Cognitive-behavioral therapy (CBT) is a psychotherapy for anxiety disorders considered to be a first-line treatment of panic disorder.  A 2004 study (Dannon et al.) published in the Annals of Clinical Psychiatry found that group CBT alone was just as effective as paroxetine (Prozac) alone for panic disorder.

If no severe comorbid disorders (e.g. severe personality disorders) are present the therapy can be brief (e.g., 15 sessions. Results are very promising, because up to 80 percent of the patients have a significant improvement. The main goal of this therapy is to identify and change underlying inappropriate thoughts and patterns that underlie and perpetuate panic attacks. Very often a vicious cycle of dysfunctional thoughts (catastrophic fears), anticipatory anxiety and agoraphobic avoidance causes a chronic condition.

CBT offers strategies to eliminate the core fears and ways to cope with the situation. The patients will learn appropriate ways to face the anxiety (exposure therapy, desensibilisation or flooding) and will get rid of the anxiety symptoms.

Cognitive behavioral therapy (CBT) is a symptom oriented therapy approach that combines psychoeducation with specific treatment intervention. The main components may include:

• psychoeducation = information
• self-monitoring of symptoms = panic monitoring
• breathing retraining / relaxation techniques
• cognitive restructuring to correct catastrophic misinterpretations of bodily sensations
• exposure therapy

1. Psychoeducation

The therapist will try to explain the normal reactions of the body and symptoms related to stress and anxiety. This will help the client to reduce catastrophic fears related to misinformation (e.g. fears to die or going crazy). The psychoeducation will try to focus on real life experiences related to anxiety or phobia. The therapist will try to explain the treatment approach of exposure therapy and should also talk about the prognosis or possible problems of therapy. Psychoeducation usually includes help to identify early signs of relapse of anxiety symptoms and self-help options to cope with these situations.

2. Self-monitoring / symptom diary

One of the most effective tools for patients with anxiety symptoms is a diary or protocol of panic attacks. To monitor the occurrence of anxiety symptoms, anxious cognitions and the consequences of changed behavior (e.g. avoidance behavior) it is very important to get a rational description of the actual problem and to evaluate the treatment process. Patients are informed that this will help in the assessment of the frequency and nature of their panic attacks and provide data regarding the relationship of panic symptoms to internal stimuli (e.g., emotions, images) and external stimuli (situation, behavior, substances).

3. Breathing retraining

Next, the therapist introduces an anxiety management technique, such as abdominal breathing, to control the physiologic reactivity. The patient is asked to practice this technique daily. Other relaxation techniques (progressive muscle relaxation) are also very good.

4. Cognitive restructuring

These techniques are used to identify and counter fear of bodily sensations. Most commonly, such thinking involves overestimation of the probability of a negative consequence and catastrophic thinking about the meaning of such sensations. Patients are encouraged to consider the evidence and to think of alternative possible outcomes following the experience of the bodily cue. Part of this process involves identifying the likely origin of the feared sensations and/or any misinformation about the meaning of the sensations. The cognitive restructuring component of CBT is usually conducted by using a Socratic teaching method.

5. Exposure to fear cues

The final and central component of the treatment involves actual exposure to fear cues. In order to conduct such exposure, the therapist frequently works with the patient to identify a hierarchy of fear-evoking situations. The degree of anxiety elicited in each of these situations is graded on a 0–10 scale, and several situations that evoke anxiety at each level are documented. The patient is then asked to enter situations, usually at the low end of the hierarchy, on a regular (usually daily) basis until the fear has attenuated. The situation that arouses the next level of anxiety is then targeted. Employing more intense initial exposures and not proceeding in a graduated manner, referred to as "flooding," has also been used. Examples of exposures to panic cues are having patients run in place, spin in a desk chair, and breathe through a straw. The cues for panic attacks are generally interoceptive, while those for agoraphobia may be either interoceptive or environmental. interoceptive exposures are usually conducted in the therapist's office and at home in naturalistic situations. Agoraphobic exposure is best carried out in the actual situation(s).