Author: NeuroAffective-CBT

A clinical story about how panic, shame, and physiological dysregulation interact and why stabilising physiological regulation can be the first step toward recovery.

Co-author: Ioana Dulcu (Clinical Psychology, Hypno-CBT)
www.neuroaffectivecbt.com
March 2026

---

Jenna’s story

When Jenna, a 26-year-old married woman, first arrived for therapy after the sudden onset of panic attacks, she dreaded that the conversation would revolve around her anxiety symptoms.

Naturally, she thought there would be questions about panic, about the frightening episode that had sent her to the emergency department, about what she had been thinking and feeling when the dizziness first appeared. In fact, she later admitted that she even anticipated she might throw up again.

What Jenna did not anticipate was that the assessment would begin somewhere more fundamental: examining the biological foundations that shape how the body responds to stress.

Sleep. Daily routines. Caffeine intake. Hydration. Movement. Even blood tests.

Like many people seeking help for panic attacks, Jenna assumed therapy would focus mainly on her thoughts, behaviours, and fears. Many people now research treatment options online before beginning therapy, and when they do, cognitive-behavioural methods such as interoceptive exposure are often presented as key evidence-based interventions, though they can also appear challenging at first.

What Jenna did not expect was that we would begin somewhere safer and more stabilising.

In the early sessions, rather than immediately exploring painful memories or emotional narratives, the work focused on regulation, restoring physiological balance through better sleep, movement, and nutritional habits.

The deeper personal stories would come later. Timing in NA-CBT is everything.

This approach reflects a core principle of NeuroAffective-CBT: when physiological arousal remains chronically elevated, emotional processing becomes far more difficult. Stabilising the body first often creates the conditions necessary for deeper psychological work to emerge safely.

Jenna had self-referred for therapy after a sudden episode of dizziness that appeared without warning two months earlier. The sensation was intense and frightening, accompanied by nausea, weakness in her knees, and a powerful fear that she might collapse or lose control. She went to the emergency department, where a full medical assessment was carried out. Neurological and vestibular causes were investigated, but no medical explanation was found.

Although the doctors reassured her that nothing serious had been detected, Jenna did not feel reassured. If anything, the uncertainty intensified her distress.

In the weeks that followed, panic attacks began to occur repeatedly. She developed a growing mistrust of her own body. Ordinary sensations—dizziness, nausea, shifts in breathing—began to feel unpredictable and dangerous. Her attention became increasingly focused inward, scanning constantly for signs that another episode might occur.

Soon the panic spread into daily life. Jenna began avoiding leaving the house alone. Shopping trips felt unsafe unless her husband accompanied her. Her world gradually narrowed as the fear of bodily sensations expanded.

Vomiting episodes also began to appear, usually during periods of intense anticipatory anxiety. These episodes seemed to provide temporary relief from the overwhelming sensations in her body, but they reinforced her belief that something was fundamentally wrong internally.

At the same time, sleep became disrupted. Fatigue increased. The body’s resilience decreased. The more exhausted she became, the more reactive her internal regulation felt.

During one of the early sessions, Jenna used a phrase that captured the essence of her distress:

“My body doesn’t feel safe anymore”.

At first glance, this presentation might seem like a relatively typical panic disorder with agoraphobic avoidance. But as the assessment unfolded, a deeper pattern began to emerge.

Jenna had been raised by a single mother together with three siblings. One memory stood out vividly. She was eight years old when her father left to work abroad and never returned. From that point forward, the emotional and practical responsibilities within the family shifted dramatically. Her mother, struggling with depression, found it difficult to maintain stability at home.

Jenna stepped in.

Even as a child, she assumed responsibilities that extended far beyond ordinary expectations. Helping her siblings became part of daily life, preparing lunches, supporting routines like cleaning and cooking and managing various responsibilities within the household.

Failure was not an option.

Getting things wrong felt dangerous. Someone might suffer if she did.

Looking back, Jenna described that period not as a conscious decision but as something she simply had to do. Over time, a quiet internal rule formed: if she remained alert enough, responsible enough, and careful enough, she could prevent things from going wrong.

The NeuroAffective-CBT formulation known as the Pendulum-Effect helps explain how such internal rules can shape coping patterns across many years.

At the centre of this pendulum system typically lies a powerful core affect—often shame, guilt, or the fear of failing others. Around this core experience, a set of self-protective strategies gradually develops in an attempt to manage the internal threat it creates.

