Panic Formulation

Panic attacks are characterized by a surge of anxiety with a rapid onset. Symptoms of a panic attack include:

• An abrupt surge of intense fear or discomfort that reaches its peak within a few minutes
• Palpitations, pounding heart, or an accelerated heart rate
• Sweating
• Trembling or shaking
• Difficulty breathing, or shortness of breath
• Feelings of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, or lightheaded
• Derealization and depersonalization
• Fear of losing control, going crazy, or passing out
• Fear of dying
• Hot flushes or cold chills
• Parathesia (numbness or tingling sensations)
• Dry mouth

The diagnosis of panic disorder is characterized by repeated panic attacks, some of which have an unexpected onset. People who struggle with panic disorder worry about the occurrence and consequences of future panic attacks, and make attempts to avoid situations or triggers they associate with panic. Panic attacks also occur in a wide range of other conditions including obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and

“One of the first steps in cognitive therapy for panic is to come to an understanding of how your panic works. Could we look at one of your recent panic attacks and see if we can work out what might have been happening for you?”

The aim of a formulation is to help the client and therapist to come to a shared understanding of what a client is experiencing. It is most helpful to encourage clients to identify a specific example of a recent time that they experienced panic. If clients struggle to do so, it may be helpful to encourage to them to use a panic self-monitoring record.

1. Situation or trigger. Help the client to become aware of internal or external triggers that precipitated their panic attack. Internal triggers can include thoughts, emotions, or body sensations. External triggers might include things that the client saw, heard, or experienced. Clients can

• Barlow, D. H., & Craske, M. G. (2006). Mastery of your anxiety and panic. Oxford University Press.
• Bernstein, D. A., & Borkovec, T. D. (1973). Progressive relaxation training: A manual for the helping professions. Research press.
• Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24(4), 461-470.
• Clark, D. M., Salkovskis, P. M. (2009). Panic disorder: Manual for improving access to psychological therapy (IAPT) high intensity CBT therapists.
• Ehlers, A. (1993). Interoception and panic disorder. Advances in Behaviour Research and Therapy, 15(1), 3-21.
• Limmer, J., Kornhuber, J., & Martin, A. (2015). Panic and comorbid depression and their associations with stress reactivity, interoceptive awareness and interoceptive accuracy of various bioparameters. Journal of Affective Disorders, 185, 170-179.
• Pompoli, A., Furukawa, T. A., Efthimiou, O., Imai, H., Tajika, A., & Salanti, G. (2018). Dismantling cognitive-behaviour therapy for panic disorder: a systematic review and component network meta-analysis. Psychological Medicine,