Cognitive behavioral therapy (CBT) is a proven method of treating many anxiety related disorders, including panic disorder. Panic disorder is a common anxiety disorder, and is often diagnosed along with other anxiety disorders, such as agoraphobia or social anxiety disorder. The main component of panic disorder is the presence of recurrent, unexpected panic attacks.1
What Is CBT?
Cognitive behavioral therapy (CBT) is one of the most common, well-supported and utilized therapeutic modality. It is known for its effectiveness in treating a wide range of mental health conditions, including panic disorder. CBT centers on the premise that faulty thoughts are contributing factors that sustain emotional distress and problematic behaviors. As such, the focus of CBT is to help an individual alter unhelpful thinking patterns so they can cope in healthy ways, reduce symptoms, and improve their quality of life.1
CBT can create lasting results using goal-oriented techniques to alleviate symptoms of panic disorder quickly and effectively. Typical CBT therapy sessions last approximately 50 minutes and occur weekly for three to six months.
Does CBT for Panic Disorder Actually Work?
Cognitive behavioral therapy is a common and effective treatment for panic disorder.2 The goal of CBT is to help the individual develop skills to recognize the connection between their thoughts, feelings, and behaviors; then apply those skills to manage how their thoughts and feelings interact and influence their behaviors.
CBT teaches coping skills specifically related to anxiety and panic attacks, including cognitive restructuring and refocusing, problem solving, relaxation techniques, and skills training.3 Through CBT, the individual can learn breathing and relaxation skills to aid in the event of a panic attack. CBT can also help people evaluate the triggers of their attacks, and learn ways to reframe these events to be less triggering.
One of the most important components of CBT in treating any disorder, including panic disorder, is that for the individual to make the most progress, he or she must practice the skills acquired in therapy outside of a therapeutic session. In other words, the skills must be applicable in the “real world” and the individual must be able to employ the skills learned when necessary outside of therapy.
CBT Techniques for Panic Disorder
There are many different techniques and tools common to Cognitive Behavioral Therapy that therapists use for treating panic disorder, including cognitive restructuring and breath control.
Some of the most common techniques utilized in CBT specifically for treating panic disorder are:
Learning About Panic Attacks & Panic Disorder
In the context of CBT, learning more about the client’s current experience, level of distress, severity of symptoms, and how these affect their overall functioning is part of the assessment process. Someone starting treatment is provided with an in-depth knowledge related to panic attacks and panic disorder. For instance, a mental health professional will explain the physiological symptoms associated with panic attacks and clarify misconceptions causing unwarranted worry and avoidant behavior, describing how this can develop into panic disorder.
Cognitive Restructuring
The aim of cognitive restructuring is to learn the difference between rational and irrational thoughts, or cognitive distortions. Once someone is able to accurately identify these distortions, then they can begin working toward restructuring their thoughts in more healthy, productive ways.
During a panic attack, it’s hard to organize thoughts in a way that makes sense to others. For example, someone who has a fear of crowds is out with a group but loses the group and finds themselves alone in a large crowd. Cognitive restructuring can help the person remember that their life isn’t in danger and come up with ways to cope and prevent separations from happening in the future.
Exposure Therapy
Exposure therapy in CBT involves exposing someone to the trigger that’s causing them stress. With prolonged exposure, the anxiety related to the trigger begins to decrease. With continued training the someone can become desensitized to the stimulus, thus decreasing the anxiety related to it.
For panic disorders, this can be helpful if someone has recurring flashbacks to a particular traumatic event. Exposure therapy can be done through visualizations with a therapist—visualizing and confronting the trigger will make that individual less impacted by it over time.
Breath Control Procedures
Breath control procedures are important skills to master for those suffering from any type of anxiety, especially panic disorder. Often during a panic attack, someone loses control of their breathing, causing the breath and heart rate to accelerate. Through breath control exercises, the individual can learn to control their breathing and reduce their heart rate. This practice of breath control is critical in battling a panic attack.
For panic attacks of any kind, breathing is a great way to stay grounded and help you focus on what is happening right now and not focus on “what-ifs.” This can be especially helpful for the individual mentioned above who has a fear of crowds and is separated from their group. A person’s physical state changes during a panic attack, and a breathing exercise can help to regulate what is happening in their body, helping slow their heart rate.
Muscle Relaxation
Muscle relaxation is another way for a person experiencing a panic attack to regain control of their body. Muscle relaxation works by focusing on individual sections of the body and relaxing the muscles in that section, moving gradually through the body until all parts of the body are relaxed.
