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How Does A Cognitive Behavioral Therapist Treat Panic Attacks?

Tom McDonagh 5
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How Does A Cognitive Behavioral Therapist Treat Panic Attacks?

As a practicing clinical psychologist, this is a question I answer on a weekly basis. Often clients call in distress, wondering why they suddenly had an attack, with no previous anxiety history.

“But I’ve never had this before in my life!”

Or sometimes there is a history of anxiety, but the attacks were something they did not think would come back.

“I used to have them in college, but they just stopped on their own. I
thought I grew out of it!”

The common theme is feeling scared, confused, with no clue how to “fix it.” Thankfully, CBT for panic has this figured out. But first…

What is a Panic Attack?

The Anxiety and Depression Association of America reports “A panic attack is the onset of intense fear or discomfort that reaches a peak within minutes and includes at least four of the following:

  • Palpitations, pounding heart, or accelerated heart rate
  • Sweating
  • Trembling or shaking
  • Sensations of shortness of breath or smothering
  • Feelings of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, unsteady, light-headed, or faint
  • Chills or heat sensations
  • Paresthesia (numbing or tingling sensations)
  • Derealization (feelings of unreality) or depersonalization (being detached
    from oneself)
  • Fear of losing control or “going crazy”
  • Fear of dying

In my 10+ years of clinical experience, the most common symptoms are a pounding heart, shortness of breath, a fear of losing control, and a fear of dying. It’s a terrifying experience, but I always remind my clients that the CBT approach is highly effective.

The Three Buckets for Treatment

CBT addresses panic attacks by breaking the symptoms into three buckets: Physical Reactions, Thoughts, and Behaviors. The treatment then addresses each of these buckets. For panic attacks, it is usually helpful to start with physical reactions, then thoughts, and finally behaviors. 

Physical Reactions

Steps to working with physical reactions of a panic attack:

  1. Identify the most intense physical symptoms
  2. Identify the triggers for these symptoms
  3. Teach new relaxation strategies to counteract each physical symptom

Typically, the most fearful component of a panic attack are the physical reactions. An intense heart rate and a feeling of choking are terrifying experiences. This is why focusing on the physical reactions of a panic attack first are so important. The ability to regain a sense of control and practice a new skill provide hope and motivation. 

When working with a CBT trained therapist, relaxation strategies will likely include diaphragmatic breathing, progressive muscle relaxation, and visualization or mindfulness skills. While addressing the physical symptoms might sound intense, gaining the ability to calm oneself is a fun and pleasant experience. 


The steps to working with panic attack thoughts are:

  1. Be aware of panic attacks thoughts in the moment
  2. Classify the type of thinking error
  3. Use skills, such as a thought record, to challenge these panic thoughts 

The goal with panic thoughts is to see the thought as a symptom of a diagnosis.  Similar to how a stuffy nose is a symptom of the common cold, anxiety thoughts are a symptom of anxiety. Recognizing this helps to externalize panic thoughts, and makes them easier to challenge.  

But watch out. There is a trap we can fall into, which is assuming everything we think is true. When anxious, the body and mind are in a fight or flight response. As a result, the area of your brain that is responsible for being highly rational is less active. (From an evolutionary perspective, it’s not useful to be able to do calculus when you’re being chased down by a tiger). This is why it feels like your anxiety thoughts are true in the anxious moments, but after the fact, when the more rational brain is back to normal, it’s easier to dismiss them.   

All anxiety thoughts assume the worst case scenario is going to happen. This is especially true for panic attack thoughts. It’s not uncommon for people with panic attacks to think:

     “The next one is going to kill me, I just know it”

     “I can’t have a panic attack now, everyone will think I’m crazy”

     “If I have a panic attack and I’m driving, I’m going to pass out and kill myself or others”  

Looking into the future and assume the worst-case scenario is going to happen is a type of thinking error called “Future Tripping.”  

With a CBT trained therapist, clients are taught how to identify the different types of thinking errors associated with panic. Then, these thinking errors are cognitively restructured or challenged using a variety of CBT skills. The most common skill is thought record. Using these restructuring skills over time helps to adjust thoughts during a moment of panic. 


The steps to working with panic attack behaviors are:

  1. Identify what triggers / situations you are avoiding
  2. Create a gradual exposure checklist
  3. Use the newly learned relaxation skills and thought skills when approaching the triggers / situations that were previously avoided 

Avoidance is the behavior that feels safe in the short term, but in the long term only reinforces panic attacks. Due to the nature of panic, clients will avoid people, places, activities, or situations that trigger the fearful physical symptoms. 