In Jenna’s case, these strategies took three familiar forms. What once began as adaptive coping gradually evolved into self-sabotaging patterns that maintained the very distress they were originally designed to regulate.

One was overcompensation. She became highly vigilant, attentive to details, and constantly alert to potential problems. Missing something important felt unacceptable. Remaining on guard all the time seemed like the safest option.

Another strategy was avoidance. Situations that might create additional stress or draw attention toward her own needs were often postponed or abandoned. Investing time in herself, hobbies, rest, or personal interests, rarely felt justified.

Eventually, these cycles led to capitulation, moments when exhaustion and self-criticism took over. When she could not meet the impossible standards she had set for herself, the internal response was harsh: self-blame, guilt, and a sense that she was failing.

These strategies oscillated continuously—overcompensation, avoidance, and capitulation—like the movement of a pendulum. Each provided temporary relief from the underlying fear of getting things wrong, yet each also reinforced the deeper shame driving the system.

For many years, this pattern functioned quietly in the background of Jenna’s life.

Until her body interrupted it.

When panic attacks appeared, the same pendulum dynamics intensified. Hypervigilance shifted toward internal sensations. Avoidance expanded into everyday life. Exhaustion and self-criticism deepened when symptoms seemed uncontrollable.

This was one of the reasons the therapist introduced the TED framework (Tired–Exercise–Diet) early in the treatment process. Lifestyle interventions in NeuroAffective-CBT are not simply recommendations for general wellbeing. They function as direct interventions within the pendulum system itself.

For someone whose life has been dominated by overcompensation and self-neglect, improving sleep, eating regularly, or creating space for physical movement becomes more than self-care. It becomes a challenge to the internal rule that personal needs must always come last.

In Jenna’s case, stabilising her daily rhythms began to soften the relentless cycle of hypervigilance and exhaustion. Less fatigue meant less physiological reactivity. More predictable routines meant her internal regulation no longer had to remain constantly on guard.

Only once this stabilisation began did the deeper emotional narratives gradually come into view.

And only then did it become clear that Jenna’s panic attacks were not simply about panic.

They were about a system that had spent many years trying not to fail anyone, until eventually the pendulum could no longer keep swinging.

To understand why this happens, we need to look more closely at how panic attacks actually develop inside the body.

Why Panic Attacks Are Sometimes Not Just About Panic

When people experience their first panic attack, it often feels as though something in the body has suddenly gone wrong.

The heart races. Breathing changes. The body may tremble or feel weak. Dizziness appears without warning. Nausea, heat, or a sense of losing control can follow within seconds. Because these sensations are so intense and unfamiliar, many people understandably assume they are experiencing a serious medical emergency.

Jenna’s experience began in exactly this way.

The sudden dizziness that sent her to the emergency department felt like something catastrophic was happening inside her body. Even after medical tests ruled out neurological or vestibular causes, the feeling of danger did not disappear. The absence of a medical explanation did not bring relief, it created uncertainty.

And uncertainty is something the body’s regulatory system does not tolerate well.

From the outside, panic attacks can appear sudden and unpredictable. Yet when we look more closely, they often emerge from an internal system that has been under pressure for a long time.

NeuroAffective-CBT approaches panic from the understanding that emotional distress rarely originates in thoughts alone. Instead, it arises from the interaction between three continuously communicating systems: the body, the brain, and affect, our emotional signalling system.

The body constantly sends signals about internal states, fatigue, hunger, hormonal shifts, blood sugar levels, sleep deprivation, muscle tension, and breathing patterns. The brain interprets these signals and attempts to predict whether the environment is safe or threatening. Affect provides the emotional tone that guides behaviour: fear, shame, anger, safety, and relief.

When these systems are balanced, signals move smoothly between them. The body senses changes, the brain interprets them accurately, and emotions guide appropriate responses.

But when the system becomes dysregulated, those signals can begin to amplify one another.

Fatigue may increase physiological sensitivity. Increased sensitivity can heighten attention toward bodily sensations. Heightened attention can make normal sensations feel unusual or threatening. Once the brain interprets those sensations as danger, the body responds with a rapid stress reaction.

At that point, the panic attack is already underway.

