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Panic attacks: what they are and what to do about them
Panic attacks: what they are and what to do about them

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3.2 What happens in CBT for panic?

Described image
Figure 9 Facing the fear

In CBT for treating panic the therapist’s central aim is to change the persons’ beliefs or interpretations (judgements) about panic attacks (think back to Stanley Law). The whole idea behind this is that the person has made a serious mistake in their understanding of what panic is and what it could do to them. If these mistaken beliefs or interpretations can be corrected they will be less afraid of panics and, as a result, the panics will become less severe and less frequent.

Typically the process involves first working out what is going on through an clinical assessment that focuses on understanding when and how the panic attacks occur and then working systematically to change how a person responds in a panic attack. The assessment involves identifying person’s panic interpretation and their avoidance and coping (safety) behaviours.

Assessment of panic interpretations: The assessment of a person’s beliefs around panic/panic attacks is the first step in therapy. No two persons have the same beliefs about panic; usually there are a whole range of complicated thoughts around panic and it is the therapist’s task to understand and untangle this. For example, a person might believe that panic sensations are an impending heart attack and that they will lose consciousness and pass out, or they might think the panic is the first stage of a nervous breakdown from which they will never recover.

Assessment of safety behaviours: In their assessment the therapist also has to work out all the person’s strategies (or their ‘safety behaviours’) for dealing with their imagined catastrophes. For instance, they might drink water, take a painkiller, lie down, steady themselves if they think they are having a heart attack, or try to counteract feelings of unreality and dizziness by shaking their head, if they think what they are experiencing is the start of a nervous breakdown.

Once the assessment is complete, typically, CBT for panic involves two elements:

  • Behavioural experiments in which the person discovers by personal experience that panic is not actually going to harm them. This involves a person not using their safety behaviours.
  • Cognitive restructuring in which the therapist uses a ‘didactic’ (teaching) approach to help the person logically explore their beliefs, so that they realise the beliefs are unfounded and incorrect.

In a way, the behavioural experiments work at an unconscious level and cognitive restructuring works at a conscious level. The experiments can be carried out in a therapist’s office or in settings where a panic is likely to occur, such as in a supermarket. Cognitive restructuring usually occurs in the therapist’s office. Most CBT therapists use a combination of both approaches, but because it is quicker and easier for a therapist to work from their own office, they often rely on patients doing ‘homework’ for the practical exercises.

Activity 9 A example of successful therapy

Timing: Allow approximately 20 minutes

Read an extract from Roger Baker’s Understanding Panic Attacks and Overcoming Fear. It describes the details of cognitive behaviour therapy received by Ralph, a 28-year-old postgraduate student with disabling panic attacks.

‘Ralph: an example of successful therapy’ [Tip: hold Ctrl and click a link to open it in a new tab. (Hide tip)]


As you read the description of Ralph’s CBT therapy for panic disorder you will notice the really long list of avoidance and coping behaviours that Ralph is using both between panic attacks and during them. You will notice how the therapist (Roger) and Ralph work together to understand how his life history has led him to develop the catastrophic interpretation that bodily symptoms of panic mean that he is disintegrating and going mad. The case example shows both how complex and individual a person’s experience of both panic disorder and treatment for it are.