Panic Disorder: Best Practices in Anxiety Therapy

Panic disorder is one of those conditions that looks straightforward on paper and feels anything but in the therapy room. The symptoms arrive like a thunderclap: rapid heart rate, air hunger, heat surges, dizziness, a sense of unreality that makes the ground tilt, and a certainty that something catastrophic is happening. Many clients land in the emergency department before they land in therapy. The medical workup comes back normal, which offers relief for a day or a week, then the cycle repeats. What breaks the cycle is not a single technique, but a structured, flexible approach that respects the physiology of panic and the psychology of avoidance.

Over years of practice, a few principles have held up. Panic thrives on misinterpretation of bodily sensations and the spiral of avoidance that follows. Treatment works when it targets both. That means education that sticks, skills that change the body in real time, exposure that is honest and doable, and a relational frame that keeps people in the chair even when their nervous system tells them to run. Below is how I build that process.

What panic disorder is, and what it is not

Panic disorder is defined by recurrent, unexpected panic attacks and persistent worry about more attacks or their consequences, often paired with behavioral changes like avoiding exercise, heat, highways, crowds, planes, or being far from home. The attacks are time limited, generally peaking within 10 minutes and subsiding within 30 minutes, although aftershocks can last. The fear is not about a realistic danger in the environment, it is about the meaning of sensations: I am going to die, go crazy, faint, or lose control.

This is not a heart attack or asthma, though those must be medically ruled out. It is also not simple stress. Panic can arrive out of a clear sky, including during sleep, which can be even more unnerving. When people learn that a panic attack is a false alarm triggered by a hypersensitive but healthy threat system, they start to regain agency. The body is doing too much of a good thing, and we can teach it to recalibrate.

The physiology you can lean on in session

Clients do better when they understand what is happening under the hood. During a panic attack, the sympathetic nervous system fires, adrenaline rises, breathing becomes shallow, carbon dioxide levels drop, and the brain reads this shift as danger, which feeds more adrenaline. The vestibular system can misfire, producing dizziness and derealization. None of this is dangerous. It is a feedback loop amplified by interpretation.

Two practical implications follow. First, targeted breathing that normalizes carbon dioxide, not just big deep breaths, will reduce the internal alarm. I favor slow diaphragmatic breathing with a soft nose inhale and a slightly longer exhale, 4 seconds in and 6 out, practiced between attacks and then used at the first hint of a surge. Second, interoceptive exposure that intentionally stirs benign symptoms, like spinning in a chair or climbing stairs, teaches the brain I can have these sensations and be safe. That learning generalizes to real life.

Assessment that maps the terrain

Early sessions are for building a precise map. What are the top feared sensations, places, activities, and thoughts. When did it start. Are there cues linked to past trauma. What is the daily pattern of caffeine, nicotine, cannabis, alcohol, and sleep. Is there comorbid depression, bipolar spectrum, obsessive compulsive symptoms, or a medical contributor like thyroid dysfunction. Do they avoid the grocery store or simply the frozen aisle because of the cool air and bright lights. Details matter because exposure must be tailored. A one size hierarchy rarely fits.

I also measure. Two quick anchor tools help: the Panic Disorder Severity Scale and a 0 to 10 daily panic worry rating. For some clients, wearables provide real time heart rate data, which can demystify and sometimes complicate. If a device increases checking, we shelve it. If it provides counterevidence, for example a normal rate during a derealization episode, we use it.

Psychoeducation that changes behavior, not just beliefs

I avoid lectures. Instead, we test ideas in the room. If a client fears fainting from a racing heart, we stand, move quickly, and watch what happens to blood pressure physiology when muscles engage. If they fear suffocation, we practice slow breathing while gently holding the breath at end exhale for 3 seconds, then release. The aim is embodied learning. I explain the role of carbon dioxide and show how overbreathing alone can produce tingling lips and dizziness. We then pair that knowledge with a skill that consistently changes the sensation.

