Panic disorder is a fear of fear with avoidance on top, and the avoidance, more than the attacks, produces the disorder. Exposure is the core treatment, with the cognitive work there to get patients doing exposures, and psychoeducation is what earns their buy-in. We do not use benzodiazepines or PRNs; an SSRI lowers the severity enough that patients start living again.
What it is
Panic disorder is acquiring a fear of fear, a fear of panic, with an avoidance pattern on top of it. It is largely a psychological phenomenon.
“panic disorder, that is acquiring a fear of fear, fear of panic and avoidance pattern on top of it. It's kind of a psychological phenomenon”
23:10Understanding Anxiety, GAD, and Treatments of AnxietyJun 2025 It is the avoidance of panic attacks that produces panic disorder, not so much the attacks themselves. In agoraphobia, too, anxious avoidance worsens the fear response.
“It is the avoidance of the panic attacks that is producing the panic disorder, not so much the panic attacks themselves. Similarly, in agoraphobia, it's the anxious avoidance that is worsening the fear response”
38:43Understanding Anxiety, GAD, and Treatments of AnxietyJun 2025
How we diagnose it
Many patients describe panic as lasting hours. Usually that is the prolonged period of distress and heightened anxiety that follows, which they still associate with the attack.
“many patients will describe panic as lasting hours because they actually have a subsequent prolonged period of emotional distress and heightened anxiety that they still associate with it”
16:19Understanding Anxiety, GAD, and Treatments of AnxietyJun 2025
Treatment
Exposure is number one. The cognitive component is number two, and its job is getting the patient to do more exposure.
“I have exposure as the top of the higher, like number one, and the cognitive component is number two, which the cognitive component is... getting them to do more exposure”
39:39Understanding Anxiety, GAD, and Treatments of AnxietyJun 2025
Medications
We do not use benzodiazepines or PRNs for it. It has to be something that globally lowers the level of neuroticism and anxiety.
“by the way i don't mean benzos or prms i don't use those okay it has to be other things that globally lower the level of neuroticism anxiety”
46:02Understanding Anxiety, GAD, and Treatments of AnxietyJun 2025 An SSRI probably does not directly treat panic disorder. It lowers the severity enough that the patient automatically starts living their life again.
“I don't think that an SSRI directly treats a panic disorder. I think an SSRI basically lowers the severity of the panic disorder to the extent that the patient will automatically start living their life again”
46:35Understanding Anxiety, GAD, and Treatments of AnxietyJun 2025
Talking to patients
Psychoeducation comes first. If patients do not understand why we are doing exposures, why would they willingly subject themselves to that pain? Give them an understanding of the illness and a hope.
“if they don't understand why we're doing the exposures and why would they... willingly subject themselves to that pain, right? It doesn't make sense. So we got to give them some kind of understanding of the disease and a hope”
42:46Understanding Anxiety, GAD, and Treatments of AnxietyJun 2025 Use your hands to show the feedback loop: a little anxiety, then the thought "oh God, I'm having a panic attack," and around it goes. Something visual helps.
“I use my hands to show feedback loops because I think something visual is helpful. And I shake my one hand and I say, what happens is you experience a little bit of anxiety and then you start having thoughts of, oh God, I'm having a panic attack”
47:01Understanding Anxiety, GAD, and Treatments of AnxietyJun 2025 Tell them there is a minimum level of anxiety, panic and distress everyone has to have. Life is hard and has a lot of scary and bad things in it.
“there is a minimum level of anxiety, panic, and distress that everyone has to have. Okay. Life is hard. Life has a lot of scary and bad things about it. There's a minimum level of suffering”
45:18Understanding Anxiety, GAD, and Treatments of AnxietyJun 2025
Pearls
Many cases of adult-onset PTSD are more akin to panic disorder, where the problem isn't having the panic attacks.
“I would say in many, many cases that you see, especially for adult onset PTSD, the issue is more akin to a panic disorder issue, right? Think of a panic disorder. The panic disorder isn't having the panic attacks”
14:57Understanding Trauma and PTSD, Diagnosis and Dissociation | Episode 21Apr 2025
It also comes up on
- AnxietyA quick map by what is feared: GAD, many topics; panic disorder, the panic attack; phobia, a specific stimulus; agoraphobia, being trapped or helpless in public.
- AvoidancePanic disorder is not having panic attacks, it is fearing and avoiding them. In the same way, PTSD that persists with or without treatment often comes down to avoidance of trauma memories.
- AnxietyAnother grouping by clinical type: GAD proper, dead-loop avoidance problems like panic disorder and agoraphobia, specific fear problems like phobias, and developmental-relational problems.
From these episodes
- Understanding Anxiety, GAD, and Treatments of AnxietyJun 2025 · 9 points
- Understanding Trauma and PTSD, Diagnosis and Dissociation | Episode 21Apr 2025 · 1 point
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.