recovery process. CBT can help in reducing symptoms on its own, but many will find a combination of treatment options to be the most beneficial. Your doctor or therapist can help you determine if CBT is right for you and assist you in developing a treatment plan that will best suit your needs.

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  1. Chambless DL, Milrod B, Porter E, et al. Prediction and moderation of improvement in cognitive-behavioral and psychodynamic psychotherapy for panic disorder. J Consult Clin Psychol. 2017;85(8):803–813. doi:10.1037/ccp0000224

  2. Fenn K, Byrne M. The key principles of cognitive behavioural therapy. InnovAiT: Education and inspiration for general practice. 2013;6(9):579-585. doi:10.1177/1755738012471029

  3. Cleveland Clinic. Cognitive behavioral therapy (CBT). Updated January 13, 2020.

  4. MedlinePlus. Panic disorder. Updated April 9, 2020.

  5. MedlinePlus. Agoraphobia. Updated March 26, 2018.

Additional Reading

  • Fenn K, Byrne M. The key principles of cognitive behavioural therapy. InnovAiT: Education and inspiration for general practice. 2013;6(9):579-585. doi:10.1177/1755738012471029
  • Burns, D. D. (2008). Feeling Good: The New Mood Therapy (2nd ed.). New York: Avon.
  • Greenberger, D. & Padesky, C. (1995). Mind Over Mood: Change How You Feel by Changing the Way You Think. New York; The Gilford Press.


Panic attacks: Help sufferers recover with cognitive-behavioral therapy

Cognitive Behavioral Therapy for Panic Disorder

With panic attacks, alarming physiologic symptoms mount swiftly—tachycardia, chest pain, sweating, trembling, smothering or choking, dizziness, fear of losing control or going crazy—even fear of dying.1 Patients constantly fear the next attack, worry about its consequences, and change their behaviors to avoid or withdraw from anxiety-provoking situations.

To relieve their suffering, cognitive-behavioral therapy (CBT) may offer benefits you would not realize with medication alone. CBT can:

  • improve long-term patient outcomes
  • enhance medication management
  • boost treatment response when medication alone is inadequate
  • ease drug discontinuation.2

Whether you or a CBT-trained psychotherapist guides the sessions, you can achieve optimal results for your patients with panic disorder.

Panic disorder is chronic, often disabling, and characterized by spontaneous, unpredictable panic attacks (Boxes 1 and 23-11). When treated with CBT, about three-quarters of patients become panic-free and maintain treatment gains at follow-up, and one-half become both panic-free and free of excess anxiety.9

Typical therapy is 12 individual, once-weekly visits for psycho-education, relaxation, and breathing training; cognitive restructuring; and exposure therapies.

Briefer protocols, “reduced therapist contact,”12 and group therapy13 also can help patients and in some studies have been as beneficial as 12 weeks of individual therapy. Although trained psychotherapists have higher success rates than nonbehaviorists when treating panic patients, nonbehaviorists also can provide effective therapy after relatively brief training.14

American Psychiatric Association15 treatment guidelines recommend medications—such as selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and benzodiazepines—as well as CBT as first-line therapies for panic disorder. Other treatment guidelines concur16 and note that CBT is more cost-effective than medications.

In comparison studies, CBT has been at least as effective for panic symptoms as SSRIs,17,18 TCAs,19 and alprazolam.20 Antidepressants are the preferred drug for panic disorder16 because they lack benzodiazepines’ dependence and abuse potential.

Providing medication during CBT may maintain patients’ therapeutic gains better than CBT alone if the medication is continued after CBT is completed. Interestingly, patients who use benzodiazepines during CBT may have higher relapse rates than those who do not use benzodiazepines, particularly when the benzodiazepines are withdrawn.9

CBT produces improvement rates similar to those of pharmacologic treatment at one-quarter to one-half the cost in the first year. Patients also appear to have better clinical outcomes if they receive CBT while SSRIs or benzodiazepines are being discontinued, compared with simply stopping the medications.8

Box 1

Panic attacks typically begin between ages 10 and 40. The cause is unknown, but evidence points to multiple factors, including heredity, neurobiology, provocations, and psychological conditioning (Box 2).3-9 prevalence is approximately 5%,10 and about three-fourths of panic disorder patients are female.11

Comorbidity. Up to 50% of persons with panic disorder also experience agoraphobia.1 Depression, other anxiety disorders, and substance abuse may complicate the clinical picture.

Box 2


Genetics. About 10% of persons who experience panic attacks have first-degree relatives with panic disorder. Twin studies suggest heritability of up to 43%

Neurobiology. Anxiety responses appear to be organized at different neuroanatomic levels:

  • automatic responses by periaqueductal grey matter or locus coeruleus
  • practiced responses by the amygdala and septohippocampal regions
  • cognitively complex responses by higher cortical regions.

The hypothalamus mediates neurohormonal responses. Panic disorder patients’ response to SSRIs, tricyclic antidepressants, and benzodiazepines suggest a link with neurotransmitters serotonin, norepinephrine, and GABA. Adenosine, cannabinoids, neuropeptides, hormones, neurotrophins, cytokines, and cellular mediators may also be involved.

Provocation. Panic disorder may have a physiologic mechanism.

When exposed in the laboratory to panicogenic substances (such as carbon dioxide, sodium lactate, yohimbine, and caffeine), persons with panic disorders experience greater numbers of panic attacks than do those without panic disorders. These laboratory-induced panic attacks resemble real attacks, and anti-panic medications block the induced panic attacks.


The cognitive-behavioral model postulates that panic disorder patients:

  • have a predisposed vulnerability to respond with physiologic arousal to negative stressors
  • tend to see anxiety symptoms as harmful
  • have negative and catastrophizing cognitions about those symptoms.

With conditioning, patients associate early physiologic arousal with other panic symptoms as the arousal progresses. Ultimately, they become hypervigilant for symptoms and develop a learned escalation of anxiety and apprehension (with accompanying negative cognitions) when the early symptoms re-occur.

Source: References 3-9

To diagnose panic disorder, conduct a thorough psychiatric evaluation that includes assessing for comorbid mental and substance use disorders.

The history and physical exam are essential to rule out medical causes of the patient’s symptoms, such as heart disease causing dizziness or palpitations.

Asking patients to keep panic attack records can help you identify panic symptoms’ frequency and triggers.9

An assessment tool such as the Albany Panic and Phobia Questionnaire (Figure) can be a useful starting point.

It has 27 items and three subscales to quantify a patient’s fear of agoraphobic situations, social phobia situations, and situations that produce bodily sensations (interoceptive symptoms).

Items on the interoceptive subscale include activities such as exercising vigorously, ingesting caffeine, and experiencing intense emotion.21 Using the Anxiety Sensitivity Index is another assessment option.22