A metaphor I use: your smoke alarm is hypersensitive. You do not smash the alarm; you adjust it and stop waving towels under it. Avoidance is towel waving. Taking the batteries out is substances or overreliance on rescue meds. We work on tuning the system and staying in the room long enough to relearn safety.

Exposure therapy, done with precision and respect

Interoceptive exposure is the backbone. We list feared sensations and create exercises to evoke them: running in place for heart rate, straw breathing for air hunger, head between knees then up for dizziness, bright lights or heat for sensory overwhelm. We stay in the exercise long enough for the fear to crest and begin to fall, usually 2 to 5 minutes. We track predictions and outcomes in writing. Over sessions, the predicted catastrophe loses credibility.

Situational exposure targets the real world. Start with small steps and short duration, then add time, distance, and complexity. A client who fears the highway might begin with sitting in a parked car at the on ramp, engine on, practicing breathing. Next drive one exit with a safe person, then solo, then during a busier time. If they fear the grocery store, we might practice cart pushing for 3 minutes, then add checkout. The trick is to build momentum while avoiding heroics that end in a bailout. Each win is a brick in a new neural pathway.

Safety behaviors deserve direct attention. Sipping ice water, carrying a paper bag, sitting near exits, constantly checking pulse, or diverting eyes from potentially dizzying patterns can all maintain panic. We identify, then drop or delay them. A staged approach helps: first reduce frequency or delay the behavior by 60 seconds, then remove it. Explaining the why prevents a power struggle, and modeling tolerance yourself, including calm silence, helps the client carry it into the world.

Brainspotting and other trauma therapy elements for panic with a history

Not all panic is trauma related, but many clients carry unprocessed fear memories that ignite their alarm system. Trauma therapy methods can be valuable adjuncts when the panic map has hotspots tied to past events. Brainspotting, for example, uses fixed eye positions to access subcortical processing. I use it when words are thin or the client reports a floaty, out of body quality. With careful resourcing and dual attunement, we find a gaze point that amplifies a felt sense tied to the panic template, then allow the system to process while tracking body cues. This often reduces the intensity of triggers that do not yield to standard exposure Visit this link alone, such as sudden derealization in crowded spaces.

Other trauma informed tools include titrated somatic tracking, orienting to the room, and pendulation between comfort and activation. The goal is to revive a sense of agency in the body. When panic coexists with childhood adversity, shame often wraps around symptoms. A stance that normalizes survival adaptations and invites curiosity can peel back layers that keep panic sticky. Importantly, do not introduce deep trauma processing while avoidance is still high and daily function is fragile. Stabilization, skill building, and early exposure come first. Then, if old material is fueling the fire, trauma therapy can cool the embers.

Medication collaboration, neither villain nor panacea

Medications are tools. For many, a selective serotonin reuptake inhibitor reduces baseline anxiety and panic frequency by 30 to 60 percent. That headroom allows exposure to land. For others, side effects like jitteriness in the first weeks can mimic panic and derail efforts. Dosing low and slow, with anticipatory guidance, prevents a lot of phone calls and dropouts. Benzodiazepines provide short term relief, but they undercut exposure learning when used preemptively. I ask clients to avoid taking them before planned exposures and, when possible, to switch to a rescue strategy that does not sedate, such as paced breathing or grounding. Close coordination with prescribers matters, especially if there is depression or a bipolar history, where an antidepressant can destabilize mood.

Herbal supplements and over the counter aids are common. I routinely ask about kava, valerian, magnesium, and CBD. Some help with sleep onset, others are neutral, and some interact with medications. Placebo effects can be strong. We decide based on risk, evidence, and the potential to reinforce checking or avoidance. The throughline: anything that teaches the body I am safe without escape grows long term gains.

Skills that change the trajectory in the first minutes

Clients need a field kit they can deploy quickly. The following compact plan often keeps people engaged long enough for exposure and cognitive work to take root.