Similar to breathing exercises, muscle relaxation can be a good way to redirect the brain to focus on other things happening in the body, such as muscle tension disappearing. For panic attacks, finding ways to use your body as a way to self-regulate is effective because of the bodily changes that happen during a panic attack. Muscle relaxation can help to disarm and refocus the brain from the subject of the panic attack.
Grounding
Grounding is a relaxation and mindfulness technique that gets someone to focus on their five senses as a way to ground themselves in the present.
Here’s an example of a grounding exercise that might be helpful if you feel a panic attack coming on:
- Find five things you can see
- Find four things you can touch
- Find three things you can hear
- Find two things you can smell
- Find one thing you can taste
Mindfulness Training
Mindfulness training in CBT involves focusing attention onto the present. This can be done through deep breathing exercises, muscle relaxation, or grounding techniques. Whichever method someone uses, the point of the exercise is to keep thoughts centered in the here and now.
Mindfulness-based CBT is a great intervention specifically for panic disorder. In a study lasting 8 weeks, it was found that individuals with panic disorder showed significant improvement on their intolerance of uncertainty as well as improvements in self reports on their overall symptoms of both depression and panic disorder. Mindfulness-based CBT can have a great impact on improving quality of life for those suffering from chronic panic attacks.4
Journaling
Journaling is usually given as homework by the CBT therapist. The act of journaling can provide a way of tracking thoughts and behaviors over time and discovering patterns in cognitive distortions. It is a valuable tool for helping someone gain insight into their irrational thoughts and beginning the process of cognitive restructuring.
S.M.A.R.T. Goals
S.M.A.R.T. goals are set by the patient with the help of their therapist, and stand for:
- Specific: The client knows exactly what it is they want to accomplish. The goal is clearly defined.
- Measurable: The client will know if progress is being made and when they have achieved their goal.
- Attainable: The client has the skills and resources necessary to reach the goal.
- Realistic: The client will devote their time and energy into accomplishing it.
- Time-specific: The therapist and patient decide on an appropriate time frame for completing the goal.
It is the therapist’s responsibility to make sure that the client sets a goal that meets the S.M.A.R.T. goal standard. Failure is more likely to occur when the client does not set reasonable and realistic goals that are unattainable given their skill level or time frame.5
Is CBT Effective for Panic Disorder?
Cognitive behavioral therapy is a proven method for treating anxiety-related disorders, including panic disorder. In fact, many studies suggest that CBT is as effective, if not more so, than other therapy methods. Cognitive behavioral therapy is, in fact, one of the few psychotherapy methods that has ample research and scientific evidence to support the claim that CBT is effective in producing change.2
- In a meta-analysis of 21 studies, it was found that CBT was the most effective intervention type for treating panic disorder, including over breathing retraining.6
- In another study looking at the brain activity, it was found that CBT was effective in reversing the effects of a panic episode in those with panic disorder as evidence by the increase of brain activity in the middle frontal and parietal lobes.7
- In a study lasting 10 weeks, it was found that internet-based CBT was effective for those with social anxiety, depression and panic disorder, and specifically those with panic disorder who have greater deficits at baseline can benefit the most from internet CBT.8
Are There Any Risks?
There are no known risks of CBT at this time. However, it may not work for everyone or may not be as effective for everyone who receives CBT only as a treatment option (some people might do better with another treatment option or with the addition of medication). When compared with no treatment, CBT does effectively help in decreasing symptoms of panic. CBT with medications also improved overall severity of panic, mania and anxiety.
The CBT Treatment Process & Timeline
CBT treatment is dependent on the individual and the severity of their symptoms, and this can impact the duration of treatment. The standard treatment model of CBT is about 12 weekly sessions on average, with each session lasting one hour.
CBT can take time to be effective depending on other mental health issues the individual is dealing with or other traumatic histories which may be at play. It’s important to go in with an open mind and with hope that, with the guidance of a therapist, you can work through these issues.
Developing a CBT Treatment Plan for Panic Disorder
As with other approaches, a CBT treatment plan entails a collaborative effort between the therapist and the client. The goal is to create awareness about the current problem (panic disorder and associated difficulties) and how CBT can help. The therapist and client work together in formulating a therapy strategy based on the client’s specific concerns, severity of symptoms, if there is presence of a comorbid condition, level of insight, lifestyle, cultural identity, etc. A treatment plan and length of therapy will likely vary from person to person.
