CBT for panic disorder session note template (interoceptive exposure)

A CBT session note for panic disorder is the written trace of each session of cognitive behavioural treatment for panic. It captures the week's panic attacks, the catastrophic thoughts worked on, the interoceptive exposure exercises (deliberately bringing on sensations similar to those of an attack) and the exposure to avoided situations, with ratings that show progress from one session to the next.

What this page adds to our other templates

The general structure of a CBT note is in our CBT session note template, exposure hierarchies in the ERP session note for OCD. Here we focus on what is specific to panic: bodily sensations as the exposure target, the attack diary and three-way rating of exercises. If you do not have a written formulation yet, start with a 5 Ps case formulation.

What official guidance says

• NICE CG113 (UK). The public version says people should receive 7 to 14 hours of CBT in total, usually in weekly sessions of 1 to 2 hours, completed within 4 months.
• HAS, ALD 23 guide on severe anxiety disorders (France, June 2007). CBT is described as the psychotherapy of choice for panic disorder, with an optimal length of 12 to 25 sessions of about 45 minutes. The goals listed are to prevent attacks, remove anticipatory anxiety and end avoidance. The guide lists the panic attack diary among the self-report tools that can be used.
• Ireland, Belgium, Switzerland. We have not read national guidance specific to panic session notes in these countries; NICE and HAS remain useful benchmarks, to be checked against your professional body's rules.

The typical course of CBT for panic disorder

Guidelines name the ingredients (psychoeducation, cognitive therapy, exposure, breathing regulation) without setting an order. The sequence below is a common working order, to adapt to your patient. For each step, we say what deserves a place in the note.

1. Psychoeducation and the vicious circle of panic

You explain the circle: a sensation (racing heart, dizziness) is read as danger ("I'm going to collapse"), fear rises, sensations grow, and they seem to confirm the reading. Write the circle in the patient's own words in the note, not a textbook version. You will come back to this personal diagram at every exercise.

2. Cognitive restructuring

You work on catastrophic interpretations and their perceived likelihood. Note the main belief and how strongly it is held, from 0 to 100, at the start and at each review.

3. Interoceptive exposure

The patient deliberately brings on the feared sensations with you (breathlessness, dizziness, palpitations) to find out that they are unpleasant but not dangerous. Start by trying several exercises to find those most similar to the attacks, then repeat those in session and between sessions.

4. In vivo exposure

Next come the situations avoided because of the sensations (exercise, coffee, heat, crowds), then the two are combined, for example climbing stairs fast in an avoided place. The hierarchy is built as for any graded exposure.

5. Relapse prevention

Final sessions: review of gains, warning signs, exercises to keep, what to do if an attack comes back. Write this plan in the final note and give the patient a copy.

What about controlled breathing?

The HAS guide mentions breathing regulation, learned over 3 to 4 sessions. Two studies by Deacon and colleagues suggest care in how it is used. In 2012, in 58 participants with high anxiety sensitivity treated in a single session, adding diaphragmatic breathing and cognitive reappraisal did not improve on interoceptive exposure alone. In 2013, a survey of therapists found that many deliver low-dose exposure paired with controlled breathing, out of concern about adverse effects that they rarely saw in practice. We therefore advise noting whether the patient uses breathing during an exercise: it may be a safety behaviour that stops them learning that sensations pass on their own.

Before the exercises: medical advice

The Centre for Clinical Interventions (CCI, Australia) sheet asks people to be in good physical health, to check the list of exercises with their doctor and not to continue if they have a health issue that physical strain might complicate. We advise getting prior medical advice from the patient's doctor before exercises that put load on the heart, breathing or balance, when there is a known health problem, current treatment or any doubt. Write the date of that advice in the file. In session, avoid combinations that risk a fall (spinning then standing up suddenly without support, for example).

Panic disorder session note template (copy and adapt)

Header

• Patient: initials or code, age
• Session no.: date, length, in person or remote
• Phase: psychoeducation, restructuring, interoceptive exposure, in vivo exposure, relapse prevention
• Medical advice for exercises: obtained on ... / to request

Past week

• Attacks: number, peak intensity 0-100, expected or unexpected (from the patient's diary)
• Anticipatory anxiety: weekly average 0-100
• Avoidance and safety behaviours: new, dropped, ongoing
• Homework: done, partly done, not done, and why

Belief worked on

• Catastrophic thought: in the patient's words
• Conviction: 0-100 at the start, 0-100 at the end of the session
• Evidence examined: two or three lines

Interoceptive exercises today (one line per trial)

• Exercise: for example fast breathing, running on the spot, straw breathing
• Duration: planned and actual (note if cut short)
• Intensity of sensations: 0-100
• Anxiety: 0-100 at peak
• Similarity to attacks: 0-100
• Prediction before the trial and what happened
• Safety behaviours observed: sitting down, holding on, slow breathing, asking whether this is normal

In vivo exposure (if planned)

• Situation, duration, anxiety before, at peak, after, safety behaviours dropped

Clinician's analysis

• What the session confirms or challenges in the formulation
• Exercise to keep, intensify or replace

Homework and next steps

• Home exercises: which ones, how many times a day, for how long
• Diary: to fill in after each attack
• Next session: planned goal

Starter list of exercises and what to note

Indicative durations from the CCI sheet; the sheet does not list the sensations, so those given here are the usual ones, to check with your patient. We advise trying them yourself before offering them: you will describe the sensations better.