Notice and name: say out loud or silently, This is a panic surge, not a medical crisis. Labeling deescalates by 10 to 20 percent.
Breathe low and slow: inhale gently through the nose 4 seconds, exhale 6 seconds, for 10 cycles. Keep shoulders down, exhale through pursed lips.
Soft eyes, wide view: unhook tunnel vision by expanding peripheral awareness. Let the gaze soften and take in left, right, up, down.
Move on purpose: slow walk or wall push for 2 minutes to reengage the vestibular and proprioceptive systems.
Stay put for one more minute: set a timer to ride the peak. Urges to flee tend to crest under 5 minutes.

I encourage daily rehearsal outside of panic, two to three times. The brain learns state dependent skills better in the target state, but baseline practice builds automaticity that pays off during surges.

Cognitive work that avoids arguing with fear

Classic cognitive restructuring can get argumentative with panic. A more effective approach is decentering and probability testing. We write predictions in concrete terms: I will faint in the checkout line. Then we examine data from interoceptive tests and prior exposures. If fainting requires a blood pressure drop and panic raises pressure, what does that imply. We keep it empirical, not affirmational. For catastrophic thoughts that feel sticky, brief use of acceptance based framing helps. You can carry discomfort and still do what matters. The goal is not to think perfect thoughts; it is to act toward values while anxiety rides along.

Working with comorbidities, especially depression

Panic disorder and depression often travel together. After months of avoidance, life shrinks and hopelessness grows. Some clients report morning dread, anergic afternoons, and shame about missed commitments. When depression is mild to moderate, behavioral activation pairs well with exposure. We schedule small, rewarding, or value aligned activities that are not purely anxiety targets, like a 15 minute walk with a friend or cooking a simple meal. For more severe depression, energy may be too low to engage exposure effectively. In that case, sequence treatment: stabilize sleep, consider medication adjustments, and set micro goals. Depression therapy principles do not replace panic work, but they cushion it.

Substance use complicates the picture. Alcohol is a common self medicator that fragments sleep and spikes morning anxiety. Cannabis can reduce anxiety acutely but worsen panic reactivity in some. Caffeine, even a single energy drink, can tip a sensitive system. I do not demand abstinence on day one, but we experiment and track. Clients often discover their own dose response curve, which is more persuasive than my warning.

Intensive therapy when life cannot wait

Some clients do not have months to inch along a hierarchy. A pilot grounded by panic, a parent who cannot enter the school, or someone who lost a job after multiple ER visits may need faster movement. Intensive therapy formats condense treatment into full or half day blocks over one to two weeks. This allows rapid immersion in interoceptive and situational exposures, integrated with skills practice and, when indicated, adjunctive methods like Brainspotting or brief trauma therapy elements.

Intensive therapy is not for everyone. It demands time off, solid medical clearance, and a willingness to work through fatigue. It also requires planning for aftercare. Gains fade without continued practice. I reserve intensives for clients with high readiness and a clear, specific set of targets. When it is a fit, the results can be striking, with functional return in days rather than months. I track outcomes at 1, 4, and 12 weeks to ensure durability.

Telehealth, groups, and family involvement

Telehealth expanded access and, for panic, offers unique leverage: in vivo exposures inside the client’s real environment. We can practice walking to the mailbox or sitting in a parked car while on video. The risk is avoidance of leaving home for therapy altogether. I set expectations that some sessions will be in person or that telehealth sessions will include leaving the house, weather and safety permitting.

Group formats add normalization and social exposure built in. Hearing others describe the same electric jolt of fear reduces shame. Coached interoceptive exercises in a group teach participants they can sweat, flush, and shake in front of others and be okay. Family members can help or hinder. A brief session to align on language and reduce accommodation, like constant reassurance or driving detours, often pays dividends. We script supportive responses that encourage approach without pressure.

