Short, intensive cognitive behavioral therapy can ease panic disorder

Bonnie Zucker, PhD, a clinical psychologist in Los Angeles, was in graduate school studying treatments for panic disorder in 2001 when she got hit by a tsunami of stress: her dissertation work, the terrorist attacks in New York, where she previously lived, and a tense dinner party where the attacks became the subject of conversation.

Sitting at the table, she suddenly felt like she could not breathe. Her heart pounded. She fled to the bathroom, wondering whether she was having a heart attack. And then she realized: She was having a panic attack.

“But because I knew that it was a panic attack, I was able to calm myself down,” Zucker said. “Someone else might have thought, I need to go to the hospital.”

Zucker’s knowledge of panic attacks had saved her from spiraling into panic disorder, a condition in which people experience recurring panic attacks and mounting fear about them. Patients can feel out of control and hopeless, but as Zucker’s experience suggests, panic disorder can be controlled. Research on this condition, dating back nearly 50 years, has shown that cognitive behavioral therapy (CBT) and some medications such as selective serotonin reuptake inhibitors (SSRIs) can ease panic disorder. Now, more recent work is revealing that even short, intensive CBT can have long-lasting benefits—and spill over to improve people’s mental health more broadly.

“For patients, it’s important to realize that focused treatments like CBT can really have a broad impact on many parts of the mind,” said Jonathan Huppert, PhD, a clinical psychologist and head of the Laboratory for the Treatment and Study of Mental Health and Well Being at the Hebrew University of Jerusalem, whose work focuses on anxiety disorders. “By focusing on thoughts, behaviors, and emotions, it can really change who you are.”

Panic disorder is defined in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) by recurrent and unexpected panic attacks, followed by a month or more of either persistent concern about more attacks or their consequences, or a significant maladaptive behavior change related to the attacks. Panic attacks are sudden surges of intense fear or discomfort that include such symptoms as heart palpitations, nausea, dizziness, and/or feelings of depersonalization (see Symptoms of a panic attack for a full list).

Panic disorder often co-occurs with agoraphobia, in which the person develops a fear of situations or places that are hard to escape or where getting help might be difficult, such as elevators, public transportation, or crowds.

The gold-standard treatment for panic disorder is CBT, which has been shown to be effective both in trials and in clinical care settings (Öst, L., et al., Clinical Psychology: Science and Practice, Vol. 30, No. 3, 2023). While this therapy is a long-standing treatment, clinicians are increasingly refining their understanding of the way people overcome their fears using CBT techniques. Where once it was thought that patients needed to habituate to their feared sensations or stimuli, there is now more focus on inhibitory learning, or replacing the learned fear with new information, even chasing the experience of a panic attack—all the better to learn that these physical sensations are not catastrophic.

“Exposure itself is insufficient,” said Reid Wilson, PhD, a clinical psychologist and director of the Anxiety Disorders Treatment Center in Chapel Hill, North Carolina, comparing habituating to panic to white-knuckling through a flight for a person with a fear of flying. “We are now looking at this model, which has more to do with distress tolerance: I am willing to experience the symptoms and then handle the symptoms, as opposed to avoiding them.”

Psychoeducation can be helpful for people who have had one panic attack and seek help, said Zucker, who has a book on panic disorder coming out with publisher New Harbinger next summer. While working as a graduate student counselor, she saw many students who just needed education on why they might be having panic attacks and why these episodes were not dangerous in order to avoid developing deeper anxiety.

For established panic disorder, structured and collaborative CBT protocols are the go-to, said Kevin Chapman, PhD, a clinical psychologist and the founder and director of the Kentucky Center for Anxiety and Related Disorders in Louisville. These protocols combine psychoeducation and symptom tracking. Therapist and patient work together to catalog feared situations and avoidance behaviors, like refusing to visit the supermarket or always sitting near an exit. This information helps shape the exposure therapy in which patients will learn to tolerate their fears. This approach typically begins with interoceptive exposure—creating the sensations of a panic attack so that the patient can work on disentangling the bodily sensations from the overwhelming feeling of threat.