For example, someone might avoid walking up a hill because they know it will cause their heart rate and breathing to increase. In this case, the person is avoiding the physical sensations of a panic attack, even if they are mild. With these situations, an interoceptive exposure approach is most effective.   

Or someone might have difficulty returning to a grocery store because that was the place where they had their last attack. “It feels jinxed.” In this case, using a systematic desensitization approach is most helpful. 

With a CBT trained therapist, clients are coached through the gradual steps to approach these fearful triggers in a useful way. The duration (staying in a place long enough), frequency (doing it often enough) and use of new skills help provide the change and extinguish the symptoms of panic attacks.

A Final Word

While the symptoms of a panic attack are highly intense and fearful, it is important to know there are cognitive behavioral treatments that are highly effective. Focusing on the physical symptoms, thoughts, and behaviors is an approach that’s proven to be highly successful. 

I hope you found this entry useful. If you live in the San Francisco area and are suffering from panic or other anxiety issues, please feel free to contact for assistance.


Dr. Thomas McDonagh is a licensed clinical psychologist in California and co-author of 101 Ways to Conquer Teen Anxiety
He grew up in the Midwest and moved around the country for college and graduate work, including Manhattan College in Bronx, NY, Vanderbilt University Medical Center in Nashville, TN and Kaiser Permanente in Santa Rosa, CA.
Through these experiences, he found his love for working with teens and adults suffering from anxiety issues. It’s a common pain that is shared by all at one point or another. From his perspective as a clinician, he wants to see that pain relieved.



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  1. Gaurav Gaur Gaurav Gaur

    Hi, Mc Donagh.
    Thanks for sharing the process of treatment on how panic attacks are taken care by Cognitive Behavioural Therapist.
    We need to be extra vigilant to identify the four major symptoms of Panic attack . Thanks for focussing the light on this important issue as we find this behaviour very common in our near and dear ones specially the teens.
    Warm Regards,
    Gaurav Gaur

  2. stephen micheal stephen micheal


  3. MissusB MissusB

    People who suffer from panic attacks should be given a lot of support from family, friends or even colleagues. This is something that shouldn’t be taken lightly because things might get serious. That is why, it is always the best option to consult a specialist to help them cope or surpass this condition. As I am recalling past event, I can say I might have experience a mild panic attack. I haven’t seek for a consultation because it was probably just one time. 

    Thanks for explaining CBT and what it does to patients suffering from this dilemma. You explained it so well and the examples you presented just made it easier for readers to understand.

  4. Todd Matthews Todd Matthews

    Crowded or foreign places are my biggest trigger and it’s been this way for eleven and a half years. This has stopped me from going on vacation; I haven’t even been out of the viewing area in a while. No real vacation in the last few years, but one reason why I’m looking to earn income from home isn’t due to the fear, it’s because I actually want to get out and travel domestically and even the world. I see those I went to school with doing it all the time and I think to myself, ‘if only I could get the thought type of panic triggers under control, I can do this, too.’

    Something you wrote that jumped out at me was exposure and duration, while doing so frequently enough. I came up with something that I would love to embark on days I’m off my day job which are similar to the criteria you laid out. One method is to simply hop in my car and travel as far as I can in one direction, perhaps to New York State. Stay there a few days, alone, and just live my life. Then in another week, drive like twelve hours down south. Perhaps to South Carolina. Do the same for the east and the west on select weeks, then work my way into an airplane and maybe finally foreign travel.

    Derealization is always a trigger when I’m in public. This has happened in grocery stores, stadiums, and other events. However, I’m always in the gym, and it doesn’t matter what gym I’m in or where I’m at, if I’m in a gym, I’m fine. Ditto for restaurants. I go to these venues frequently, so perhaps your strategy of exposure works wonders, and it gives me hope for my future travels. 

  5. Aabidah Ahmed Aabidah Ahmed

    This is a very interesting topic. I’ve always been interested in knowing how and why panic attacks happen. I’ve never experienced this but I have a friend that does. 

    She cannot explain how and why it happens, it just happens. So ever since I knew of what she goes through, I found an interest in this by doing research. 

    I’m happy to understand how and why. 

    Thank you for sharing and all the best.

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