• Breathe fast and hard through the mouth: breathlessness, tingling, light head. 1 minute.
• Shake the head side to side, eyes open, then look straight ahead: dizziness. 30 seconds.
• Head between the legs, then stand up: head rush. 30 seconds.
• Run on the spot or up steps: racing heart, breathlessness. No duration given on the sheet; agree one with the patient.
• Tense all muscles: tension, shaking. 1 minute.
• Hold the breath: air hunger. 30 seconds or as long as possible.
• Spin on a swivel chair: dizziness, nausea. 1 minute.
• Breathe through a narrow straw, nose held: feeling of suffocation. 1 minute.
• Stare at a spot on a wall or in a mirror: sense of unreality. 1.5 minutes.

Note the three ratings for each. Exercises with high similarity (above 50 out of 100, for example) are the ones worth repeating; a very intense but dissimilar exercise teaches less.

Panic attack diary (to give to the patient)

The HAS guide lists the panic attack diary among self-report tools. Here is a simple version, to fill in as soon as possible after each attack.

• Date, time, approximate length
• Where I was, what I was doing
• I expected it: yes / no
• Sensations: racing heart, short of breath, dizzy, shaking, hot, nausea, tingling, unreal, other
• Peak intensity: 0-100
• What I thought was going to happen
• What I did: left, sat down, called someone, took medication, other
• What actually happened next

Add one line a day for anticipatory anxiety from 0 to 100, even on days without an attack.

Fictional example over two sessions

Fictional patient, Ms R., 36. Attacks for a year, fear of a heart problem despite reassuring tests from her doctor. She has given up coffee and running and climbs stairs slowly. Formulation and psychoeducation done in sessions 1 to 3. Her GP has cleared her for the exercises.

Session 4: trying the exercises

• Week: 2 attacks, peak intensity 80, one unexpected on waking. Average anticipatory anxiety 55. Diary completed.
• Belief: "if my heart beats too fast, it will give out". Conviction 70 at the start.
• Fast breathing 1 min: intensity 60, anxiety 50, similarity 40.
• Running on the spot 1 min: intensity 70, anxiety 75, similarity 80. Prediction "I'll have to stop". Completed the minute; put her hand on her chest (safety behaviour).
• Swivel chair 1 min: intensity 50, anxiety 30, similarity 20.
• Analysis: the fear is about heart rate. Running on the spot is the target exercise; the chair is dropped.
• Homework: running on the spot 1 min, 3 times a day, no hand on chest. Note the three ratings each time.

Session 5: repetition and first in vivo trial

• Week: 1 attack, peak intensity 60, expected (after climbing stairs fast). Average anticipatory anxiety 40. Exercises done 15 times out of 21 planned.
• Belief: conviction 50 at the start.
• Running on the spot 2 min, no hand on chest: intensity 75, anxiety 45, similarity 75. Prediction "my heart will race and not stop". Heart rate settled in under two minutes at rest.
• In vivo: climbing two floors fast in the practice building. Anxiety before 50, peak 60, after 25.
• Conviction at the end: 35.
• Analysis: anxiety falls at the same intensity, consistent with the formulation. Next step: reintroduce a morning coffee.
• Homework: running on the spot 2 min, twice a day; fast stairs once a day; diary.

Scales: what you can note

The PDSS (Panic Disorder Severity Scale) is used to track panic disorder severity; it is not cited in the HAS guide, which lists a Beck inventory, the attack diary and the Marks and Mathews Fear Questionnaire. In the note, write the tool's name, the date and the score you obtained using the author's scoring. Do not copy items into a document shared with others without checking the rights. Delta does not calculate any score: it uses the one you give it.

Common mistakes

• Rating anxiety only. Without similarity, you repeat exercises that do not resemble the attacks.
• Stopping at the first sensations. We advise noting the actual duration: an exercise cut short every week signals avoidance.
• Missing subtle safety behaviours: hand on the pulse, water bottle, slow breathing during the exercise.
• Changing scale mid-treatment (0-10, then 0-100). Keep the same one throughout.
• Not noting the date of medical advice before the exercises.

Why Delta fits this kind of follow-up

Delta is the clinical assistant for psychologists, more than a scribe: it keeps the memory of each patient. During the session it transcribes what is said, including ratings spoken aloud during exercises; or you dictate your observations after the session. It generates the session report (short summary, detailed summary, topics for next session) taking the CBT approach into account, and updates the patient record, so the course of attacks and goals is in one place. Data stays in Europe, in France, on infrastructure certified for health data; the patient's name is pseudonymised before the AI and no audio file is kept. See also our page on CBT therapist software, our clinical document templates and Delta for psychologists.

Sources

• NICE CG113, What treatments should I be offered for panic disorder? (information for the public; guideline published January 2011, last updated June 2020)
• HAS, ALD 23 guide for doctors, severe anxiety disorders (France, June 2007, in French)
• Centre for Clinical Interventions, Panic Information Sheet 08, Physical Symptoms and Panic
• Deacon et al., Journal of Cognitive Psychotherapy, 2012, 26(3), 257-269
• Deacon et al., Therapist perceptions and delivery of interoceptive exposure for panic disorder, Journal of Anxiety Disorders, 2013, 27(2), 259-264