Panic Attacks and Panic Disorder

What is a panic attack?

A panic attack is an intense wave of fear characterized by its unexpectedness and debilitating, immobilizing intensity. Your heart pounds, you can’t breathe, and you may feel like you’re dying or going crazy. Panic attacks often strike out of the blue, without any warning, and sometimes with no clear trigger. They may even occur when you’re relaxed or asleep.

A panic attack may be a one-time occurrence, although many people experience repeat episodes. Recurrent panic attacks are often triggered by a specific situation, such as crossing a bridge or speaking in public—especially if that situation has caused a panic attack before. Usually, the panic-inducing situation is one in which you feel endangered and unable to escape, triggering the body’s fight-or-flight response.

You may experience one or more panic attacks, yet be otherwise perfectly happy and healthy. Or your panic attacks may occur as part of another disorder, such as panic disorder, social phobia, or depression. Regardless of the cause, panic attacks are treatable. There are strategies you can use to reduce or eliminate the symptoms of panic, regain your confidence, and take back control of your life.

Panic attack signs and symptoms

The signs and symptoms of a panic attack develop abruptly and usually reach their peak within 10 minutes. They rarely last more than an hour, with most ending within 20 to 30 minutes. Panic attacks can happen anywhere and at any time. You may have one while you’re in a store shopping, walking down the street, driving in your car, or even sitting on the couch at home.

Panic attack symptoms include:

• Shortness of breath or hyperventilation.
• Heart palpitations or racing heart.
• Chest pain or discomfort.
• Trembling or shaking.
• Choking feeling.
• Feeling unreal or detached from your surroundings.
• Sweating.
• Nausea or upset stomach.
• Feeling dizzy, light-headed, or faint.
• Numbness or tingling sensations.
• Hot or cold flashes.
• Fear of dying, losing control, or going crazy.

Is it a heart attack or a panic attack?

Most of the symptoms of a panic attack are physical, and many times these symptoms are so severe that you may think you’re having a heart attack. In fact, many people suffering from panic attacks make repeated trips to the doctor or the emergency room in an attempt to get treatment for what they believe is a life-threatening medical problem. While it’s important to rule out possible medical causes of symptoms such as chest pain, elevated heart rate, or difficulty breathing, it’s often panic that is overlooked as a potential cause—not the other way around.

Panic attack vs. anxiety attack

People often use “anxiety attack” and “panic attack” interchangeably. However, the terms can mean very different things. One key difference is that the Diagnostic and Statistical Manual of Mental Disorders (DSM) doesn’t list anxiety attacks as a condition. There’s no formal definition or diagnosis criteria for an anxiety attack.

Anxiety attacks may refer to distress that has built up over time due to consistent stressors or fears of the future. Imagine that you’ve been stressed about your workplace responsibilities all week, and now your feelings have reached a boiling point. During an anxiety attack, life can feel overwhelming. You might experience tension, irritability, restlessness, or lack of focus.

Panic attacks, on the other hand, are always sudden and often come with symptoms like derealization or a feeling of approaching doom. Panic attacks typically pass within 30 minutes, while an anxiety attack—although less intense—may last minutes or hours. 

Signs and symptoms of panic disorder

While many people experience just one or two panic attacks without further episodes or complications—and there’s little reason to worry if that’s you—some people go on to develop panic disorder. Panic disorder is characterized by repeated panic attacks, combined with major changes in behavior or persistent anxiety over having further attacks.

You may be suffering from panic disorder if you:

• Experience frequent, unexpected panic attacks that aren’t tied to a specific situation.
• Worry a lot about having another panic attack.
• Are behaving differently because of the panic attacks, such as avoiding places where you’ve previously panicked.

While a single panic attack may only last a few minutes, the effects of the experience can leave a lasting imprint. If you have panic disorder, the recurrent panic attacks take an emotional toll. The memory of the intense fear and terror that you felt during the attacks can negatively impact your self-confidence and cause serious disruption to your everyday life. Eventually, this leads to the following panic disorder symptoms:

Anticipatory anxiety – Instead of feeling relaxed and like your normal self in between panic attacks, you feel anxious and tense. This anxiety stems from a fear of having future panic attacks. This “fear of fear” is present most of the time, and can be extremely disabling.

Phobic avoidance – You begin to avoid certain situations or environments. This avoidance may be based on the belief that the situation you’re avoiding caused a previous panic attack. Or you may avoid places where escape would be difficult or help would be unavailable if you had a panic attack. Taken to its extreme, phobic avoidance becomes agoraphobia.

Nocturnal panic attacks

During a nocturnal panic attack, you wake up while experiencing a sudden episode of fear and distress. These attacks occur while you’re in stage 2 or stage 3 of non-REM sleep, and generally only last between two and eight minutes. However, the unpleasantness of the experience can make it difficult for you to go back to sleep or even lead you to try to avoid sleep.

Nocturnal panic attacks are common in people with panic disorder, affecting more than half of all patients. Some experts theorize that these types of panic attacks are caused by a fear of uncertainty or vulnerability. In other words, you feel anxious about your inability to react to threats while asleep.

