A racing heart, shaking hands, a strange feeling 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 people with panic disorder, this sensation is very 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 anxiety proposed by Clark (1989) has led to the development of highly effective treatments (Clark et al., 1999). Such interventions specifically target the catastrophic misinterpretations of bodily sensations that are characteristic of panic disorders (e.g., “My heart is beating fast, so I’m having a heart attack”) through carefully designed behavioral experiments.
Within the stepped-care approach adopted by NHS Talking Therapies (NHSTT), however, individuals with mild to moderate panic disorder (ie, those allocated to low intensity care) currently receive a computerized 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 results in a significantly lower recovery rate (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 lower intensity therapists can be trained to successfully deliver more effective therapy within these settings, and whether there are clinical benefits of doing so.
Although effective treatments have been developed for panic disorder, recovery rates do not achieve the same level of success in regular low-intensity settings.
methods
This parallel randomized controlled trial (RCT) assessed the feasibility and effectiveness of training psychological well-being 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 emphasizes formulation and behavioral experiments designed to challenge participants’ destructive misinterpretations. The trial was conducted in two NHSTT services, and participants were adult service users whose main problem was panic disorder with or without agoraphobia.
Fifty participants were randomized to receive focused CBT or treatment as usual, which was either computerized CBT (CCBT) or guided self-help (GSH). Before the trial, PWP in the focused CBT arm received training in this treatment, delivered by a senior therapist over two half-day workshops.
Both GSH and focused CBT consisted of 6–8 30-minute sessions. In GSH, participants were guided by PWP through low-intensity CBT-based exercises (e.g., graded exposure). In contrast, CCBT was delivered via the ‘SilverCloud’ platform in seven modules with online review from the PWP and an optional telephone review at the end of treatment. Focused CBT requires participants to complete a workbook module prior to their session, which introduces them to the core CBT components.
Outcomes were captured with self-report questionnaires completed at baseline, each treatment session, and post-treatment; These included measures of anxiety, depression and generalized anxiety symptoms and daily functioning. Participants also completed a modified measure of security-seeking and approach-supportive behavior at pre-, mid-, and post-treatment.
Result
While 50 participants were randomized, only 46 received their allocated intervention (focused CBT, n = 22; TAU, n = 24) and were included in the 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 anxiety severity, decreased over time with a medium effect size of 0.515. However, panic scores at baseline were unbalanced such that the focused CBT group experienced more severe symptoms than the TAU group (M = 16.36 and M = 13.04, respectively). After taking this difference into account in the analyses, results showed that participants who received focused CBT reported significantly lower post-treatment anxiety severity than those who received TAU. In terms of recovery rates, this is a 73% recovery for focused CBT relative to only 35% recovery for TAU. While symptoms of depression, generalized anxiety, and functional impairment decreased over time for all participants with small to medium effect sizes, there were no significant differences between groups. This suggests that CBT focused on TAU had no additional benefit on these outcomes.
Exploratory analyzes revealed that participants’ level of engagement in safety-seeking behaviors could predict pre- to post-treatment change in their anxiety severity, but this was not the case for approach-supportive behaviors. This implies that the treatment was effective in reducing safety-seeking behaviors, and this may be one of the mechanisms of symptom improvement.
PWP reported moderate confidence in their ability to provide CBT for anxiety before receiving test-specific training; After participating in the study, their self-confidence was significantly improved for both the in-person and online treatment formats. The training was considered “very useful”, with qualitative feedback identifying workbooks, videos, role-plays and supervision as particularly helpful elements of focused CBT. The PWP suggested more detail on treatment materials and making workbooks provided to patients more concise as areas for improvement.
Of the 15 clinical skills assessed, 12 PWPs were rated “very good”, indicating good proficiency in most clinical techniques. Overall adherence to the session guides was a maximum of 4.3 out of 6, and this was taken to indicate good adherence.
The numbers in this trial are too small to draw any reliable conclusions about the safety or effectiveness of the treatment.
conclusion
The results show 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 computerized CBT. The authors concluded that their findings “support previous research showing that identifying fearful misinterpretations of physical sensations and safety-seeking behaviors and targeting them within treatment using belief affirmations leads to greater improvements in panic than risk-based habituation”.
This feasibility study suggests that low-intensity therapists may be able to provide targeted therapy for panic with only a little additional training.
Strengths and limitations
This RCT has several strengths; Most notable is the fact that it was conducted within regular NHS services, with treatment delivered by talking therapy practitioners. Recovery rates exceeded 70% in the focused CBT group, indicating better than average outcomes for this more targeted – yet still brief – intervention. Intervention PWPs received two additional half-day training sessions, and received equal or less supervision than those providing standard care; Therefore, it has good scalability with relatively low resource burden in addition to routine treatments and can be delivered remotely.
The use of an active control condition allows for a more rigorous assessment of efficacy, meaning we can have greater confidence in the additional benefit of focused CBT compared to regular GSH or CCBT. Therapists’ feedback indicated that the intervention was acceptable, with the training sessions successfully increasing their confidence.
However, the limitations of the study should be considered along with its strengths. In the analysis, participants who were allocated to the trial arm but dropped out before receiving their assigned treatment were excluded. This factor cautions study results, as it increases the likelihood of biased results. With the small sample size, with less than 50 participants receiving treatment, the extent to which the results can be generalized is limited and requires replication.
Without 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). In addition to conducting formal cost-effectiveness analyses, future research should aim to replicate the long-term effects of focused CBT.
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) have presented 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 with good fidelity by low-intensity physicians.
From a theoretical perspective, this finding supports previous evidence for the success of psychological treatments that focus on the frightening cognitions that allegedly cause panic disorder in Clark’s cognitive model. However, the study also has implications for practitioners and policy makers, as it highlights that only a small amount of additional training is required for PWPs embedded within standard clinical services to confidently deliver this more targeted and effective treatment. Given the current environment, in which the NHS is in desperate need of interventions that deliver greater change with fewer resources, this promising finding warrants further investigation.
Since this was a small feasibility study, it was conducted to identify overall effects, but not to disentangle the mechanisms driving them. A larger future trial will be able to identify any opportunities to further refine and improve the therapy; For example, by identifying specific panic-related cognitions or behaviors that are key drivers of symptom change. Additionally, a larger trial would be able to identify moderators of treatment success – in other words, to find out what works for whom and under what 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 in the same department as the research team (Department of Experimental Psychology, University of Oxford), but has no personal involvement in the study and has no other connections with the researchers.
edited by
Dr. Daffney Katsampa.
Link
primary paper
Aslam, S.Y., Jenkin, A., Zortia, T., Wykes, C., Sadler, S., and Salkowski, P.M. (2025). Evaluating the effectiveness of focused CBT training for panic disorder: a randomized parallel trial.. Psychological Medicine, 55, E356, 1-10
Other references
Aslam, S.Y., Zortia, T., and Salkovskis, P. (2024). The cognitive theory of panic disorder: a systematic narrative review.. Clinical Psychology Review, 113.
Clark, D. (1989). Anxiety states: nervousness and generalized anxiety. Of. Houghton, P. Salkowski, J. In Kirk, and D. Clark (eds.), Cognitive Behavioral Therapy for Psychiatric Problems: A Practical Guide (pp. 52-96). Oxford University Press.
Clark, D.M., Salkowski, P.M., Hackman, 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, WR (2009). Phenomenology and epidemiology of panic disorder. Annals of Clinical Psychiatry, 21(2), 95-102.
