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Cognitive-Behavioural Therapy (CBT) for Panic Disorder

by edinburghtherapyservice
10 minutes read

If you’ve ever experienced a panic attack, you know how terrifying and debilitating it can be. Your heart starts racing, you break out in a sweat, and you may feel like you’re choking or going crazy. Panic attacks are the hallmark symptom of panic disorder, a condition that causes recurring bouts of severe anxiety, fear, and physical symptoms like chest pain, dizziness, and nausea.

While panic disorder is highly treatable, the condition can significantly diminish one’s quality of life. Many panic disorder sufferers become so afraid of having another panic attack that they start avoiding situations, places, or activities where they’ve previously panicked. This avoidance and anticipatory anxiety only perpetuates the panic cycle.

One of the most effective treatments for panic disorder is cognitive behavioural therapy (CBT). CBT is a practical and hands-on type of therapy that teaches you concrete skills to better understand and change the thoughts and behaviours that are causing and maintaining your panic attacks. Here’s how this evidence-based treatment works:

Your panic disorder therapist in Edinburgh

Edinburgh Therapy Service is a counselling and psychotherapy practice based in Edinburgh. We specialise in cognitivie-behavioural therapy (CBT) for panic disorder. Whether you’re seeking therapy in person here in Edinburgh or preferonline sessions, we are here to support you. Contact us today!

Cognitive restructuring

A core component of CBT for panic disorder involves cognitive restructuring. This technique helps you identify and challenge the catastrophic, irrational thoughts that drive your panic attacks and anxiety. Common cognitive distortions seen in panic disorder include:

➤ Overgeneralizing (e.g. “If I panic here, I’ll panic everywhere”)

➤ Catastrophizing (e.g. “This chest pain means I’m having a heart attack”)

➤ All-or-nothing thinking (e.g. “If I can’t control this panic attack, I’ll go crazy”)


Your therapist will guide you to recognize these unhelpful thought patterns and replace them with more balanced, realistic self-talk. For example:

Irrational thought: “I can’t breathe, I’m going to suffocate!”

Alternative thought: “This is just anxiety making me feel short of breath. I’ve experienced it before and know it will pass.”

Some strategies used in CBT for panic disorder include:


Recording panic attacks

You may track details of panic episodes in a journal or voice recorder immediately afterwards. Reviewing the recorded thoughts and feared outcomes versus what actually happened helps identify cognitive distortions.

For example, you may have thoughts like “I’m going to make a scene and embarrass myself horribly” but the actual outcome was feeling anxious for 15 minutes, then moving past it without incident.


Weighing the evidence

You’ll look at objective evidence and facts that contradict your distorted panic thoughts. For instance, if you have the thought “I’m having a heart attack” during a panic attack, evidence against this could include:

➤ Your cholesterol/blood pressure levels are normal

➤ You have no family history of heart disease

➤ The symptoms always subside after 20-30 minutes

➤ You’ve had similar symptoms many times before without it being a heart attack

Listing the contradictory evidence helps reality-test the validity of your feared thoughts.


Brainstorming alternative thoughts

You’ll generate a list of other more realistic ways to interpret the situation than your initial panic thought. So instead of thinking “I’m going crazy from this dizziness,” alternatives could include:

➤ “It’s just an adrenaline rush, it will pass”

➤ “I’ve had lots of panic attacks before and been fine”

➤ “Dizziness may feel uncomfortable but it’s not dangerous”

Having a “menu” of rational alternatives makes it easier to coach yourself through panic situations.

Learning to rein in catastrophic thinking and “talk back” to your anxious inner voice is a powerful way to reduce panic attacks. CBT combines this cognitive approach with behavioural techniques like interoceptive exposure and in vivo exposure.

Interoceptive exposure

Another CBT technique involves intentional interoceptive exposure, where you practise confronting the very physical sensations you fear most, such as dizziness, racing heart, or shortness of breath. This may involve simple exercises like:

➤Running in place or doing jumping jacks to make your heart race

➤Breath-holding or hyperventilating to induce dizziness/breathlessness

➤Spinning around or shaking your head to trigger imbalance

➤Tensing muscles to create tingling sensations


At first, your therapist may guide you through these interoceptive exercises. The goal is to allow the scary physical symptoms you fear to fully arise, then pass through you without catastrophe. You learn on a visceral level that the sensations are unpleasant but not truly dangerous.

Step-by-step, your excessive fear and anxiety around bodily panic symptoms diminish as you realise you can tolerate them without needing to escape or avoid them. Interoceptive exposures help “recode” your brain’s threat detector.

In vivo exposure

Perhaps the most challenging but crucial part of CBT for panic involves in vivo (real-world) exposure. This means confronting the actual situations, places or activities you’ve been avoiding due to your fear of panic attacks, rather than avoiding or escaping them.

Your therapist will collaborate with you to create an exposure hierarchy, starting with mildly anxiety-provoking scenarios and building up to your most feared situations over time. Examples could include:

➤ Going to a shopping mall or crowded store

➤ Taking transit or driving over bridges

➤ Speaking or performing in front of others

➤ Exercise or other panic trigger activities

During these exposures, the goal is to remain in the feared situation long enough for your anxious arousal to peak, then start declining naturally on its own. You’ll practise applying your new cognitive restructuring skills to challenge unhelpful thoughts. Importantly, you do not try to suppress, fight or escape the panic symptoms, but allow them to arise and pass.

While extremely uncomfortable at first, exposure therapy works through the principles of habituation and fear extinction. By repeatedly facing your fears, the anxious associations and panic response gradually diminish over time. You build trust in your ability to tolerate and overcome panic symptoms. Furthermore, you give yourself permission to challenge catastrophic beliefs, examining them closely. This practice enables you to discover that the feared catastrophe often doesn’t materialise. Even if a feared outcome does occur, you learn to cope effectively with the situation.

A commitment to practise

While the CBT techniques may sound simple in theory, effectively unlearning the panic disorder cycle requires a commitment to consistent practice, both during therapy sessions and in your daily life. Your therapist will provide clear instructions and guidance every step of the way, along with encouragement to gradually face your fears rather than avoid them.

Over time, completing interoceptive and real-world exposure work provides evidence that panic symptoms, while uncomfortable, are not truly dangerous. This flies in the face of your previously-held catastrophic beliefs. As aversive as it may initially feel, choosing to allow panic attack symptoms to occur and pass through your body is how you start to diminish their power over you. The hard work of CBT for panic disorder pays major dividends. 

If you’re struggling with panic attacks and panic disorder, cognitive behavioural therapy can help you regain control over your anxiety and your life. 

If you’d like support from a qualified CBT therapist experienced in managing panic disorder, we’re here to help you on your journey. Contact us!

Further reading

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The Edinburgh Therapy Service is a psychotherapy and counseling practice based in Edinburgh, Scotland (United Kingdom). We offer therapy both in-person in Edinburgh and online, available in English and Spanish.

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Contact us for more information or to book your first appointment: [email protected]