Below is a general overview of a CBT treatment plan for panic disorder:2,9
Goals
- Diminish the frequency, intensity, and duration of panic attacks
- Reduce the fear associated with inability to manage panic attacks
- Minimize/eliminate evading places and activities thought to provoke panic attacks
Objectives
- Identify automatic unreasonable fear-based thoughts
- Challenge and replace faulty beliefs with healthy alternatives
- Build self-confidence to manage and overcome panic attacks
- Confront situations/places/things that are avoided out of fear of having a panic attack until these no longer create such a response
- Develop an after-care plan to maintain progress upon completion of therapy
Interventions
- Modeling to train client on identifying distorted thoughts and replacing these with healthy self-talk
- Teaching relaxation techniques that will increase self-confidence to cope with panic attacks and decrease avoidant behavior
- Assigning homework to help identify personal distorted thoughts and replace them with reality-based alternatives, engage in gradual exposure to potential panic-inducing situations, etc.
- Discussing and establishing strategies so that a client can support themselves after treatment
How to Find a CBT Therapist
Because of the proven effectiveness of CBT for treating many mental health conditions, it is one of the most-utilized types of therapy, so it shouldn’t be too hard to find a provider. You can ask your primary care physician for a referral, or call the number on the back of your insurance card.
You can also use an online therapist directory where you can search for therapists who provide CBT. When contacting a therapist, don’t be afraid to ask how much clinical experience they have using CBT specifically for panic disorders. Let that information be one part of the criteria you use in choosing the therapist you want to work with.
How Much Does CBT Cost?
Because CBT has been proven to work well for many mental health concerns, it is generally covered by mental health insurance. While coverage can significantly lower the cost of therapy, there is still usually a copay for mental health services. These can range from $10 and upwards of $100 depending on the network. Looking at “in-network” providers might be able to help with the out-of-pocket costs with copays and keep the cost down.
Out-of-network providers (those who do not accept insurance) may charge anywhere from $80 to $200 per session, some of whom may have a sliding scale option. It’s important to talk with your insurance provider about the amount of sessions they would cover, and be in contact with your therapist about the expected length of treatment.
Is CBT or Medication Better for Treating Panic Disorder?
Generally, CBT can improve symptoms of panic disorder on its own. In some cases, though, adding medication to a therapy plan may be necessary for people with acute symptoms or who aren’t fully recovering with psychotherapy alone. In general, antidepressants like SSRIs and SNRIs are deemed first-line options for panic disorder since these are effective and usually well tolerated. However, the type of medication someone may be prescribed will likely depend on a host of factors such as their medical history, severity of symptoms, tolerance to side effects, having a coexisting condition, etc. It’s best to speak with a health care practitioner who can assess if the person is a good candidate for medication as well as which type, dosage, and length of treatment.10,11
What Other Therapies Can Help Treat Panic Disorder?
CBT is usually the gold standard approach to treat a variety of anxiety conditions including panic disorder. Nonetheless, there are other therapeutic options that can help treat panic disorder either as a stand-alone method or an add-on strategy to the main treatment.
Other therapy techniques that can help with panic disorder include:
- Bibliotherapy: Entails the use of books or other reading materials for self-improvement. Within a clinical context, it is often prescribed by counselors as a supplementary intervention to improve treatment outcomes.
- Mindfulness-Based Stress Reduction: This is an evidence-based approach that combines mindfulness meditation practices with contemporary psychological strategies to enhance overall wellbeing and ease chronic anxiety symptoms.12
- Acceptance and Commitment Therapy: ACT is a new generation of CBT that utilizes mindfulness and acceptance techniques aimed at encouraging people to make positive life changes despite the hardships they may be experiencing.13
- Biofeedback: This is a psychophysiological intervention that enables people to recognize physical signs associated with stress and anxiety. In turn, a person can self-regulate bodily reactions, feel more relaxed, and diminish anxiety episodes.14
At-Home CBT Exercises for Panic Disorder
While Cognitive Behavioral Therapy should only be practiced by a qualified and experienced professional, there are certain CBT related relaxation exercises that you can try at home that can help relieve symptoms of panic disorder:
Deep Breathing Exercise
A simple deep breathing exercise that can be performed at home is a 4-4-6. To do this exercise:
- Breath in through your nose for 4 seconds.
- Hold the breath in your lungs for 4 seconds.
- Breath out through your mouth for 6 seconds.
- Repeat.
Practice this for about 5-10 minutes at a time. This technique can be used to calm your breathing and slow your heart rate when you are feeling anxious.
