This programme is a treatment manual written for mental health professionals. It assumes clinical training, experience of conducting exposure, and a supervision framework. It replaces neither your clinical judgement nor your professional responsibility. Diagnostic criteria are reformulated in our own words and never reproduced: refer to the original manuals for the wording itself.
1. The programme at a glance
Indication. Panic disorder in adults, with or without agoraphobia: recurrent and unexpected panic attacks, persistent concern that they will return or about what they mean, and changes of behaviour intended to avoid them.
Reference model. The cognitive model of panic: a benign bodily sensation is interpreted as the sign of an imminent catastrophe, the interpretation amplifies the sensation, and the loop closes. Treatment conducts two distinct exposures — to sensations and to situations — and removes what prevents learning.
Format. Twelve 50-minute sessions, except sessions 5 to 9 which last 90 minutes because they take place partly outside. One session a week, closer together at the start if avoidance is massive. Two follow-ups, at one month and at three months.
Target mechanism. To have the person discover through experience that the feared sensations are produced by anxiety itself, that they lead nowhere, and that they can be produced deliberately. The conviction does not come undone through reasoning: it comes undone by reproducing the sensation and observing that nothing follows.
| Session |
Subject |
Session output |
| 1 |
Assessing and sorting |
Focus identified, baseline measures |
| 2 |
The personal formulation |
The loop written, in their own words |
| 3 |
Sensations first |
Three inductions done in session |
| 4 |
Varying the inductions |
The closest sensation identified |
| 5 |
Going out |
First outing without accompaniment |
| 6 |
Removing the crutches |
Outing with no object and no person |
| 7 |
Combining |
Sensations produced in the situation |
| 8 |
The worst case |
The most avoided situation, faced |
| 9 |
Alone and with no way out |
Long outing, alone, with no escape |
| 10 |
Generalising |
Three new contexts |
| 11 |
Medication and daily life |
Reduction plan agreed |
| 12 |
Review, relapse, maintenance |
Written plan, measures repeated |
What the person takes away. Seven printable worksheets, listed in section 38: my record of attacks, what I tell myself, my sensations, my crutches, my outings, the corner for those close to me, my plan for what comes next.
What sets this programme apart from the other anxiety manuals on this site. Three things. The initial sorting, which is about the focus of apprehension and not about places. Interoceptive exposure, which exists in no other programme on this site and which is here the heart of the treatment. And the explicit treatment of controlled breathing, which this manual deliberately removes from the toolbox.
2. Before you begin
Who this programme is for
This text is addressed to psychologists, psychiatrists, psychotherapists and doctors trained in cognitive behavioural therapy. It assumes that you accept deliberately producing unpleasant sensations in session, in someone who dreads them, and staying seated while they rise.
It is not addressed to patients or to the people close to them. It contains induction procedures which, read without support, would mostly produce apprehension.
The four decisions that come first
What is the focus? That is the sorting of section 3, and it governs everything. Someone who avoids the underground because they dread fainting there, someone who avoids it because they dread being shut in, and someone who avoids it because they were assaulted there do not belong to the same manual.
Has the medical work-up been done? Section 10. Certain medical causes imitate panic, and there is a short list that must have been ruled out. It is not a formality, and it is not a reason to postpone treatment indefinitely either.
What is being taken? As-needed benzodiazepines, alcohol, cannabis, stimulants, caffeine. Section 13. The answer changes the plan of the first eight sessions.
How extensive is the avoidance? From the person who flies with gritted teeth to the person who has not left home for two years, you do not start in the same place. Section 5.
What this programme does not treat
It does not treat specific phobia. A fear of the lift that is about being shut in, and not about the body, belongs to another manual.
It does not treat social anxiety. Avoidance of public places for fear of being looked at is not treated by interoceptive exposure.
It does not treat post-traumatic stress disorder on its own. Panic attacks triggered by traumatic reminders are treated within trauma-focused care.
It does not treat a medical condition. This manual treats the fear of sensations, not the sensations themselves when they have an organic cause.
What this programme is not
It is not a stress management method. We are not going to learn to relax or to breathe: section 32 explains why that omission is deliberate and what goes in its place.
It is not a therapy of self-confidence, nor work on distant causes. Many people expect us to go back to childhood; section 37 says why that is not the path.
It is not a drug treatment, and section 13 explains why the most requested medication is also the one that most harms the result at follow-up.
How to use it
Read the whole thing before the first session, particularly sections 3, 6, 29, 31 and 32: the sorting, the model, interoceptive exposure, safety behaviours, and the question of breathing. Those are the five places where a well-intentioned treatment becomes ineffective.