“For instance, if they get lightheaded, then we might spin them in the office chair for a minute and then have them stand up quickly,” Wilson said. “We are provoking the sensations, but we’re reducing the threat because they’re in the safety of their relationship with us in our office.”

Then come field trips that take patients into real places they would prefer to avoid. In keeping with the inhibitory learning approach, the idea is to break the link between the patient’s anticipatory dread and the actual outcome. It is also important to move from an attitude of “I have to do this” to “I want to do this,” Wilson said.

The goal of CBT is to teach people that it does not matter if they have a panic attack, said Martin Antony, PhD, chair of the Department of Psychology at Toronto Metropolitan University and a specialist in anxiety disorders.

“When people are finally willing to welcome these sensations that they don’t like and to say, ‘OK, come on panic attack, come get me,’ that’s when they stop having panic attacks,” Antony said.

A typical CBT course for panic disorder might run 9 to 12 weeks, but there are shorter, more intensive options as well. The Bergen 4-Day treatment for panic disorder is a concentrated CBT method developed in Norway that was first used for obsessive-compulsive disorder but has also proven effective for panic. It begins with psychoeducation in a group setting and first focuses on establishing the patient’s intentions to lean into their discomfort. On Day 2 of the treatment, the patient chooses an individual plan for exposure tasks and launches into these tasks with the help of a therapist. These tasks are both interoceptive and in vivo, such as going somewhere the person would normally avoid because of agoraphobia. Group sessions throughout Days 2 and 3 allow participants to share their experiences and draw support from fellow patients. OnDay 4, patients learn how to continue training and maintain changes in their daily lives, making an exposure plan for the next 3 weeks.

A long-term follow-up on 30 patients who underwent this protocol found that there were significant and continuing decreases in symptoms at 3 months, as measured by the Panic Disorder Severity Scale. At 18 months, these gains were maintained, and 90% of patients were in remission. Though panic was the focus of the intervention, participants also saw reduced depression and generalized anxiety, persisting through 18 months (Eide, T. O., et al., BMC Psychiatry, Vol. 25, No. 107, 2025opens in new window).

Other research also suggests that narrowly focused treatment for panic can have wider effects. Huppert and his colleagues have found that CBT treatment for panic disorder can improve anxious attachment, which is a relationship style marked by fear of abandonment and a strong need for reassurance, despite attachment not being a focus of treatment (Psychotherapy Research, Vol. 29, No. 3, 2019opens in new window). A follow-up study found a similar improvement in anxious attachment in an asynchronous, internet-based CBT module—in other words, when no human therapist was involved (Journal of Counseling Psychology, Vol. 69, No. 2, 2022). This finding suggests that anxious attachment improved not because of a therapeutic relationship but as a direct result of the treatment reducing patients’ sensitivity to anxiety. The patients may have relied less on other people to cope with anxiety as their sensitivity to anxiety declined, Huppert said.

In a final study, Huppert and his team randomized 128 participants to single-session CBT, psychodynamic therapy, or a control group, this time focusing on targeting anxiety sensitivity specifically. They found that CBT reduced anxiety sensitivity compared with the control group, while psychodynamic therapy did not. CBT also improved interpretation bias, or the tendency to interpret bodily sensations as catastrophic. Interestingly, Huppert said, those who improved their anxiety sensitivity in the CBT condition also saw an improvement in reflective functioning (Psychotherapy Research, 2025opens in new window).

“One potential interpretation of this is that when one is doing good CBT, it affects psychodynamic processes of attachment and reflective functioning as well, even if they’re not directly addressed,” Huppert said.

The growing understanding of the processes underlying related disorders has led to more interest in transdiagnostic treatment. Panic disorder is often comorbid with other anxiety disorders and depression; a transdiagnostic approach helps the patient learn to regulate their emotions more effectively across the board, rather than sequentially tackling each diagnosis.

“With generalized anxiety disorder, worry is a strategy people use in response to anxiety, just like escape and avoidance is a strategy people use to respond to panic,” Chapman said. “What we say now is, all these symptoms are emotional dysregulation. Let’s teach skills to address that at the core, and then you conclude with exposures.”

