A racing heart, shaking hands, a strange sense of detachment or unreality, and a rising wave of anxiety. This feeling will be familiar to those of us who have ever experienced a panic attack – and for those with panic disorder, the sensation is all too common.
With a prevalence rate of approximately 2% (Yates, 2009), panic disorder can be debilitating for those it affects. But there is a glimmer of hope: the influential cognitive model of panic, proposed by Clark (1989) has led to the development of highly effective therapies (Clark et al., 1999). Such interventions specifically target the catastrophic misinterpretations of bodily sensations that characterise panic disorder (e.g., “my heart is racing, so I must be having a heart attack”) through carefully crafted behavioural experiments.
Within the stepped-care approach adopted by NHS Talking Therapies (NHSTT), however, individuals with mild to moderate panic disorder (i.e., those who are allocated to low intensity care) currently receive a computerised CBT or guided self-help approach that does not directly target catastrophic panic-specific cognitions, but instead uses a more general CBT-based formulation. This yields significantly lower recovery rates (43%) than Clark’s brief targeted therapy (70-90%) with the same number of sessions (Aslam et al., 2025; Clark et al., 1999) – raising the question of whether low intensity practitioners could be trained to successfully deliver the more effective therapy within these settings, and the clinical benefits of doing so.
Whilst effective treatments for panic disorder have been developed, recovery rates in routine low intensity settings do not achieve the same level of success.
Methods
This parallel randomised controlled trial (RCT) assessed the feasibility and effectiveness of training Psychological Wellbeing Practitioners (PWPs) to deliver a low-intensity focused CBT intervention for panic disorder. This was based on the treatment outlined by Clark et al. (1999), which emphasises formulation and behavioural experiments tailored to challenge participants’ catastrophic misinterpretations. The trial was conducted across two NHSTT services, and participants were adult service users whose main presenting problem was panic disorder with or without agoraphobia.
Fifty participants were randomised to receive focused CBT or treatment as usual, which was either computerised CBT (cCBT) or guided self-help (GSH). Prior to the trial, PWPs in the focused CBT arm received training in this treatment, delivered by a senior clinician over two half-day workshops.
Both GSH and focused CBT consisted of 6-8 30-minute sessions. GSH involved the participant being guided through low-intensity CBT-based exercises (e.g., graded exposure) by a PWP. In contrast, cCBT was delivered through the ‘SilverCloud’ platform across seven modules with online reviews from a PWP, and an optional telephone review at the end of treatment. Focused CBT required participants to complete a workbook module before their sessions, which introduced them to core CBT components.
Outcomes were captured with self-report questionnaires completed at baseline, each treatment session, and post-treatment; these comprised measures of panic, depression, and generalised anxiety symptoms, and daily functioning. Participants also completed a modified measure of safety-seeking and approach-supporting behaviours at pre-, mid-, and post-treatment.
Results
Whilst 50 participants were randomised, only 46 received their allocated intervention (focused CBT, n = 22; TAU, n = 24) and were included in analyses. The majority (67.4%) were female, White British (80.4%), and taking medication (58.7%). Their age ranged from 18-67 years (mean = 35.9 years).
The primary outcome, self-reported panic severity, reduced over time with a moderate effect size of 0.515. However, panic scores were imbalanced at baseline such that the focused CBT group experienced more severe symptoms than the TAU group (M = 16.36 and M = 13.04, respectively). After accounting for this difference in analyses, results revealed that participants who received focused CBT reported significantly lower panic severity at post-treatment compared to those who received TAU. In terms of recovery rates, this translated to 73% recovery for focused CBT relative to only 35% recovery for TAU. Whilst depression, generalised anxiety, and functional impairment symptoms reduced over time for all participants with small to moderate effect sizes, there was no significant difference between groups. This suggests that there was no additional benefit of focused CBT over TAU on these outcomes.
Exploratory analyses revealed that participants’ level of engagement in safety-seeking behaviours at post-treatment could predict their pre- to post-treatment change in panic severity, but this was not the case for approach-supporting behaviours. This implies that treatment was effective at reducing use safety-seeking behaviours, and that this may be one of the mechanisms of symptom improvement.
PWPs reported moderate confidence in their ability to deliver CBT for panic before receiving trial-specific training; after taking part in the study, their confidence had improved significantly for both in-person and online treatment formats. The training was deemed “very useful”, with qualitative feedback identifying workbooks, videos, role-play, and supervision as particularly helpful elements of focused CBT. PWPs suggested more detail on treatment content, and making the workbooks provided to patients more concise, as areas for improvement.
Out of 15 clinical skills that were assessed, PWPs were rated as “very good” at 12, indicating good proficiency across most therapeutic techniques. Overall adherence to session guides was 4.3 out of a maximum of 6, and this was taken to indicate good adherence.