Nocturnal panic attacks vs. nightmares and night terrors

Although nocturnal panic attacks may seem similar to nightmares or sleep terrors, they are distinct issues and occur at different stages of sleep.

Night terrors involve episodes of screaming and flailing while asleep. When you have a night terror, you likely won’t remember the experience when you wake up later. On the other hand, if you have a nocturnal panic attack, you’ll wake up during the experience.

Nightmares are bad dreams that occur during rapid eye movement (REM) sleep. You can likely recall a few nightmares you’ve had in your life. Nocturnal panic attacks don’t involve a dreaming experience.

Panic disorder with agoraphobia

Agoraphobia was traditionally thought to involve a fear of public places and open spaces. However, it is now believed that agoraphobia develops as a complication of panic attacks and panic disorder. Although it can develop at any point, agoraphobia usually appears within a year of your first recurrent panic attacks.

If you’re agoraphobic, you’re afraid of having a panic attack in a situation where escape would be difficult or embarrassing. You may also be afraid of having a panic attack where you wouldn’t be able to get help. Because of these fears, you start avoiding more and more situations.

For example, you may begin to avoid:

• Crowded places such as shopping malls or sports arenas.
• Cars, airplanes, subways, and other forms of travel.
• Social gatherings, restaurants, or other situations where it would be embarrassing to have a panic attack.
• Physical exercise in case it triggers panic.
• Certain food or drinks that could provoke panic, such as alcohol, caffeine, sugar, or specific medications.
• Going anywhere without the company of someone who makes you feel safe. In more severe cases, you might only feel safe at home.

Causes of panic attacks and panic disorder

Although the exact causes of panic attacks and panic disorder are unclear, the tendency to have panic attacks runs in families. There also appears to be a connection with major life transitions such as graduating from college and entering the workplace, getting married, or having a baby. Severe stress, such as the death of a loved one, divorce, or job loss can also trigger panic attacks.

Panic attacks can also be caused by medical conditions and other physical causes. If you’re suffering from symptoms of panic, it’s important to see a doctor to rule out the following possibilities:

1. Mitral valve prolapse, a minor cardiac problem that occurs when one of the heart’s valves doesn’t close correctly.
2. Hyperthyroidism (overactive thyroid gland).
3. Hypoglycemia (low blood sugar).
4. Stimulant use (amphetamines, cocaine, caffeine).
5. Medication withdrawal.

Self-help tips for panic attacks

No matter how powerless or out of control you may feel about your panic attacks, it’s important to know that there are many things you can do to help yourself. The following self-help techniques can make a big difference to helping you overcome panic:

Tip 1: Learn about panic and anxiety

Simply knowing more about panic can go a long way towards relieving your distress. Read up on anxiety, panic disorder, and the fight-or-flight response experienced during a panic attack. You’ll learn that the sensations and feelings you have when you panic are normal and that you aren’t going crazy.

Become familiar with the sensations. Panic is often driven by discomfort with physical sensations. For example, you might worry that your chest tightness is actually a heart attack. That kind of catastrophizing—jumping to the worst possible conclusion—can propel you into a panic attack.

Learning more about normal physical sensations, including heart palpitations, tight throat, nausea, tremors, and headaches, can help maintain a more grounded perception. It’s also important to recognize that the mental sensations, such as fear of losing control and derealization, are temporary states.

Tip 2: Experiment with relaxation techniques

When practiced regularly, activities such as yoga, meditation, and progressive muscle relaxation strengthen the body’s relaxation response—the opposite of the stress response involved in anxiety and panic. And not only do these relaxation practices promote relaxation, but they also increase feelings of joy and equanimity.

Learn how to control your breathing. Hyperventilation brings on many sensations (such as lightheadedness and tightness of the chest) that occur during a panic attack. Deep breathing, on the other hand, can relieve the symptoms of panic. By learning to control your breathing, you can calm yourself down when you begin to feel anxious. And if you know how to control your breathing, you’re also less likely to create the very sensations that you’re afraid of.

Some breathing exercises to try

Paced breathing. Slowly inhale through your nose for two to four seconds, expanding your chest and belly as you pull in the air. Exhale through your mouth. Aim to make your exhale about twice as long as your inhale. Repeat this several times.

Cyclic sighing. Inhale deeply through your nose. Take a second, shorter inhale, further filling your lungs. Exhale slowly through your mouth. Repeat this exercise for five minutes.

Tip 3: Reframe your relationship to panic

In the book “DARE: The New Way to End Anxiety,” Barry McDonagh offers a four-step process for handling anxiety and panic. The process, DARE, isn’t about reaching a state of calm but rather adopting a new mindset toward your symptoms.

Defuse. Often, panic is escalated by negative “what if” statements, such as “What if I’m having a heart attack?” So, when you feel panic attack sensations beginning, say, “So what? This is harmless.” Or rely on a more personalized coping statement, such as, “The last panic attack I had didn’t kill me.”