Each session is described within the same frame: the aim, the sequence of steps, what you say, common mistakes, and the criterion for moving on.
Three warnings specific to this presenting problem.
People arrive after the emergency department. Many have been several times, have had several electrocardiograms, and keep the conviction that something has been missed. Treatment starts by taking that conviction seriously, not by contradicting it.
Quick relief is a trap. The first explanations relieve a great deal, and many treatments stop there. A relieved patient who has done no induction and no outing has not been treated.
And your own discomfort counts. Producing dizziness in someone who tells you they are about to faint requires staying calm for two very long minutes. Shortened inductions demonstrate nothing.
3. Four situations not to be confused
It is the section that decides everything else, and it takes ten minutes. Four people can say the same sentence — "I don't take the underground any more" — and belong to four different treatments.
1. Panic disorder with agoraphobia
What you observe. Attacks that rise within minutes, sometimes with no identifiable trigger, with physical sensations in the foreground. Between attacks, a constant apprehension that is about the attacks themselves.
What is feared. The body. Dying, fainting, going mad, losing control, vomiting, being seen falling apart.
The question that settles it. "What is the worst that would happen, on the underground?" If the answer describes a bodily event, it belongs here.
What that implies. This is the programme described here.
2. Specific phobia
What you observe. A fear of an identifiable object or situation, almost immediate, focused. Away from the situation, the person is fine and does not think about it.
What is feared. The thing itself: being shut in, the height, the animal.
The question that settles it. The same question. If the answer is "the door gets stuck and I'm trapped", it is a phobia, and interoceptive exposure has no place in it.
What that implies. A different, shorter protocol.
3. Social anxiety
What you observe. Avoidance of situations which, looked at closely, involve being watched: the queue, the meeting, the restaurant.
What is feared. Being judged. And often, in these people, panic itself is feared for what it would show.
The question that settles it. "Would it be the same if you were completely alone?" If the fear falls away, it is social.
What that implies. A different protocol. Beware the mixed case: fearing an attack in public is very common in panic disorder and does not make a social anxiety disorder.
4. Post-traumatic avoidance
What you observe. The avoidance is dated and it follows an event. There is re-experiencing, hypervigilance, nightmares.
What is feared. That it will happen again, or that the memory will come back.
The question that settles it. "Since when, and since what?"
What that implies. The trauma is treated in its own right. Exposing to sensations someone whose sensations are traumatic reminders can make things worse.
The three other things to have ruled out
A medical cause. Section 10. It comes first, and it must be neither neglected nor dwelt on.
Intoxication or withdrawal. Cannabis, stimulants, alcohol, benzodiazepine withdrawal. Attacks triggered by a substance are common and they change what you do.
A depression with anxiety. When mood has been in the foreground for months and the attacks appeared afterwards, the order of priorities changes. Section 9.
The three sorting questions
"What is the worst that would happen?" The most productive question. It almost always separates the four cases.
"Would it be the same if you were alone?" Separates panic disorder from social anxiety.
"Since when, and since what?" Separates panic disorder from post-traumatic avoidance and picks up onsets linked to a substance.
The particular case of nocturnal panic
Waking up in the middle of an attack is common and very alarming. It does not change the diagnosis, it adds a differential — sleep apnoea, reflux, nightmares — and it calls for treating the fear of falling asleep, which installs itself quickly.
4. The panic attack, in detail
What it is
An abrupt surge of intense fear, reaching its peak within minutes, accompanied by a set of physical and cognitive sensations. It then subsides, always, and that is the one point the person does not believe.
The sensations, and what they become in the mind
The racing heart becomes a heart attack.
Breathlessness becomes suffocation.
Dizziness and light-headedness become an imminent faint.
Tingling becomes a stroke.
The sense of unreality becomes madness.
Heat, sweating, trembling become the visible sign that everyone will notice.
The lump in the throat and the tightness become choking.
And nausea becomes vomiting in public.
What has to be explained, and in this order
That these are normal reactions of an alarm system. The body is preparing to flee or to fight: the heart accelerates to bring blood to the muscles, breathing speeds up to supply oxygen, vision narrows to concentrate on the danger.
That the alarm goes off at the wrong moment, and that this does not make it dangerous.
That the attack has a limited duration. The nervous system cannot sustain this activation: there is a physiological brake, and it engages on its own.
And that people do not faint during a panic attack, except in one precise case — blood and injection phobia, which has the opposite physiology. Elsewhere, blood pressure rises, and fainting requires it to fall.