The numbers in this trial are too small for us to come to any reliable conclusions about treatment safety or effectiveness.
Conclusions
Results imply that focused CBT, delivered by trained low intensity therapists in routine NHS settings, is a more effective treatment for adults with panic disorder than guided self-help or computerised CBT. The authors concluded that their findings “support previous research showing that identifying catastrophic misinterpretations of bodily sensations and safety-seeking behaviors and targeting them within treatment using belief disconfirmation results in greater improvements in panic when compared to exposure-based habituation”.
This feasibility study suggests that low-intensity practitioners may be able to deliver targeted therapy for panic with only a small amount of additional training
Strengths and limitations
This RCT has many strengths; most notably, the fact that it was conducted within routine NHS services with treatment delivered by Talking Therapies clinicians. The recovery rate exceeded 70% in the focused CBT group, indicating better-than-average outcomes for this more targeted – yet still brief – intervention. PWPs who delivered the intervention received an additional two half-day training sessions, and received equal or even less supervision than those delivering standard care; therefore, it has good scalability with relatively low resource burden over and above routine treatment, and can be delivered remotely.
Use of an active control condition results in a more stringent evaluation of efficacy, meaning that we can have greater confidence in the added benefit of focused CBT compared to routine GSH or cCBT. Therapist feedback suggests that the intervention was acceptable, with training sessions successfully increasing their confidence.
However, the limitations of the study should be considered alongside its strengths. In the analyses, participants who were allocated to a trial arm but dropped out before receiving their designated treatment were omitted. This factor caveats the results of the study, as it raises the possibility of biased outcomes. Combined with the small sample size, with less than 50 participants receiving treatment, the degree to which results can be generalised is limited and replication is needed.
Without a follow-up assessment, the study cannot determine whether the beneficial effects of focused CBT were maintained. However, post-treatment data are promising, and the authors cite a recent systematic review (conducted by their group) that shows sustained effects of this therapeutic approach (Aslam et al., 2024). Future research should aim to replicate the long-term impact of focused CBT, in addition to conducting a formal cost-effectiveness analysis.
Further research is needed to establish whether the treatment is safe and effective in the short- or long-term.
Implications for practice
Aslam and colleagues (2025) present preliminary evidence for the feasibility and efficacy of focused CBT for panic disorder within routine NHS settings. Importantly, this treatment achieved significantly better outcomes than standard care and could be delivered by low-intensity therapists with good fidelity.
From a theoretical perspective, this finding supports previous evidence for the success of psychological therapies which focus on the catastrophic cognitions that purportedly drive panic disorder in Clark’s cognitive model. However, the study also has implications for clinicians and policymakers, as it highlights that only a small amount of additional training is needed for PWPs embedded within standard clinical services to confidently deliver this more targeted and effective treatment. Given the current climate, in which the NHS is in desperate need of interventions that provide greater change with less resources, this promising finding warrants further investigation.
As this was a small feasibility study, it was powered to identify overall effects but not to untangle the mechanisms driving them. A larger future trial would be able to identify any opportunities to further refine and improve the therapy; for instance, by identifying specific panic-related cognitions or behaviours that are key drivers of symptom change. Additionally, a scaled-up trial would enable the identification of moderators of treatment success – in other words, to unpick what works for whom, and under which circumstances.
Focused CBT by trained PWPs makes logical sense and this small trial shows promise, but more work is needed.
Statement of interests
Lottie Shipp works within the same department as the research team (Department of Experimental Psychology, University of Oxford) but has no personal involvement with the study and has no other connections to the researchers.
Edited by
Dr Dafni Katsampa.
Links
Primary paper
Aslam, S. Y., Jenkin, A., Zortea, T., Wykes, C., Sadler, S., & Salkovskis, P. M. (2025). Evaluating the effectiveness of a focused CBT training for panic disorder: a randomized parallel trial. Psychological Medicine, 55, e356, 1–10
Other references
Aslam, S. Y., Zortea, T., & Salkovskis, P. (2024). The cognitive theory of panic disorder: A systematic narrative review. Clinical Psychology Review, 113.
Clark, D. (1989). Anxiety states: Panic and generalised anxiety. In K. Hawton, P. Salkovskis, J. Kirk, & D. Clark (Eds), Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide (pp. 52–96). Oxford University Press.
Clark, D. M., Salkovskis, P. M., Hackmann, A., Wells, A., Ludgate, J., & Gelder, M. (1999). Brief cognitive therapy for panic disorder: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 67(4), 583–589.
Yates, W. R. (2009). Phenomenology and epidemiology of Panic Disorder. Annals of Clinical Psychiatry, 21(2), 95–102.