Nocturnal panic, health anxiety, and other edge cases

Not all panic looks alike. Nocturnal panic wakes clients from sleep in a full surge. Daytime skills still apply. We also target pre sleep routines, reduce late caffeine and alcohol, and introduce body scans that emphasize safety signals. If sleep apnea is suspected, a study is warranted, since apneic arousals can mimic panic and fuel the cycle.

Health anxiety intertwines with panic when bodily sensations are central fears. The temptation is to chase reassurance with more tests. Therapy directs that energy toward tolerating uncertainty and reducing checking. We write out rules for medical evaluation, for example one visit per new symptom cluster or a 72 hour wait period unless red flags appear. Then we return to interoceptive work, since the core learning is the same.

Agoraphobia adds a spatial component, with fears of being unable to escape or get help. Exposures must include time and distance from perceived safety, not just being in a location. That can mean increasing minutes in a store, then intentionally selecting the far checkout line. It can mean riding a bus and staying seated as other stops pass. We celebrate time on target, not comfort level.

Measuring progress and preventing relapse

Panic treatment works. Clients often see meaningful improvements within 4 to 8 weeks if they engage exposures consistently. I track three things: frequency of attacks, intensity of anticipatory anxiety, and life regained. Can they shop, drive, attend class, sit in meetings. Numbers matter, but so does function. We set maintenance goals early, like one interoceptive drill daily for 60 days, and then taper to a weekly booster. Relapse prevention hinges on normalizing future spikes. Life will jolt your system now and then. Expect it, label it, and do what you practiced.

A brief written plan helps clients respond rather than react when symptoms return after a long quiet stretch. We include the top two drills that reliably work for them, a short exposure Anxiety therapy target list, and a reminder of the time course of a typical attack. Clients who keep their plan visible use it. Those who do not often end up improvising in the heat of the moment.

Common missteps and how to avoid them

Chasing comfort too early: dropping exposure intensity at the first sign of distress prevents corrective learning. Aim for tolerable discomfort, not ease.
Using benzodiazepines before exposure: this blunts fear learning. If needed, keep them as a rescue after efforts to ride the wave.
Overexplaining: long lectures do not change physiology. Pair brief education with in session practice.
Leaving safety behaviors untouched: exposure with a crutch is exposure to the crutch. Identify and wean them.
Ignoring values: without a why, the work feels like suffering. Tie exposures to what matters, like attending a child’s recital or keeping a job.

A brief case example

A 32 year old software engineer came in after three ER visits for chest pain and shortness of breath. Workups were normal. He stopped exercising, avoided hot showers, and only drove surface streets. The first session mapped triggers and avoided places. He rated his fear of fainting at 9 out of 10. We practiced slow breathing, then did stair runs in the building. His heart rate hit 145. He stayed with the sensation for 3 minutes while narrating, I am safe, my body is pumping blood, not losing it. We repeated until fear dropped to 4.

Week two focused on straw breathing for air hunger and bright light exposure in a hardware store. He learned that light and heat produced a spike, then a predictable fall. We identified safety behaviors, including carrying a sports drink and checking his pulse. He agreed to leave the drink in the car and wear a watch face without heart rate for two weeks.

By week four, he drove the highway one exit solo, then two. He added short treadmill runs and resumed 10 minute hot showers. We introduced Brainspotting in week five when he described a floaty, detached feeling in crowded spaces that did not respond to exposure. He located a gaze position that amplified the floatiness, then processed with dual attunement for 20 minutes, punctuated by orienting to the room. The dissociative quality softened. By week eight, he reported one brief surge per week, handled with his plan, and returned to the office two days weekly. He kept a weekly interoceptive drill as maintenance for three months.

Therapist stance that keeps people coming back

Technique matters, and so does tone. Panic makes people feel defective and out of control. A stance that is calm, direct, and nonreactive builds trust. I tell clients I expect discomfort in our work and that my job is to keep it safe and effective. I name avoidance kindly and early. I also celebrate effort more than outcomes. If they did three exposures and panic still flared, we look at what they learned. This is not cheerleading; it is accurate reinforcement of the behaviors that produce change.

