A Cognitive Behavioral Therapy Approach to Panic Attacks – Case Study
Panic Attacks After a Relationship Break-Up
27-year-old Ryan* came to therapy to address a recent onset of panic attacks following a breakup with his long-term girlfriend. His panic symptoms included crying, breathing heavily, feeling a “pit in his stomach,” and feeling completely out of control of his emotions and physiological sensations. Through trial and error he figured out some ways of managing his symptoms in the midst of the panic attack (e.g., physically removing himself from the anxiety-provoking situation), but these strategies didn’t always work and at times he was unable to implement them. Ryan sought therapy to understand what causes his panic attacks and to develop effective strategies to feel more in control of his feelings and behavior so that he can prevent future panic attacks.
* Names and identifying information have been changed.
A Case of Negative Automatic Thoughts and Self-Perceptions
In reviewing Ryan’s history, it became apparent that he’d developed certain negative automatic thoughts and self-perceptions in response to specific life stressors in his younger years. These thoughts included, “I’ll let (someone) down,” “I’m negatively affecting others’ lives,” “I’m dumb, lazy, or selfish,” and “If I say no, I’ll look like a real jerk.” Once the particular stressor passed or became less problematic, his negative automatic thoughts receded to the back of his mind and became less present in his awareness. However, these thoughts were easily reactivated in the face of new stressors, which would bring him right back to the same feelings he experienced with earlier stressors: anxiety, guilt, shame, etc. as well as the physical sensations of panic. In effect, these thoughts had become his habitual way of responding to emotionally-charged experiences, so that with each stressor, he tended to fall into a loop of negative thinking, self-judgments, and self-criticisms, which then led to feelings of anxiety and panic. As a result, he was unable to assess the situation realistically, problem-solve, consider alternatives, and move forward productively.
Anxiety in Today’s Fast-Paced, Hyper-Connected World
Anxiety is a natural and valuable human emotion: it helps us remain alert to potential threats in our environment so that we can respond to protect ourselves. However, anxiety can also be debilitating when it becomes so overwhelming that it interferes with our daily functioning or ability to enjoy life and make decisions.
Anxiety affects many of us in today’s fast-paced, hyper-connected world. Although there are many contributing factors, in my practice I see that social media often plays a role in inducing or reinforcing people’s anxiety. Social media magnifies our tendency to compare ourselves negatively to others. It also raises our expectations of what we “should” be accomplishing or who we “should” be—even though the information on social media is often incomplete, misleading, or unrealistic. Thus, anxiety may arise from a disconnect between how we think of ourselves and our idealized image of who we want to be. At the same time, these days we are often overloaded with information and constantly exposed to distressing situations on both a macro (global events) and micro (a barrage of emails to answer) level. Under these circumstances, it can be hard to evaluate the relative severity of these threats or even to distinguish between which are real and which are perceived threats, which can also lead to feelings of anxiety or panic.
Exploring Treatment Options: Psychotherapy and Medication
Over the course of our work, Ryan and I discussed various strategies to help him better manage his anxiety. As part of this process, we considered the option of medication to help alleviate his panic symptoms. We explored the potential benefits, possible concerns, and Ryan’s feelings and thoughts about what it would mean for him to take medication. We agreed that I would refer him to a psychiatrist for a consultation, and together they decided that he could benefit from an anti-anxiety medication taken on an as-needed basis. Ryan felt reassured by having a prescription on hand as an immediate source of relief if necessary. However, he preferred to focus on learning tools to manage his symptoms without the regular use of medication.
Tailored Tools to Manage Thoughts and Emotions
Ryan’s anxiety and panic symptoms were ultimately brought under control when he learned to develop more reality-based alternative thoughts in response to situations that trigger his negative automatic thoughts. For example, when he noticed himself starting to think, “I’m a terrible person because I hurt someone,” he was able to shift his self-talk toward thoughts such as: “Even good people unintentionally hurt others sometimes,” and “I may have hurt (someone), but we will both survive and move past this event.”
Ryan’s panic symptoms also diminished as he began to understand the connection between his present anxiety and his past experiences and relationships, as well as how his thought patterns had developed. This provided a context to understand the roots of feelings, so they made more sense to him. It also allowed him to consider ways in which his current circumstances are similar or different to past experiences so that he could consider and evaluate alternative perspectives and choices.
Learn to Ride the Waves: Feeling in Control Over Anxiety
Therapy helped Ryan understand his internal thought and emotional processes so he could develop tools to minimize his anxiety. Along the way, he learned to identify the types of stressors that were most likely to induce his symptoms so that he could consider more helpful ways of thinking to prevent or, at least, short-circuit future panic attacks. By learning to control his thoughts and emotions better, Ryan gained a sense of security in his ability to manage life’s inevitable stressors and soothe himself. At the same time, he developed his sense of who he is as an individual and a deeper understanding of his process of development. In doing so, he learned to separate out the internal voices that reinforce his anxiety from those that offer a more compassionate and realistic perspective.
Moving Past Panic Attacks
Ryan’s anxiety has significantly diminished since starting therapy and his panic attacks have almost completely stopped. Now that he has learned to manage his automatic negative thoughts, his emotions are more tolerable, and he feels a greater sense of control over his internal state. While he recognizes that life sometimes brings on anxiety, he feels less threatened by anxious feelings and is confident that he has the tools necessary to move past the occasional anxiety-provoking situation.
I address issues that affect people from childhood through adulthood, and I currently work with a significant population of adults in their 20s, 30s, and 40s. Services include individual, couples and family psychotherapy, and parent counseling. I also offer referrals to psychiatrists in cases where psychopharmacology might be helpful to manage symptoms.
Dr. Saltzman is a member
of the WMHC:
Women’s Mental Health Consortium of NYC
How Often Will We Meet? Depending on your needs and availability, sessions are either weekly or twice weekly. In my experience, the success of therapy is strongly related to the client’s commitment to and investment in working on a consistent and regular basis; therefore, I generally do not offer therapy less frequently than once a