How the problem presents
A client may arrive asking to stop panic while describing a life organized around preventing it: sitting near exits, avoiding exercise, traveling only with a trusted person, or checking a pulse before leaving home. Another client has frequent attacks without broad avoidance. Clarify what the client fears will happen: death, fainting, humiliation, losing control, being trapped, or having no help. Similar outward behavior can serve different purposes.
Panic attacks do not by themselves establish panic disorder. Agoraphobic avoidance also deserves assessment in its own right. Neither presentation demonstrates an undisclosed trauma history. Bodily fear may be associated with a remembered event, but a plausible memory formulation must be discovered collaboratively rather than supplied by the therapist. [20]
Assessment and treatment context
Begin with the pattern and consequences of recent episodes. Ask what preceded the sensations, how the person interpreted them, what they did next, and what happened afterward. Explore sleep, substances, medication changes, medical conditions, and previous evaluations. A prior anxiety diagnosis is not permission to dismiss a new or materially changed physical symptom. Arrange medical assessment when indicated and urgent care when the presentation warrants it.
NICE recommends CBT for panic disorder and describes medication options within shared treatment planning. NIMH identifies interoceptive exposure and exposure to avoided situations as CBT methods for panic-related fear. These require appropriate competence and an individualized assessment, not improvised sensation-induction exercises during target discovery. [21] [20]
EMDR also has direct trial evidence in panic disorder, discussed in the practical treatment section below. Use an explicit panic formulation to select relevant memories and triggers, and agree how panic symptoms, avoidance, and functioning will be monitored alongside memory distress. Coordinate approach practice and medical guidance when these are part of the plan.
Candidate targets conditional on the history
The attack remembered as catastrophe. A particular episode may remain vivid: the ambulance doors closing, collapsing in a queue, or believing death was imminent. Establish what makes this episode salient now. The first attack is not automatically the best starting point.
An experience of being unable to obtain help. Consider an actual event only when the client links it to present expectations. Being dismissed in an emergency department may matter more than the sensation itself.
Secondary humiliation or restriction. A remembered public reaction, coercive treatment, or frightening attempt to push through symptoms may carry its own charge. Separately record present cues and future predictions; an imagined collapse is not a historical event.
Assessment Script
Opening invitation: “Could you take me through a recent episode, beginning just before you noticed anything changing? What did you notice first? What did that seem to mean? What did you do to protect yourself, and what did that make easier or harder?”
Memory inquiry: “When we discuss that situation, is there a particular experience you remember, or is the difficulty mainly about what might happen next? You do not need to find an earlier event. If a memory does come to mind, which moment feels relevant, and what connects it with the problem you want help with?”
Fit and consent: “Would working with that memory fit your priorities? What concerns would you have? What would tell us that this work was helping in daily life, rather than only making the memory easier to discuss?”
These questions support assessment. They are not a reprocessing script or a method for discovering concealed events.
A fictional past present and future map
Presenting situation. Leila, a fictional client, stops using trains after an episode of intense dizziness. Her medical clinician has assessed the symptoms and provided a plan for changes that require review. Leila wants to commute independently. She is receiving panic-focused CBT, but an image of being shut inside the carriage remains intrusive.
Past candidate. She identifies the moment the train stopped between stations and she believed help could not reach her. Her target description is specific: the dark window, the announcement, and “I cannot get help.” She does not identify a childhood parallel, and none is required. The clinician assesses possible PTSD separately rather than inferring it from the image.
Present cues. Closing doors, warmth, and a delayed announcement evoke the same expectation. Pulse checking and repeated route searches are recorded as current maintaining behaviors, not treated as additional memories.
Future aim. Leila wants to ride one stop while responding flexibly to uncertainty and following an agreed medical plan. She does not need a promise that dizziness will never recur.
Rationale. This event offers a bounded EMDR target connected to Leila's own account of present interference. The plan links processing the carriage memory with checking current door and delay cues, installing a realistic future template, and reviewing actual travel. Memory change and regained mobility are complementary treatment outcomes.
EMDR treatment of panic: work with the remembered catastrophe
There is direct research on EMDR for panic disorder, not only an extrapolation from PTSD. In a randomized study of 84 patients assigned to EMDR or CBT, adjusted analyses supported EMDR's non-inferiority for catastrophic thoughts and fear of bodily sensations; results for agoraphobic mobility were inconclusive. This supports EMDR as a treatment option while making avoidance a separate outcome to track. Horst and colleagues, 2017
Which panic targets are likely to emerge?