I also model the pace I want. If I rush, they feel it. If I avoid silence, they learn that silence is dangerous. If I say we will try a 2 minute exercise and we stop at 60 seconds because I am uncomfortable, I just taught them to bail when distressed. Small consistencies in the room become big consistencies outside.

Where Brainspotting, Anxiety therapy, and the broader toolkit meet

There is no single door into healing for panic disorder. Evidence based Anxiety therapy gives us the core: psychoeducation, breathing that corrects carbon dioxide, interoceptive and situational exposure, and measured cognitive strategies. Trauma therapy tools, including Brainspotting, add depth and reach when fear networks are tied to earlier experiences or when dissociative states block learning. Depression therapy principles keep momentum when mood dips and motivation flags. Intensive therapy offers a way to climb out of a deep hole fast when circumstances demand.

The art is in knowing which lever to pull when, and in what dose. Some weeks are all about walking a parking garage and riding the elevator, three times in a row. Another week is a 25 minute brainspotting set to loosen the knot behind a stuck pattern. Always, the throughline is approach. Move toward what scares you, just enough, with support, until your nervous system relearns what your rational mind already suspects: you can handle this.

Dr. Katrina Kwan, Licensed Psychologist

Name: Dr. Katrina Kwan, Licensed Psychologist

Address: Online-only practice

Phone: +1 650-387-2578

Website: https://www.drkatrinakwan.com/

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Dr. Katrina Kwan, Licensed Psychologist offers online therapy for adults in Florida, Utah, and Washington State.

Her services include Brainspotting, trauma therapy, anxiety therapy, depression therapy, intensive therapy, somatic therapy approaches, nervous system regulation support, and accelerated resourcing.

The practice may be a fit for adults seeking therapy for trauma, anxiety, depression, overwhelm, nervous system dysregulation, or neurological recovery concerns.

Because sessions are offered online, clients can ask about therapy from home without needing to travel to a physical office.

The website describes a body-mind approach that integrates Brainspotting, somatic work, parts work, and related therapeutic methods.

Dr. Kwan’s website lists state licensure in Florida, Utah, and Washington, so prospective clients should confirm current eligibility and fit before scheduling.

To contact Dr. Katrina Kwan, call +1 650-387-2578 or visit https://www.drkatrinakwan.com/.

The public map listing identifies the online practice profile and hours, but no public walk-in street address was verified from the accessible listing data.

Clients should use the website and phone number to confirm appointment availability, online session requirements, and whether the practice is appropriate for their needs.

Landmarks Near Dr. Katrina Kwan’s Online Therapy Service Areas

Seattle, WA — Washington clients near Seattle can contact the practice to ask about online therapy availability.

Spokane, WA — Spokane-area clients can use the online format to ask about therapy access without traveling to a physical office.

Tacoma, WA — Tacoma is a practical Washington reference point for clients exploring online therapy in the state.

Olympia, WA — Clients near Washington’s capital can contact Dr. Kwan to confirm online session availability.

Salt Lake City, UT — Utah clients near Salt Lake City can ask about online therapy services listed by the practice.

Provo, UT — Provo-area adults can use the website to request information about online therapy options.

Ogden, UT — Clients in northern Utah can confirm whether Dr. Kwan’s online therapy services are a fit for their needs.

Park City, UT — Park City is a useful Utah-area reference for clients considering online care from home or while managing a busy schedule.

Orlando, FL — Florida clients near Orlando can contact the practice to confirm online therapy availability and scheduling.

Tampa, FL — Tampa-area adults can use the online format to ask about therapy services without a local commute.

Miami, FL — Miami clients can visit the website to learn about online therapy options listed for Florida.

Jacksonville, FL — Jacksonville is a practical Florida reference point for adults exploring online therapy with Dr. Katrina Kwan.

Tallahassee, FL — Clients near Florida’s capital can call or use the website to confirm whether online care is available for their situation.