Panic & Avoidance
Maya, 29, marketing manager
Fictional teaching case
Compare the formulations ↓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, telling 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."
Read the full case history and clinical context
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.
Compare how approaches understand this case
Two approaches to begin with; change them below. These are starting examples, not a clinical ranking.
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Showing 2 of 10 formulations.
CBT
Catastrophic misinterpretation of bodily sensations (interoceptive conditioning). Avoidance maintains the fear cycle by preventing disconfirmation.
Psychoeducation on panic cycle, cognitive restructuring of catastrophic appraisals, interoceptive exposure, graded in vivo exposure to avoided situations.
"Your body is having a false alarm. The sensations are uncomfortable but not dangerous. Let's test that belief together."
ACT
Experiential avoidance of anxiety sensations is narrowing her life. Fusion with the thought 'I'm going crazy' drives the avoidance cycle. Values around career and independence are being sacrificed.
Willingness to have panic sensations, cognitive defusion from catastrophic thoughts, values clarification, committed action toward what matters.
"What if the goal isn't to stop the panic, but to take it with you on the work trip, because the trip matters to you?"
DBT
Emotion dysregulation on the biosocial model: high biological emotional sensitivity meeting a childhood where Maya's job was to stay calm while her mother could not. Panic escalates because she has no learned skill for riding an intense emotion to its end. The shame and fear about panicking are secondary emotions stacked on the primary one, and they do most of the damage.
Distress tolerance skills, mindfulness of current emotion, opposite action for avoidance, interpersonal effectiveness for asking for support.
"Right now your emotion mind is in the driver's seat. Can we find wise mind together? What's one thing you know to be true even when panic is loudest?"
Existential Psychotherapy
The panic is a confrontation with existential anxiety: the promotion exposed groundlessness, the freedom and responsibility of a larger life. The 'fear of dying' is existential, not just somatic.
Exploring what the panic reveals about her relationship to freedom, death, and responsibility. Not eliminating anxiety but understanding its message.
"You say you feel like you're going crazy. What would it mean if you were actually becoming more sane, more aware of something real?"
IFS
A Protector part is generating panic to keep Maya away from something, probably an Exile carrying old terror or helplessness. The avoidance is another Protector. The more she fights the panic, the harder the Protector works. The system is in a feedback loop.
Approach the panic with curiosity rather than trying to fix it. Help Maya's Self get to know the panicking part: what is it protecting? What Exile does it guard? Unblend from the panic (I am not the panic; a part of me panics). Only once the protectors give permission, and slowly, go toward what's underneath.
"What if this panic isn't your enemy? What if it's a part of you that's been trying to protect you from something? Can you get curious about it? Ask it what it's afraid would happen if it stopped?"
Gestalt Therapy
Maya is split into topdog and underdog: the part that panics and the part standing over it insisting she should be able to control this. She has lost contact with her organismic experience. The avoidance is a creative adjustment that once made sense but now constricts her vitality. The panic itself may be unfinished business demanding attention.
Attend to what is happening NOW: body sensations, breath, the panic itself as an alive process. Explore the panic through dialogue (empty chair with the panic). Experiment with approach rather than avoidance. What is the panic trying to complete?
"Instead of running from it, can you stay here with me and describe what the panic actually feels like right now? Where is it in your body? If it had a voice, what would it say?"
Psychoanalysis
Panic as the return of what has been defended against: most likely a conflict over autonomy and dependency reactivated by the promotion, in which moving up and away carries anger toward the people she would be leaving. The body 'hijacks' her because the affect is barred from consciousness and returns somatically instead.
Free association, exploring what the promotion means unconsciously, linking current panic to childhood experiences of parental divorce and mother's anxiety. Attention to resistance, and to the same conflict as it gets played out with the analyst.
"You mention your body hijacking you. What comes to mind when you sit with that feeling of being taken over?"
Hakomi
Panic reflects core organizing beliefs formed in childhood: likely around safety, control, and self-reliance. The body carries implicit material that the mind hasn't integrated.
Mindful self-study, tracking bodily experience, accessing core beliefs through experiments in mindfulness, following the organization.
"Just notice what happens inside when I say: 'You can let someone else drive.'"
Somatic Experiencing
Incomplete fight-or-flight activation: the nervous system is stuck in a survival response that never completed. Avoidance prevents discharge.
Titrated pendulation between activation and resource states. Tracking bodily sensations. Completing truncated defensive movements.
"Where in your body is that right now? Stay with just the edge of it, a few seconds, no more. Now come back to your feet on the floor and tell me what you notice there."
EMDR
Current panic may be linked to earlier disturbing memories (parental divorce, mother's anxiety) stored with unprocessed affect. The body's alarm system is responding to past danger, not present threat.
History-taking and treatment planning, identify touchstone memories, bilateral stimulation to reprocess foundational experiences feeding the panic.
"When you notice the panic, what's the earliest memory that comes with a similar feeling? Let's start there."
Where Approaches Genuinely Disagree
Interoceptive and in vivo exposure should begin early: avoidance maintains the fear cycle.
The nervous system is already overwhelmed. Jumping to exposure without body-based regulation risks flooding.
Catastrophic misinterpretation of bodily sensations drives panic. Correct the thinking.
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.
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.
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.
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.
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.