Useful candidates include the first attack when it remains central, the worst remembered attack, an attack in which help seemed unavailable, being shamed for symptoms, and a failed attempt to return to an avoided setting. The central meaning attached to a selected panic episode may be “I am helpless”; assess that meaning alongside its image, emotions, and sensations. At work, a client may identify becoming dizzy during a briefing, feeling unable to leave a conference room, or being reprimanded after requesting a break.
Map the present cues precisely: a warm room, a closed door, an increased heartbeat while climbing office stairs, or a meeting invitation. Separately record the catastrophe the person imagines next time. Ask, “What does the sensation seem to predict, and what particular moment makes that prediction feel so convincing?” Use the answer to select a target, not to argue the client out of fear.
Leila's processing pathway
Fictional continuation. Leila selects the moment the train stopped and the window went dark. After preparation, Phase 3 establishes that image, “I am helpless,” and a preferred cognition such as “I have choices now.” The clinician assesses how credible that cognition currently feels, her fear and distress, and the chest or stomach sensations accompanying the image. The cognition must fit a realistic capacity to respond, not a promise that trains never stop.
During Phase 4, use the selected target and agreed dual-attention stimulation, asking briefly what emerges between sets. Allow the processing to move through the fear, helplessness, anger, or other material that actually appears. Do not interrupt every bodily sensation with reassurance that nothing is wrong; equally, a genuinely new medical concern follows the previously agreed medical plan. When appropriate target resolution has occurred, proceed with installation, body scan, and closure. This uses the standard treatment sequence, tailored to a panic-linked memory. APA's EMDR phase description
Complete the past–present–future sequence
At reevaluation, check the train memory and the next encounter with closing doors. If the memory has settled but the door sound retains disturbance, assess that present cue. A persistent image of collapsing without help may call for separately formulated anticipatory-fear work, rather than repeated processing of a now-neutral memory.
Leila's future template includes boarding, noticing possible anxiety, responding according to her plan, and completing an agreed journey. Actual travel and panic-focused behavioral work test what has changed outside the room. Review journeys attempted, restrictions, checking, and recovery after symptoms—not only attack counts. For the worker avoiding conference rooms, the equivalent aim may be attending a chosen meeting while retaining permission to request a practical adjustment. EMDR, approach practice, and medical guidance can each contribute without being confused with one another.
When to reconsider the formulation
Reconsider if memory distress falls but avoidance remains unchanged, if a previously unrecognized medical problem appears, or if the client is chiefly struggling with ongoing catastrophic interpretation rather than intrusive recollection. Review whether reassurance rituals, financial barriers, inaccessible transport, or lack of panic-specific treatment better explain the impasse.
If Leila becomes detached or loses orientation while discussing the train, assess that response rather than increasing emotional intensity to obtain a “better” target. A quiet presentation can reflect many things. Absence of visible distress neither establishes readiness nor proves avoidance.
Preparation and pacing
Make the distinction between medical safety and anxiety-driven certainty seeking explicit without asking the client to ignore their body. Agree how clinical changes will be escalated and who handles medical questions. Offer choices about pacing, orientation, and pausing. Discuss what the client can do if the session increases worry about bodily sensations afterward.
Coordinate care with consent. Grounding or settling practices should support participation, not become compulsory rituals that supposedly prevent catastrophe. Do not begin memory work merely because a scheduled exposure task feels difficult; understand the difficulty and preserve the agreed treatment rationale.
Future Planning Script
“Picture an ordinary version of the journey you want to make, including the possibility that you feel anxious. What would you notice first? What response would fit the medical advice and the work you are doing on panic? What choices would remain available if the train were delayed? Which part can you practice in daily life, and what help would make that practical? How will we review what you learned without judging the journey solely by whether anxiety appeared?”
Imaginal rehearsal here supports planning. It is not evidence that an actual journey will be comfortable or medically risk-free.
Common errors
Selecting the earliest attack by rule. Compare relevance, client preference, and readiness instead of chronology alone.
Calling every bodily cue a trauma response. Preserve medical and condition-specific formulations.
Confusing preparation with protection from panic. The goal is workable engagement, not dependence on a therapist or technique.
Using memory ratings as the only outcome. Ask about transport, exercise, work, and time spent checking.
Consultation and companion connection
Seek consultation when the boundary between panic, medical symptoms, dissociation, and trauma-related re-experiencing remains unclear, or when two treatment plans conflict. Bring the proposed target, alternatives, informed-consent discussion, and functional outcome data rather than only a diagnosis.
In Metaphors That Open Doors, Book Two, choose any relevant metaphor only after Leila's formulation is clear. An image about alarms or restricted movement may help her describe experience, but it must not tell her that a trauma caused her panic or that every alarm is medically false.