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Panic disorder and telehealth psychology in Sydney: what it is, how treatment works, and what to expect

Panic attacks are among the most distressing experiences a person can have. If you have been having them — and especially if you are now worried about having more, or have started avoiding situations because of them — this guide explains what panic disorder is, how psychologists treat it, and how telehealth fits into that.

What is a panic attack?

A panic attack is a sudden surge of intense fear or discomfort that peaks within minutes and involves four or more of the following symptoms:

• Racing or pounding heartbeat (palpitations)
• Sweating
• Trembling or shaking
• Shortness of breath or a feeling of being smothered
• Chest pain or tightness
• Nausea or stomach distress
• Dizziness, lightheadedness, or feeling faint
• Chills or hot flushes
• Numbness or tingling sensations
• Derealization (the world feeling unreal) or depersonalization (feeling detached from yourself)
• Fear of losing control or "going crazy"
• Fear of dying

The symptoms appear suddenly and are frightening partly because they mimic the signs of a heart attack or serious medical emergency. Many people experiencing their first panic attack go to an emergency department — this is understandable and not a sign of weakness. The body sensations are real, intense, and overwhelming; what distinguishes them from a cardiac event is that they are driven by the autonomic nervous system in the absence of a physical danger.

Panic attacks can be "expected" (triggered by a specific situation, object, or cue) or "unexpected" (arriving with no obvious trigger). Unexpected panic attacks are a hallmark feature of panic disorder. They can occur during the day or, less commonly, at night while asleep (nocturnal panic attacks).

What is panic disorder?

Not everyone who has had a panic attack has panic disorder. Panic disorder is a specific clinical presentation that involves:

• Recurrent unexpected panic attacks
• At least one month of at least one of the following following an attack:
  • Persistent worry about having more panic attacks ("anticipatory anxiety")
  • Worry about the implications or consequences of the attacks (e.g. believing they signal heart disease, that you are "going crazy," or will lose control)
  • A significant change in behaviour related to the attacks — such as avoiding exercise, certain foods, or situations perceived as associated with attacks

The behavioural change component is important. When people start modifying their lives to manage the fear of future panic attacks — avoiding public transport, avoiding crowds, avoiding being alone, avoiding exercise because it raises heart rate — this is when panic disorder often begins to significantly impact day-to-day functioning. In more severe cases, the avoidance broadens into agoraphobia, discussed further below.

What causes panic disorder?

Panic disorder is understood to involve an interaction of biological and psychological factors. Research has identified several components:

The role of the autonomic nervous system

The autonomic nervous system (ANS) governs the body's fight-or-flight response — heart rate, breathing, blood pressure, sweating, and so on. In panic disorder, the ANS becomes hyperactivated by internal cues (body sensations) rather than external threats. Elevated interoceptive sensitivity — heightened awareness of and sensitivity to internal body signals — is a well-established feature of panic disorder.

The cognitive model

The dominant psychological model of panic disorder was developed by David Clark and colleagues in the 1980s and remains central to treatment today. It proposes a vicious cycle:

1. A trigger (internal or external) leads to a brief sense of threat or physical sensation.
2. The person notices the sensation and catastrophically misinterprets it — for example, interpreting a racing heart as evidence of a heart attack, or dizziness as evidence of an imminent faint or stroke.
3. This misinterpretation produces anxiety, which in turn intensifies the physical sensations.
4. The intensified sensations confirm the catastrophic interpretation, spiralling into a full panic attack.

Safety behaviours — sitting down when dizzy, placing a hand on the chest when the heart races, gripping the wall when lightheaded — provide momentary relief but prevent disconfirmation of the catastrophic belief, maintaining the cycle.

Avoidance

Avoidance of situations or sensations associated with panic attacks reduces short-term distress but prevents the nervous system from learning that the sensations are not dangerous. Over time, avoidance tends to broaden and worsen the disorder.

What is agoraphobia and how does it relate to panic disorder?

Agoraphobia involves fear and avoidance of situations where escape might be difficult, or where help would be unavailable if a panic attack occurred. Common agoraphobic situations include:

• Public transport (trains, buses, ferries)
• Shopping centres, supermarkets, and other crowded public spaces
• Cinemas, theatres, and events where leaving would be conspicuous
• Open spaces (parks, wide streets)
• Being in a car (particularly as a passenger, or in a tunnel)
• Being alone outside the home, or being alone at home
• Queues, particularly when escape would be slow

Agoraphobia often develops as a secondary response to panic disorder — people start to associate places where attacks have occurred (or where help seems unavailable) with danger, and progressively restrict their world to reduce the perceived risk of another attack. In severe cases, people can become housebound or extremely restricted in their activities.

Agoraphobia can also occur without a history of panic attacks or panic disorder. When both are present, treatment addresses both through exposure work.

How do psychologists treat panic disorder?

Cognitive Behavioural Therapy (CBT) is the most extensively researched psychological treatment for panic disorder and is considered first-line by clinical guidelines. Treatment typically involves several components, which a psychologist will tailor to your specific presentation.

Psychoeducation

Understanding what is happening physiologically during a panic attack is a core early step. When people understand that a racing heart is a normal physiological response (the body preparing for fight or flight), not a sign of cardiac arrest, the catastrophic interpretation begins to lose its grip. Psychoeducation about the role of hyperventilation in producing symptoms like tingling and dizziness is also typically included.