What not to do with this explanation
Do not give it as reassurance. Give it as a hypothesis to be tested. "Here is what I think is happening. We are going to check it together, by producing it." The difference between the two wordings decides the rest of the treatment.
Expected and unexpected attacks
The first occur in an identified situation, the second seem to come from nowhere. Both exist in panic disorder, and the existence of unexpected attacks is what most clearly distinguishes it from a phobia.
In practice, many "unexpected" attacks have an internal trigger the person has not spotted: standing up too fast, a coffee, climbing stairs, the end of an effort, waking with a start. Worksheet 3 is there to find them, and finding them is an enormous relief.
5. Agoraphobia
What it is
A fear of several situations linked by a common theme: it would be difficult to get out of them, or difficult to be helped in them if something happened. Transport, shops, queues, crowds, open spaces, bridges, motorways, being alone away from home.
What has to be understood
It is not a fear of places. It is the fear of what might happen in those places, without help. A patient crossing the same square in an ambulance has no problem at all.
It is built by learning. After an attack, the situation becomes a signal. Avoidance relieves immediately, that relief reinforces avoidance, and the territory shrinks in concentric circles.
It spreads faster than people think. From the motorway to the A road, from the A road to the journey to work, from the journey to work to leaving the neighbourhood. Six months is enough.
The degrees, which change the starting point
Mild. Situations are faced with discomfort, sometimes with a crutch.
Moderate. Some are avoided, others are done only with someone.
Severe. Home is the boundary, or nearly. Here the first sessions are sometimes done at home or by video, and section 36 returns to it.
The subtle avoidances, which get missed
Times of day. Doing the shopping at eight in the morning.
Seats. Always near the exit, always at the end of the row, always on the ground floor.
Routes. The longest way because it passes pharmacies.
Conditions. Only driving on roads where you can stop.
And company. Never going out without a charged phone, without a partner who can be reached, without knowing where the hospital is.
These avoidances are not reported: they are found by asking how the person manages, not what they avoid.
Frequently asked questions
The patient refuses interoceptive exposure.
That is common and it is almost always a question of order and credibility. Do it yourself first, choose the mildest induction, announce the exact duration, and accept thirty seconds rather than sixty for the first time. What is not negotiable is the principle.
And what if they have a real attack during the induction?
That is the best thing that can happen, and it should be said that way before starting. You stay, you do nothing, you let it pass, and you debrief. An attack gone through in session without doing anything is worth ten explanations.
Do I need a cardiology work-up before having someone run in the consulting room?
In a young person with no history, a normal examination and a normal electrocardiogram, no. With a cardiac history, respiratory disease, advanced age or any doubt, you ask the doctor. See section 29.
The patient says their sensations are "real", not psychological.
They are. The sensations are perfectly real; it is their meaning that is in question. That distinction takes one sentence and it unblocks many interviews.
What do I do when they have a known heart condition?
You distinguish with them, and with the cardiologist if possible, which sensations belong to what. You keep the prescribed precautions, you remove the invented ones, and you adapt the inductions.
They are better but refuse to reduce their anxiolytic.
It is often a question of sequence: the reduction comes after several victories, not before. Work first on the tablet as an object — pocket, car, home — then on the dose, with the prescriber.
They have no more attacks but still do not go out.
They avoid better. It is the most deceptive configuration in the field. The criterion is not the absence of attacks, it is the territory.
How many outings a week?
Three at the minimum. That is the figure that predicts the result.
Should I accompany the patient outside?
Yes, at session 5, moving away in the first few minutes. A therapist who always accompanies teaches that it can be done accompanied.
The partner wants to attend every session.
One joint session is useful, permanent presence is not. Worksheet 6 and session 9 are there for that.
Are nocturnal attacks treated differently?
No, but you add work on the fear of falling asleep, inductions done in the evening, and a sleep assessment if apnoea is suspected.
How many sessions?
Twelve in this manual. Without agoraphobia, eight are often enough. With severe agoraphobia, benzodiazepine dependence or associated depression, more are needed.
An attack came back six months later.
It is expected, and it is written on worksheet 7. An isolated attack cancels nothing. What matters is not to reintroduce avoidance in the days that follow.
Should I look for the origin of the disorder?
The context of the first attack is useful and it is found in ten minutes. Beyond that, the search for the origin fills the sessions and reopens no route.
The patient still consults their doctor regularly about symptoms.
Treat it as checking, list it among the crutches, and write to the doctor. Coordination is worth more here than any argument.