Panic & Avoidance

Maya, 29, marketing manager

Presentation

Three months of escalating panic attacks — heart racing, derealization, chest tightness, fear of dying. The first one happened in a crowded Target on a Saturday afternoon. She thought she was having a heart attack. ER visit, bloodwork normal, discharged with a pamphlet. Since then, the attacks have spread: driving on the freeway, elevators, any enclosed space with no clear exit. She canceled a work trip to Chicago — told her boss she was sick. Now takes surface streets everywhere and shops only at off-hours. Her world is shrinking and she knows it. Says: "I feel like I'm going crazy. My body just hijacks me and there's nothing I can do about it."

History

No prior mental health treatment. Parents divorced at 10; mother had untreated anxiety and avoided driving for years — Maya remembers being the one who stayed calm. High-achieving, self-described perfectionist. Recent promotion to senior manager with increased travel demands and a team of six direct reports. Lives with her partner of three years, who is supportive but increasingly frustrated. Maya recognizes the avoidance is irrational but cannot override it.

Clinical note: Panic disorder has one of the strongest evidence bases in psychotherapy. CBT with interoceptive and in vivo exposure produces ~75-90% panic-free status at follow-up (Barlow et al., 2000; NICE CG113: recommended; Sánchez-Meca et al., 2010 meta-analysis: d = 0.83). ACT shows comparable outcomes through a different mechanism — willingness rather than habituation (Arch et al., 2012). The clinical question with Maya is whether her panic is primarily a learned fear of bodily sensations (CBT model), a manifestation of experiential avoidance narrowing her life (ACT model), or an expression of deeper relational material activated by the promotion — separation anxiety reactivated by new autonomy (psychodynamic), incomplete fight-flight stuck in the nervous system (SE), or a Protector part signaling buried distress (IFS). These are not just different treatments but different claims about what panic is. In practice, many clinicians sequence: CBT or ACT to stabilize panic frequency, then somatic or psychodynamic work to address what the panic may have been expressing. But this pragmatic sequencing conceals an epistemological bet — if the panic is 'just' conditioned fear, depth work is unnecessary; if it's meaningful, CBT may resolve the symptom while leaving the cause intact. The mother's untreated anxiety is clinically significant — intergenerational anxiety transmission occurs through both genetic vulnerability and learned behavior (Hettema et al., 2001), and Maya's perfectionism may represent an anxious attachment style that predates the panic.

Where Approaches Genuinely Disagree

Expose immediately or stabilize first?

CBT

Interoceptive and in vivo exposure should begin early — avoidance maintains the fear cycle.

vs.

Somatic Experiencing

The nervous system is already overwhelmed. Jumping to exposure without body-based regulation risks flooding.

Is this about thoughts or about the body?

CBT

Catastrophic misinterpretation of bodily sensations drives panic. Correct the thinking.

vs.

Hakomi

The body is producing a signal that needs to be listened to, not overridden.

Philosophical Lenses

These are not treatment plans. They are ways of seeing — philosophical perspectives that illuminate aspects of this case that clinical modalities may not address directly.

Martin Heidegger

Maya's panic is not a malfunction. It is the sudden disclosure of what is normally concealed: the groundlessness of existence. In anxiety (Angst), the familiar world withdraws — tools fail, meanings collapse, the everyday 'they-self' can no longer maintain its reassuring hold. Her derealization is not a symptom to be corrected but a mood that reveals the uncanniness (Unheimlichkeit) of Dasein — the fact that we are never fully at home in the world. The therapeutic question is not how to eliminate the anxiety but whether she can endure what it discloses and live more authentically in its light.

Maurice Merleau-Ponty

Maya's body is not sending false signals. It is expressing a collapse of the lived body-world relation. Normally, perception and movement form a seamless arc — the body inhabits its environment without reflection. In panic, this pre-reflective coherence fractures. The heart becomes an object of scrutiny rather than the silent ground of being. Her avoidance of elevators and crowds is not irrational — it is the body's attempt to recover a sense of motor coherence in a world that has become threatening. Treatment must address the body not as a mechanism to be recalibrated but as a subject whose way of inhabiting space has been disrupted.

Søren Kierkegaard

Anxiety is the dizziness of freedom. Maya stands before the open possibility of her own existence and recoils. The panic is not about elevators or crowded stores — those are the finite occasions on which infinite possibility presses in. She is 29, at the threshold where the commitments of early adulthood either deepen or reveal their contingency. Her question 'Am I going crazy?' is really a question about whether the self she has constructed can hold. Kierkegaard would say the way through is not the elimination of anxiety but the leap — the willingness to choose oneself in the face of uncertainty.

10 Formulations

Select 2–3 modalities to compare side by side:

Sources & Method

This is a composite fictional case — no real client is depicted. Formulations represent how each modality would typically conceptualize and approach a case with this presentation, based on published clinical literature and training materials. Each formulation draws on the modality's own theoretical framework, key texts, and clinical principles as documented on its modality page. Full source citations for every modality are available on the Sources page.