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…
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 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.
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.
Steps to working with physical reactions of a panic attack:
Identify the most intense physical symptoms
Identify the triggers for these symptoms
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:
Be aware of panic attacks thoughts in the moment
Classify the type of thinking error
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:
Identify what triggers / situations you are avoiding
Create a gradual exposure checklist
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.
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.
For help with panic and other forms of anxiety, feel free to reach out to Good Therapy SF.