In Jenna’s case, the first episode of dizziness acted like a spark in a system that was already vulnerable. Her autonomic state had spent many years in heightened vigilance, trying to anticipate problems, trying not to miss anything important, trying not to fail the responsibilities she had carried since childhood.

Hypervigilance can be a powerful survival strategy. It helps people remain alert, organised, and prepared. But when the body remains in this state for too long, it becomes increasingly sensitive to internal signals.

Even small fluctuations in breathing, blood pressure, or balance can suddenly feel alarming.

The body begins sending signals of danger not because there is a real external threat, but because the regulatory system has become overly reactive.

Once that cycle begins, panic attacks can develop quickly. The body senses something unusual, the brain interprets it as threat, and the emotional system amplifies the response.

This is why panic attacks often persist even when people know intellectually that nothing medically dangerous is happening.

The mind may understand that the body is safe, but the body’s internal regulation has not yet learned that lesson.

And this is also why treatment that focuses only on thoughts may not always be sufficient.

If the body remains exhausted, overstimulated, sleep deprived, or metabolically unstable, it will continue sending signals that the brain interprets as danger. The emotional system then reacts accordingly.

In other words, the panic attack may be the final expression of a much larger regulatory imbalance.

This was the case for Jenna.

Her panic attacks were not simply the result of catastrophic thinking about bodily sensations. They were emerging from a system that had been operating under prolonged pressure, physiologically, emotionally, and psychologically.

Before the deeper emotional narratives could be explored, her body first needed something much more basic. It needed stabilisation.

And that is why, in the early sessions of therapy, the focus turned toward something Jenna had not expected to discuss at all, how she slept, how she ate, how she moved, and how her body had been carrying the weight of many years of responsibility.

The next step was learning something much harder: how to experience safety again inside her own body.

Learning to Trust the Body Again

Understanding the pendulum was an important step for Jenna.

But understanding alone was not enough.

Her mind could now see the pattern, how vigilance, avoidance, and self-criticism had reinforced one another for years, but her body was still reacting as if danger could appear at any moment. The dizziness, the nausea, the waves of anxiety still felt unpredictable.

And unpredictability is exactly what keeps the nervous system on guard. So the next phase of therapy focused on something very practical: helping Jenna experience safety again inside her own body. This required gently reversing several habits that had developed since the panic attacks began.

One of the most powerful of those habits was constant monitoring of internal sensations. Jenna had become extremely attentive to what was happening inside her body. Small changes in balance, breathing, or stomach sensations immediately triggered concern.

Ironically, this kind of monitoring often intensifies the very sensations people fear. The more attention we place on internal signals, the louder those signals can become.

Part of the work therefore involved gradually shifting Jenna’s attention outward again—toward activities, environments, and everyday experiences—rather than constantly scanning for signs of danger within her body.

At the same time, we began introducing graded exposure.

This did not mean forcing Jenna into overwhelming situations. Instead, it meant carefully testing the predictions her anxiety was making.

For example, one of Jenna’s fears was leaving the house alone. Her mind predicted that if she went out without her husband, she might experience dizziness, lose control, or be unable to cope with panic. Rather than arguing with those predictions, therapy focused on gently testing them.

The first step was simply stepping outside alone for a short walk. Then walking a little farther. Then entering a shop independently. Each step was small enough to remain manageable, but meaningful enough to challenge the belief that she could not cope.

Each successful experience quietly sent a new message to her nervous system:

The body can feel uncomfortable and still be safe.

Another important part of this process involved what psychologists call interoceptive exposure—learning to tolerate bodily sensations that had previously triggered panic.

For Jenna, sensations like dizziness or nausea had become signals of danger. The immediate instinct was to escape them as quickly as possible. In the past, vomiting had sometimes served as a way to relieve the sensation temporarily.

But the relief was short-lived. And each time the behaviour occurred, it reinforced the belief that the sensation itself was intolerable.

Instead, Jenna gradually practiced allowing these sensations to rise and fall without reacting to them. She noticed the dizziness, the changes in breathing, the slight waves of nausea, and remained with them long enough to observe that they eventually passed on their own.

This was not easy at first. But over time something important began to shift. The sensations that once felt catastrophic began to feel simply uncomfortable.

And uncomfortable is very different from dangerous.

