Introduction

Panic attacks are among the most distressing symptoms clients bring into the therapy room. The sudden surge of fear, racing heart, dizziness, and sense of impending doom can leave clients terrified of losing control or even dying.

While CBT provides effective tools like interoceptive exposure and cognitive restructuring, some clients continue to experience panic despite treatment. The Deconstructing Anxiety model offers a fresh lens: beneath the panic lies a core fear that has not yet been addressed.

This case study illustrates how identifying the core fear can transform treatment.

Client Background

Client Profile:

  • 32-year-old professional, “Anna” (pseudonym)
  • Presented with panic attacks triggered by work-related stress
  • Reported fears of making mistakes and being judged by colleagues
  • Previous CBT helped reduce surface symptoms, but attacks persisted during high-pressure situations

The Surface Layer: Panic and Perfectionism

Anna’s presenting symptoms included:

  • Sudden panic before presentations
  • Insomnia the night before deadlines
  • Excessive preparation to “avoid mistakes”

At first glance, this looked like performance anxiety reinforced by perfectionism. Exposure and relaxation strategies helped somewhat, but the attacks persisted.

Deconstructing the Fear

Using the Deconstructing Anxiety model, the clinician began to ask progressive questions:

  • “What would it mean if you made a mistake at work?”
    → “I’d disappoint my boss.”
  • “And if you disappointed your boss, what would happen?”
    → “She’d think I’m not competent.”
  • “If you were seen as not competent, what would that mean for you?”
    → “It would mean I’m worthless.”

Through this process, Anna uncovered her core fear: loss of identity — the fear that without success, she is “nothing.”

The Chief Defense

Anna’s defense was perfectionism: working long hours, triple-checking her work, and avoiding leadership roles to prevent exposure. While these defenses temporarily lowered her anxiety, they kept the cycle alive.

Intervention: Doing the Opposite

The clinician introduced The Warrior’s Stance, a Deconstructing Anxiety technique that encourages clients to do the opposite of their defense.

  • Instead of over-preparing, Anna deliberately allowed small imperfections in her work.
  • She practiced presenting without excessive rehearsal.
  • With support, she confronted the core fear: “Even if I’m not perfect, I still have value.”

Outcome

Over several weeks:

  • Panic attacks decreased in frequency and intensity
  • Sleep improved
  • Anna reported greater confidence and willingness to take professional risks
  • Most importantly, she felt less defined by her work performance and more connected to her sense of identity beyond achievements

Clinical Takeaways

  • Panic attacks often mask deeper existential fears.
  • Progressive questioning can reveal a client’s core fear.
  • Defenses may reduce anxiety in the short term but reinforce it long-term.
  • Doing the opposite of the defense creates space for lasting transformation.

Conclusion

By uncovering the core fear of loss of identity, Anna was able to move beyond symptom management into deeper healing. For clinicians, the Deconstructing Anxiety model provides tools to reveal and transform the fears that fuel anxiety disorders.

👉 Want to learn how to apply these methods in your practice? Join Dr. Todd Pressman for a live, 6-hour intensive training on Sept. 20, 2025: [Register Here]