Progressive Muscle Relaxation Exercise
An easy muscle relaxation exercise to try at home is the progressive muscle relaxation exercise:
- Feet: Curl your toes tightly into your feet, hold for 5 seconds, then release.
- Calves: Point your feet, hold for 5 seconds, then release.
- Thighs: Squeeze your thighs tightly together, hold for 5 seconds, then release.
- Torso: Tighten the muscles of your abdomen, hold for 5 seconds, then release.
- Back: Squeeze your shoulder blades together, hold for 5 seconds, then release.
- Shoulders: Lift your shoulders up toward your ears and squeeze them together, hold for 5 seconds, then release.
- Arms: Make fists and bend your arms, bringing your forearm toward your biceps and squeezing the muscles in the arms, hold for 5 seconds, then release.
- Hands: Make tight fists by curling your fingers into your palms, hold for 5 seconds, then release.
- Face: Scrunch your facial features and pull them toward the center of your face, hold for 5 seconds, then release.
- Full body: Tighten and squeeze all the muscles in your body together at the same time, hold for 5 seconds, then release.
Practice this muscle relaxation exercise daily to release anxiety-induced tension from your body.
Grounding Exercise
A grounding exercise can be done to keep focus on the here and now by seeking out sensory stimuli in your current environment. An imagery-guided grounding exercise can also be used as a way to calm anxiety.
To begin, think of a place you find comforting. Somewhere in your house, a favorite spot, a beach, or a memory from your childhood. Now spend 5-10 minutes visualizing this place that you have conjured in your mind.
Use your senses to help you:
- What do you see? Look around and take in your surroundings in this space. What can you see in the distance? What do you see close to you? Try to notice small details you might normally miss?
- What do you hear? Listen closely to the noises around you. Are the noises you hear soft or loud? Do they sound close by or far away?
- What do you taste? Are you eating or drinking something? If so, what does it taste like? Is it sweet or savory?
- What can you feel? Is it warm or cool? Is there a breeze? Is the sun shining on you warming your skin? Or are you bundled up in a soft blanket? Concentrate on how everything feels.
- What can you smell? What does the air smell like here? Is the scent strong or faint? Focus on the scents you smell and appreciate them.
Use this exercise to relax your mind when you are feeling anxious or stressed. Spend as long as you need visualizing your comfortable space. Allow yourself to feel calm and safe.
Examples of CBT for Panic Disorder
Cognitive Behavioral Therapy can use many techniques when working with someone who has panic disorder. The key with any treatment is to tailor therapy to the individual. Treatment for panic disorder may focus heavily on one specific aspect of CBT, or a combination of different techniques may be applied. Some patients find different techniques more helpful for them than others, and therapy can be modified to fit the needs of the individual.
Exposure Therapy for Agoraphobia-Induced Panic Attack
For someone suffering from panic disorder who makes the decision to see a CBT therapist, one common and highly effective treatment used for anxiety disorders is exposure therapy. During an exposure therapy session they would be exposed to whatever the stimulus is that triggers their anxiety.
Sara is a 25-year-old woman who has agoraphobia, an anxiety disorder that causes extreme discomfort in public settings in which you feel you cannot escape. When placed in these uncomfortable situations, Sara often experiences intense panic attacks.
Sara’s therapist uses exposure therapy to treat this condition, gradually introducing her to the anxiety-inducing environments. At the start of the session, when introduced to the stressor, Sara’s anxiety increases exponentially. But by staying in the situation and allowing herself to feel the anxiety and adjust to it, she begins to become desensitized to the stressor.
Over time, Sara’s anxiety decreases to a much lower, more manageable degree. With repeated exposure therapy sessions, being in public settings becomes less and less anxiety-provoking for her.
Relaxation Techniques for Panic Attacks
There are many different relaxation techniques utilized in CBT. Breathing techniques, muscle relaxation, and grounding exercises are among the most common. For Darcy, a fifty-five-year-old mother of three, a CBT therapist would spend time during therapy sessions explaining the different procedures they would like Darcy to use when she feels on the verge of a panic attack. The therapist would then guide her through the exercise until she feels comfortable using the technique.
Darcy’s therapist also assigns homework for her to complete between sessions. With relaxation techniques, the more she can practice on her own in times that are less stressful and panic-inducing, the better she becomes at using the techniques when they are needed.
For Further Reading
Cognitive Behavioral Therapy for Panic Disorder Infographics