The stabilising routines introduced earlier through the TED framework also played an important role during this phase. Better sleep meant her nervous system was less reactive. Regular meals and hydration helped prevent energy fluctuations that could mimic anxiety symptoms. Daily walking continued to strengthen her confidence in movement and balance.

Together, these changes created a more stable physiological foundation against which exposure could work effectively.

Little by little, Jenna began to experience something she had not felt in months. Moments of ordinary life. A walk outside without scanning for danger. A shopping trip completed alone.
An evening of sleep without waking in panic.

These were small victories, but they carried enormous meaning. Each one helped recalibrate a system that had been locked in fear. Gradually, the pendulum that once swung wildly between vigilance, avoidance, and collapse began to slow.

And with that slowing came something else Jenna had not felt in a long time: the sense that her body might once again be a place she could trust.

But the most important change was not simply the disappearance of panic.

The Moment Therapy Almost Changed Direction

Recovery from anxiety rarely follows a straight line.

For Jenna, the first months of therapy had already brought meaningful changes. The panic attacks had stopped. Vomiting episodes had reduced significantly. She was sleeping better, moving more, and gradually testing situations that had once felt impossible.

From the outside, it might have looked as though the hardest part was over.

But around the fifteenth session, something shifted.

During that week Jenna arrived at therapy noticeably distressed. The anxiety had intensified again, and the familiar sensations, dizziness, internal tension, waves of fear, felt closer to the surface than they had for several weeks. Although the panic attacks themselves had not returned, the emotional pressure she was experiencing was unmistakable.

Moments like this can be unsettling in therapy.

When symptoms reappear after progress has been made, it is easy for both therapist and client to wonder whether the improvement was temporary. The mind quickly begins asking uncomfortable questions: Is this working? Should something else be tried?

During that session we discussed the possibility of returning to her psychiatrist for a medication review. Jenna had already been taking escitalopram, and adjusting the medication was a reasonable option to consider if her distress continued to increase.

At first, the suggestion seemed as though it might signal a setback.

But something unexpected happened.

Instead of experiencing the conversation as a sign that therapy was failing, Jenna responded differently. The possibility of adjusting medication appeared to sharpen her awareness of how much progress she had already made. She realised that she did not want to retreat from the work she had been doing.

In that moment, something subtle but important shifted.

Rather than relying solely on external solutions, medication, reassurance, or avoidance, Jenna began to recognise her own role in the recovery process. The exposure exercises, the lifestyle changes, the effort to tolerate difficult sensations: these were not things being done to her. They were actions she had been taking herself.

Paradoxically, the conversation about medication strengthened her sense of responsibility and commitment.

In the sessions that followed, her engagement with the therapeutic work deepened noticeably. Exposure exercises became more consistent. She approached situations with greater confidence, even when anxiety appeared.

Instead of interpreting discomfort as a signal that something had gone wrong, she began to see it as part of the process of retraining her nervous system.

This is an important moment in many therapeutic journeys.

Recovery often accelerates when people move from seeing themselves as passive recipients of treatment to active participants in change. The focus shifts from “How do I make the anxiety disappear?” to “How do I respond differently when anxiety appears?”

For Jenna, this shift marked the beginning of a more stable phase of recovery.

The pendulum that had once swung violently between vigilance, avoidance, and collapse was slowing. The sensations that once felt catastrophic were becoming manageable.

And perhaps most importantly, the sense that her body had betrayed her was gradually being replaced by something new: a quiet but growing confidence that she could handle what her body was feeling.

Closing Reflection

Jenna’s story is not unusual. Many people who experience panic attacks assume the problem lies entirely in anxiety itself. They focus on the frightening sensations in the moment, the racing heart, the dizziness, and the feeling that something is about to go terribly wrong.

But panic often emerges at the intersection of several interacting systems: a body that has become physiologically over-reactive, an emotional system shaped by years of responsibility or vulnerability, and a mind that tries to make sense of sensations that suddenly feel unfamiliar.

When these systems fall out of balance, panic can become the language through which the nervous system signals distress. What Jenna’s journey reminds us is that recovery does not always begin where people expect. Sometimes it begins with sleep, with nourishment, and with learning to move again without fear. Sometimes it begins with understanding the patterns that quietly shaped our responses to stress long before anxiety appeared.

And sometimes, as the pendulum slows, people discover something they had not realised they had lost: the ability to trust their own body again.