Breathing retraining

Hyperventilation (over-breathing, often via shallow upper-chest breathing) reduces carbon dioxide levels in the blood and produces many symptoms that are prominent in panic attacks — tingling in the hands and face, dizziness, lightheadedness, a feeling of unreality. Controlled breathing techniques help to interrupt this process. These are tools for managing acute distress, not a cure; they are most useful in combination with the cognitive and exposure work.

Cognitive restructuring

This involves working with a psychologist to identify, examine, and modify catastrophic misinterpretations of physical sensations. For example: "My heart is racing — is this really evidence of a heart attack, or is it the normal response of a heart to adrenaline?" Evidence is examined, alternative explanations considered, and over time the automatic catastrophic thought loses its automatic quality. This is not positive thinking; it is guided re-evaluation of the evidence.

Interoceptive exposure

Interoceptive exposure is considered one of the most powerful components of CBT for panic disorder. It involves deliberately inducing mild, brief body sensations similar to those in a panic attack — under controlled conditions — to build tolerance and reduce fear of the sensations themselves.

Common interoceptive exposure exercises include:

• Spinning in a chair (to induce dizziness)
• Breathing through a narrow straw or with nostrils pinched (to induce shortness of breath)
• Running in place or doing jumping jacks (to induce elevated heart rate)
• Tensing muscles or holding breath (to induce pressure sensations)
• Staring at a bright light and then at a plain surface (to induce visual disturbance)

Each exercise is done for a brief period (often 30 to 90 seconds), followed by monitoring the sensations, challenging any catastrophic thoughts that arise, and allowing the anxiety to subside. Repeated practice teaches the nervous system that the sensations, while uncomfortable, are not dangerous — and the fear response progressively diminishes.

These exercises are done by the person themselves, guided by the psychologist. Because they are performed in the person's own environment, they are well-suited to telehealth delivery.

Situational exposure (for avoidance and agoraphobia)

Where avoidance of situations has developed, graduated exposure to those situations is added. A hierarchy of feared situations is built collaboratively, starting with lower-fear situations and working progressively toward higher-fear ones. This is done in real life (not via telehealth), though the planning, debriefing, and support occur within sessions.

Relapse prevention

The final stage of treatment involves consolidating what has been learned, identifying early warning signs of relapse, and developing a clear plan for managing any future increase in anxiety or panic attacks — usually without returning to avoidance.

Can telehealth psychology treat panic disorder?

Research supports CBT for panic disorder delivered via videoconference as effective for most people with this presentation. Telehealth suits panic disorder well for several reasons:

• Interoceptive exposure is home-based anyway. Unlike some exposure work that requires a particular physical environment, interoceptive exposure exercises are done in everyday settings and can be easily guided via video.
• Reduced barrier to accessing treatment. Some people with panic disorder and agoraphobia have difficulty accessing a clinic in person — telehealth removes that barrier for initial and ongoing sessions.
• Normalised environment for learning. Being in a familiar, controlled environment during sessions may help some people engage more readily with exposure exercises than they might in a clinical consulting room.

There are situations where in-person delivery may be preferable — for example, where practitioner assessment of physical symptoms is relevant in early sessions, or where severe agoraphobia requires a more intensive in vivo support component. A psychologist will discuss what approach is best suited to your situation.

Medicare rebates apply equally to telehealth psychology sessions as to in-person sessions, provided you have a current Mental Health Treatment Plan. See our guide to costs and Medicare rebates.

What to look for in a psychologist for panic disorder

When considering a psychologist for panic disorder, look for:

• AHPRA registration. Any practitioner calling themselves a "psychologist" must be registered with AHPRA (the Australian Health Practitioner Regulation Agency). You can verify registration at ahpra.gov.au.
• Specific experience with anxiety and panic. While CBT is a general skill, psychologists who have worked extensively with anxiety and panic presentations will have refined their use of interoceptive exposure and are more likely to have a clear, structured protocol.
• CBT training. CBT and exposure-based approaches are the evidence base for panic disorder. Ask whether the psychologist uses these approaches and what treatment typically looks like.
• Clarity about what happens in sessions. A good psychologist will explain the treatment rationale before beginning and will set realistic expectations about timelines and what the work involves.

You can use our directory of telehealth psychologists for anxiety in Sydney to filter by specialty and find practitioners with panic and anxiety experience.

How to get started

1. Get a Mental Health Treatment Plan (MHTP) from your GP. This allows you to access up to 10 rebated psychology sessions per calendar year. You do not need to describe your symptoms in clinical language — tell your GP what you have been experiencing in plain terms. See our guide to getting a Mental Health Treatment Plan.
2. Look for a psychologist with anxiety and panic experience who offers telehealth. Our directory lists registered practitioners in Sydney who offer telehealth for anxiety. Check their bios, specialties, and availability.
3. Book an initial assessment session. The first session is usually an assessment — the psychologist will ask about your history, what you have been experiencing, and what you are hoping to work toward. This is also an opportunity to ask questions. You are not committing to an ongoing arrangement by attending a first session.

Frequently asked questions