Allow. Practice accepting the symptoms, even though they’re unpleasant. The shaking, the rapid heartbeat, the sense of detachment—know that it’s all the result of a temporary flood of adrenaline.

Run towards it. Dare the symptoms to intensify. Tell yourself that the adrenaline is exciting rather than threatening. Think of this as a form of exposure therapy. You’re intentionally inviting in the sensations that alarm you so you can discover how harmless they actually are.

Engage. Once the adrenaline begins to subside, ground yourself in another activity. Whether it’s a conversation with your friend or a walk around the neighborhood, try to focus entirely on your current experience. This keeps you from dwelling on the panic and pulls you back into the present moment. You might still feel a little shaky from the experience, but acknowledge the shaking as a natural reaction.

Tip 4: Make time for self-care

Certain self-care habits can help reduce your overall anxiety levels. This could, in turn, reduce the severity of panic attacks or help you better cope with them.

Exercise regularly. Exercise is a natural anxiety reliever so try to get moving for at least 30 minutes on most days (three 10-minute sessions is just as good). Rhythmic aerobic exercise that requires moving both your arms and legs—like walking, running, swimming, or dancing—can be especially effective.

Get enough restful sleep. Insufficient or poor quality sleep can make anxiety worse, so try to get seven to nine hours of restful sleep a night. If sleeping well is a problem for you, these tips to getting a good night’s sleep can help.

Avoid smoking, alcohol, and caffeine. These can all provoke panic attacks in people who are susceptible. If you need help to kick the cigarette habit, see How to Quit Smoking. Also, be careful with medications that contain stimulants, such as diet pills and non-drowsy cold medications.

Tip 5: Find the right support

Connect face-to-face with family and friends. Symptoms of anxiety can become worse when you feel isolated, so reach out to people who care about you on a regular basis. If you feel that you don’t have anyone to turn to, explore ways to meet new people and build supportive friendships.

Join a support group. Friends and family members can offer comfort but, unless they also struggle with panic disorder, they might not fully understand what you’re going through. Consider joining a support group, either in-person or online, for people with anxiety disorders, panic disorder, or panic attacks. Not only can the members relate to your experiences, but they may also share coping techniques and strategies that work for them.

Treatment for panic attacks and panic disorder

The most effective form of professional treatment for tackling panic attacks, panic disorder, and agoraphobia is therapy. Even a short course of treatment can help.

Cognitive behavioral therapy focuses on the thinking patterns and behaviors that are sustaining or triggering your panic attacks and helps you look at your fears in a more realistic light. For example, if you had a panic attack while driving, what is the worst thing that would really happen? While you might have to pull over to the side of the road, you are not likely to crash your car or have a heart attack. Once you learn that nothing truly disastrous is going to happen, the experience of panic becomes less terrifying.

Exposure therapy for panic disorder allows you to experience the physical sensations of panic in a safe and controlled environment, giving you the opportunity to learn healthier ways of coping. You may be asked to hyperventilate, shake your head from side to side, or hold your breath. These different exercises cause sensations similar to the symptoms of panic. With each exposure, you become less afraid of these internal bodily sensations and feel a greater sense of control over your panic.

Exposure therapy for panic disorder with agoraphobia includes exposure to the situations you fear and avoid is also included in treatment. As in exposure therapy for specific phobias, you face the feared situation until the panic begins to go away. Through this experience, you learn that the situation isn’t harmful and that you have control over your emotions.

Medication for panic attacks and panic disorder

Medication can be used to temporarily control or reduce some of the symptoms of panic disorder. However, it doesn’t treat or resolve the problem. Medication can be useful in severe cases, but it should not be the only treatment pursued. Medication is most effective when combined with other treatments, such as therapy and lifestyle changes, that address the underlying causes of panic disorder.

Medications used may include:

Antidepressants. It takes several weeks before antidepressants begin to work, so you have to take them continuously, not just during a panic attack.

Benzodiazepines. These are anti-anxiety drugs that act very quickly (usually within 30 minutes to an hour). Taking them during a panic attack can provide rapid relief of symptoms.

How to help someone having a panic attack

Seeing a friend or loved one suffering a panic attack can be frightening. Their breathing may become abnormally fast and shallow, they could become dizzy or light-headed, tremble, sweat, feel nauseous, or think they’re having a heart attack. No matter how irrational you think their panicked response to a situation is, it’s important to remember that the danger seems very real to your loved one. Simply telling them to calm down or minimizing their fear won’t help. But by helping your loved one ride out a panic attack, you can help them feel less fearful of any future attacks.

Stay calm yourself. Being calm, understanding, and non-judgmental will help your loved one’s panic subside quicker.

Focus your loved one on their breathing. Find a quiet place for your friend to sit and then guide them to take slow, deep breaths for a few minutes.

Do something physical. Together, raise and lower your arms or stamp your feet. It can help to burn off some of your loved one’s stress.

Get your friend out of their own head by asking them to name five things around them or talking soothingly about a shared interest.

Encourage your loved one to seek help. Once the panic attack is over, your loved one may feel embarrassed about having an attack in front of you. Reassure them and encourage them to seek help for their anxiety.