For clinicians, Jenna’s case also illustrates an important point. Panic disorder can rarely be understood purely as a cognitive problem. When physiological instability, shame-based self-evaluation, and behavioural avoidance interact, treatment may need to address all three systems simultaneously.

For those experiencing panic themselves, the message is equally important.

The sensations may feel overwhelming. They may feel unpredictable. They may even feel dangerous.

But very often, they are the nervous system’s attempt to adapt.

And with the right support, the same system that once generated panic can learn something new: how to settle, how to rebalance, and how to move forward again.

This article does not aim to redefine the established understanding of panic disorder. Instead, it suggests that in some cases panic attacks may represent the final expression of earlier experiences marked by emotional neglect, which can contribute to broader regulatory imbalances involving physiological arousal, emotional signalling, and cognitive interpretation.

Traditional CBT offers well-established and effective models for the treatment of panic disorder. However, Jenna’s story illustrates how panic symptoms can sometimes emerge from earlier life experiences marked by prolonged stress, hypervigilance, and role reversal within the family. Standard CBT approaches typically focus on the maintenance of panic symptoms in the present and may explore early experiences only when they are directly linked to current beliefs or behaviours.

Contemporary CBT protocols for panic disorder commonly incorporate excellent techniques such as cognitive restructuring and interoceptive exposure, originally developed within the Panic Control Treatment model of David H. Barlow and colleagues, alongside cognitive approaches such as the catastrophic misinterpretation model proposed by David M. Clark.

Over time, however, prolonged patterns of stress and self-regulation can contribute to dysregulation across physiological, affective, and cognitive systems. Restoring balance within this body–brain–affect network can gradually transform how anxiety is experienced and regulated.

In this sense, treating panic may sometimes require more than addressing fear itself, it may require accepting a painful history and helping the body, the mind, and the emotional system learn how to work together again.

Further reading:

Barlow, D.H. (2002) Anxiety and its disorders: The nature and treatment of anxiety and panic. 2nd edn. New York: Guilford Press.

Barlow, D.H., Craske, M.G. and Meadows, E.A. (2000) ‘Mastery of your anxiety and panic: Therapist guide’, 3rd edn. New York: Oxford University Press.

Barlow, D.H., Gorman, J.M., Shear, M.K. and Woods, S.W. (2000) ‘Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial’, Journal of the American Medical Association, 283(19), pp. 2529–2536.

Barrett, L.F. (2017) ‘The theory of constructed emotion: An active inference account of interoception and categorization’, Social Cognitive and Affective Neuroscience, 12(1), pp. 1–23.

Clark, D.M. (1986) ‘A cognitive approach to panic’, Behaviour Research and Therapy, 24(4), pp. 461–470.

Clark, D.M. (1997) ‘Panic disorder and social phobia’, in Clark, D.M. and Fairburn, C.G. (eds.) Science and practice of cognitive behaviour therapy. Oxford: Oxford University Press, pp. 121–153.

Craske, M.G. and Barlow, D.H. (2007) ‘Mastery of your anxiety and panic: Therapist guide’, 4th edn. New York: Oxford University Press.

Hirsch, C.R. and Mathews, A. (2019) ‘Approaching cognitive behaviour therapy for generalized anxiety disorder from a cognitive process perspective’, Frontiers in Psychiatry, 10, p. 796.

McEwen, B.S. (2007) ‘Physiology and neurobiology of stress and adaptation: Central role of the brain’, Physiological Reviews, 87(3), pp. 873–904.

Mirea, D. (2018) NeuroAffective-CBT®: Advancing the frontiers of cognitive-behavioural therapy. Available at: https://neuroaffectivecbt.com/2018/07/24/describing-na-cbt/ (Accessed: March 2026).

Mirea, D. (2019) The underlayers of NeuroAffective-CBT®. Available at: https://neuroaffectivecbt.com/2018/10/19/the-underlayers-of-neuroaffective-cbt/ (Accessed: March 2026).

Mirea, D. (2025) The transdiagnostic application of NeuroAffective-CBT®: A case study of chronic stress and burnout. Available at: https://neuroaffectivecbt.com (Accessed: March 2026).

National Institute for Health and Care Excellence (2020) Generalised anxiety disorder and panic disorder in adults: Management (CG113). London: NICE.

Confidentiality note: Jenna is a composite clinical vignette based on several cases. Identifying details have been altered to protect confidentiality.