While CBT is typically the first-line psychotherapy for panic disorder, SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs) are also effective (Chawla, N., et al., BMJ, 2022opens in new window). The research shows that medications work faster than CBT at reducing panic attacks, Wilson said, though CBT is more effective over time. Medications can be used in conjunction with psychotherapy, Wilson added, noting that therapists should be aware of a few concerns. One is that in reducing the panic symptoms, these medications may lessen the opportunities patients have to practice confronting and accepting their feared sensations. That can mean a higher chance of relapsing if the person stops taking the medications. Another concern is that patients who are working on CBT while also using medication may attribute their gains to the medication rather than to their hard work, Wilson said.

“When there is an issue regarding external attribution...they have a tendency to attribute it to the medication and not their efforts,” he said, “so there’s a drawback for people with a particular perspective.”

On the other hand, Wilson said, medications can put a damper on symptoms, so patients feel more comfortable starting to confront them. And some patients with panic disorder may reject taking medications because of their worries about possible side effects such as nausea or dizziness, which might mimic their feared panic symptoms. Wilson counsels patients on the pros and cons and works with their preferences.

In addition to the psychological models of panic disorder, biological models suggest that for some people, panic may arise because of oversensitivity to feelings of suffocation. These people overreact to the buildup of carbon dioxide in the blood, which triggers the urge to breath faster and more deeply. Ironically, however, overbreathing can cause the body to take in more oxygen than it needs while not clearing enough carbon dioxide. This can lead to a cycle of feeling even shorter of breath.

“It sets a brittle balance, a brittle homeostasis, that can be tripped into full-bore panic,” said Robert Cuyler, PhD, the chief clinical officer at Freespira Inc., a company that offers a capnometry-guided respiratory intervention (CGRI). For 4 weeks, patients spend about 20 minutes twice a day breathing into a capnometer, a medical device that measures the concentration of carbon dioxide in a patient’s exhalations. The device translates the measurements into visual and audio instructions on how to inhale and exhale to keep oxygen and carbon dioxide in a normal range.

CGRI is based on capnometry-assisted respiratory training (CART), an FDA-approved therapy developed by Alicia Meuret, PhD, a professor of psychology and director of the Anxiety and Depression Research Center at Southern Methodist University and chair of the scientific council and board of directors at the Anxiety and Depression Association of America. (Meuret is not involved with Freespira Inc.)

Breathing and biofeedback have a long history of controversy in panic disorder treatment, Meuret said. In the early 2000s, teaching breathing techniques in CBT fell out of favor over concerns that breathing would dampen the physical symptoms that patients needed to confront. There were also concerns that breathing might become a safety behavior, or a crutch, to which patients attributed their success, rather than seeing themselves as in control during a panic episode. (Today, some therapists use breathing techniques in CBT, while others downplay them.)

The problem, Meuret said, is that traditional breathing techniques can be counterproductive for people with panic disorder precisely because these techniques might cause them to overbreathe. When people breathe more slowly, she said, they compensate by taking in a larger volume of air. “Instead of breathing at a normal volume, they double or triple their volume, which basically would be as if they’re tripling their respiratory rate,” she said. CART can help patients normalize their breathing and reduce panic symptoms by correcting lower-than-normal levels of carbon dioxide and feelings of shortness of breath, Meuret and other researchers have found (Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, Vol. 3, No. 6, 2018opens in new window; Kim, S., et al., Journal of Clinical Psychiatry, Vol. 73, No. 7, 2012opens in new window).

Moving forward, there may be ways to tailor treatments or to determine which people will respond best to each treatment, Antony said. Newer research is also working on understanding the relationships among these disorders, their treatments, and underlying psychodynamic processes, Huppert said.

“We’re starting to switch over from looking at CBT directly for panic or anxiety sensitivity and using unified protocols to see how wide this impact is on some of these processes, including things like attachment and reflective functioning,” he said. “You don’t always need to be doing psychodynamic techniques in order to facilitate psychodynamic processes.”