Panic disorder: understanding crises and treating them with CBT

Dear readers and friends of psychologyetserenite.com,

My name is Gildas Garrec, and as a CBT psychopractitioner in Nantes, I often have the opportunity to support people whose lives are turned upside down by a phenomenon as intense as it is confusing: panic disorder. Imagine for a moment being caught off guard, for no apparent reason, by a wave of terror so powerful that it takes your breath away, makes your heart pound, and makes you feel like you might lose your footing, die, or go mad. It’s the terrifying experience of a panic attack. And when these attacks repeat themselves, leaving behind persistent anxiety that they will occur again, it is called panic disorder.

Fortunately, there are ways out of this maze of fear. Cognitive-Behavioral Therapy (CBT), my area of ​​expertise, offers concrete and proven tools to understand, master and ultimately overcome this disorder.

Understanding the Panic Attack: A False Alarm from the Body

A panic attack is a sudden, intense manifestation of fear or discomfort, reaching its peak within a few minutes. Its symptoms are multiple and can include:

* Physical symptoms: Palpitations, fast heart rate, sweating, tremors, feelings of shortness of breath or choking, chest pain or discomfort, nausea or abdominal discomfort, feelings of dizziness, unsteadiness, lightheadedness or fainting, chills or hot flashes, feelings of numbness or tingling (paresthesias).
* Cognitive and emotional symptoms: Feeling of unreality (derealization) or of being detached from oneself (depersonalization), fear of losing control or going crazy, fear of dying.

What makes these attacks so confusing is that they often occur without an obvious trigger, or for reasons that would not normally provoke such a reaction. The body, in fact, activates its “fight or flight” alarm system inappropriately. This mechanism, vital in the face of real danger (a lion, a fire), is supposed to prepare us to react. But in a panic attack, it triggers when there is no immediate danger, transforming normal bodily sensations (a heart beating faster after exercise, for example) into signals of impending doom.

Panic Disorder: When Fear Takes Power

Panic disorder is not limited to isolated attacks. It is characterized by:

Recurring and unexpected panic attacks.

A persistent worry about the occurrence of new attacks or their consequences (fear of having a heart attack, of fainting in public).

A significant change in behavior linked to crises, often in the form of avoidance (no longer taking public transport, avoiding crowds, enclosed places, or even physical activities that could provoke sensations similar to those of panic). This avoidance can lead to agoraphobia, a fear of situations from which it would be difficult to escape or get help in a crisis.

The daily life of affected people is then considerably reduced, and their quality of life altered. This is where CBT comes in, providing a structured approach to breaking this vicious cycle.

CBT: A Concrete Approach to Regain Peace of Mind

Cognitive Behavioral Therapy is recognized as one of the most effective treatments for panic disorder. It focuses on the interactions between our thoughts (cognitions), our emotions, our physical sensations and our behaviors. The goal is to change the thought and behavior patterns that maintain anxiety.

Here are the pillars of CBT for panic disorder:

1. Psychoeducation: Understanding to Act Better

The first step is to demystify the panic. I take the time to explain to my patients how the autonomic nervous system works, the "fight or flight" response, and why their symptoms, although terrifying, are not dangerous.

Clinical example: When Marie came to see me, she was convinced that she was going to die of a heart attack with each attack. By explaining to him how adrenaline accelerates the heart and causes chest pain without damaging the organ, and by showing him the biological mechanisms of fear, we were able to begin to deconstruct this fear of dying. Knowing that his heart was safe, even if it was beating very hard, was a crucial first step towards calming down.*

Understanding that panic is a false alarm, an overly sensitive smoke detector, is essential.

2. Cognitive Restructuring: Challenging Catastrophic Thoughts

Panic attacks are often fueled by catastrophic interpretations of bodily sensations. CBT helps identify and challenge these “negative automatic thoughts.”

* Practical exercise: The Thought Journal
* When a crisis or anxiety occurs, note:
1. The situation: Where have you been? What were you doing?
2. Physical sensations: Racing heart, dizziness, etc.
3. Automatic thoughts: "I'm going to pass out", "It's a heart attack", "I'm going to lose control".
4. The emotion: Intense fear (rate the intensity from 0 to 100).
5. Evidence for and against this thought: Is there concrete evidence that this thought is true? And any proof that it isn't?
6. More realistic alternative thoughts: “It’s unpleasant, but it’s just a panic attack, it will pass”, “My body is reacting to anxiety, not real danger”.
7. The new intensity of emotion: Compare with the initial.

This exercise allows you to take a step back and replace unrealistic thoughts with more rational ones.

3. Breathing and Relaxation Techniques: Taking Back Control

Hyperventilation (breathing too quickly and too shallowly) is common during attacks and can worsen symptoms (dizziness, tingling). Learning to breathe correctly is a powerful tool.

* Practical exercise: Abdominal Breathing
1. Sit comfortably or lie down. Place one hand on your stomach, the other on your chest.
2. Inhale slowly and deeply through your nose for 4 seconds, feeling your stomach expand (the hand on your stomach should rise, the hand on your chest should move as little as possible).
3. Hold your breath for 2 seconds.
4. Exhale slowly through your mouth (like through a straw) for 6 seconds, feeling your stomach deflate.
5. Repeat this exercise 5 to 10 minutes a day, and at the first signs of anxiety. This helps calm the nervous system and reduce the intensity of symptoms.

4. Interoceptive and In Vivo Exposure: Confronting to Unlearn Fear

It is one of the most important and often the most feared, but also the most effective pillars. This involves gradually exposing oneself to the physical sensations of panic (interoceptive exposure) or to avoided situations (in vivo exposure). The goal is to unlearn the association between these sensations/situations and danger.

* Interoceptive Exposure:
* If you fear palpitations: Go up and down stairs quickly for one minute.
* If you fear dizziness: Turn your head from left to right quickly for 30 seconds.
* If you fear shortness of breath: Hold your breath for 30 seconds (without putting yourself in danger).
* If you fear depersonalization: Stare at yourself in a mirror for several minutes.

These exercises are carried out under the supervision of the therapist at first, then independently, to learn that these sensations, although unpleasant, are not dangerous and eventually disappear on their own.

* In Vivo Exhibition:
Clinical example: Jean avoided supermarkets, fearing he would have a seizure there and not be able to escape. We established a hierarchy: first, stand in front of the supermarket for a few minutes; then, go in and take a quick stroll in a little-used area; then, do some shopping at an off-peak hour; and finally, doing your full shopping during peak hours. At each stage, John stayed in the situation until his anxiety subsided, learning that what he feared was not happening, or that he was capable of handling it.*

Exposure is gradual and controlled, always respecting the patient's pace. It allows the brain to relearn that these situations and sensations are not threats.

A Word of Hope by Gildas Garrec

The path to overcoming panic disorder takes courage and perseverance, but it is entirely possible. CBT offers you a complete toolbox to take back control of your life, step by step. By understanding what's happening in your body, challenging your most fearful thoughts, controlling your breathing, and gradually confronting what you fear, you can free yourself from the grip of panic.

Always remember that you are not alone. If you recognize yourself in these descriptions and panic impacts your daily life, do not hesitate to consult a CBT professional. Together, we can work to rebuild your peace of mind.

Gildas Garrec, CBT psychopractitioner in Nantes