The fear of fear
Panic attacks and panic disorder are a type of anxiety that may have started out from an actual situational experience: getting sick when you were little, being extremely embarrassed by a seemingly innocuous situation, or being stuck somewhere briefly. After that experience you may find yourself avoiding similar situations for fear that the panic will happen again.
Panic and full-blown panic attacks are so unbelievably unpleasant and uncomfortable that we will do pretty much anything to try and avoid having them again.
This may sound a bit like trauma and we could certainly identify the triggering event as traumatic, however it differs from trauma in that the primary symptom of panic disorder is the fear that the panic attack will happen again.
Someone may have a legitimate negative experience (nearly passing out on a crowded subway), but the subsequent anxiety symptoms are not about the memory of the incident (like with PTSD). Rather, it is the fear that they will lose control in public that causes them to avoid going back on the subway. This avoidance of anything stressful causes a fear of panic or activation symptoms, which in turn triggers additional anxiety and panic.
The best way to challenge the combination of physical panic symptoms plus behavioral avoidance is to engage in exposure therapy that is specifically tailored to the client’s symptoms. I usually work to help expose patients first to the physical bodily sensations associated with panic (interoceptive symptoms) and later the activities and environments that are avoided due to fear of experiencing panic in everyday life.
Exposure therapy for panic disorder is usually 10-12 weeks.