Photo by Mark Henley/Panos
A panic attack is a dramatic false alarm clanging in body and mind. Recognising this is the first step to dialling it down
by Christian Jarrett
Photo by Mark Henley/Panos
is deputy editor of Psyche. A cognitive neuroscientist by training, his books include The Rough Guide to Psychology (2011) and Great Myths of the Brain (2014). His next, Be Who You Want: Unlocking the Science of Personality Change, will be published in 2021.
Edited by Sally Davies
Evolution has equipped our bodies with an emergency response when faced with extreme danger: extra blood rushes to our muscles, vision is narrowed, breathing speeds up and digestion shuts down. The body is primed to fight or flee. These changes can be life-saving, but when there’s a false alarm and the fight-or-flight response is triggered unnecessarily or out of proportion to the threat, we can experience a ‘panic attack’. The UK-born author and film-maker Jon Ronson, who has lived with anxiety for decades, likens the experience to hanging on to a cliff by your fingers.
Between 15 to 30 per cent of us will go through this at least once in our lifetimes – and, as you know if you’ve ever had one, such episodes can be terrifying. The intensity of the sensations can lead you to believe you’re dying or going crazy or losing control. The heart pounds and your hands or entire body might tremble. You can experience a dry mouth, sweating, nausea or dizziness. Often, you’re seized by an overwhelming urge to escape.
For some people, the trigger is obvious – the claustrophobic crush of an overcrowded train carriage, or an email bearing bad news. For others, the panic rises as if from nowhere, perhaps precipitated by a shortness of breath, a hot flush or some other bodily sensation. When the mind catastrophically misinterprets these feelings, it can activate the brain’s survival reflexes. The situation then spirals, so that the uncomfortable physiological sensations fuel yet more alarm and fear. The entire episode can last anywhere from a few minutes to more than an hour (although that’s rare). Usually, the panic reaches its crescendo within 10 minutes before subsiding.
The more intense and unpleasant an initial episode, the greater the risk that you’ll later develop a panic disorder – that is, recurring attacks and a fear of them. So knowing what to do in the event of a panic attack isn’t just useful for preventing distress in the moment, but also for maintaining your wellbeing over the longer term.
Understand the panic cycle
In the grip of a panic attack, the body produces three interconnected reactions: catastrophic thoughts (eg, I can’t breathe, I’m going to die); physical symptoms (eg, increased heart rate); and a powerful urge to escape. These reactions typically escalate in a self-perpetuating cycle – fearful thoughts increase the bodily symptoms, which fuels the fear, which drives the urge to escape.
The physiological changes associated with panic, such as a racing heart and sweaty palms, are driven by the fight-or-flight centre in the brain stem, known technically as the ‘autonomic nervous system’ (ANS). The ANS has two components that are in constant opposition: the sympathetic nervous system, which gears you up to fight or flee via the release of adrenaline and other hormones, and the parasympathetic system, which calms the body and is more strongly activated when you are feeling relaxed.
The first way to break the panic cycle is to change how you interpret stress-related bodily symptoms, such as a racing heart and trembling hands, so that you restore balance to your ANS and allow the calming parasympathetic system to increase its influence. For some people, learning a little about the basic physiology of the fight-or-flight response is enough to help make their own reaction seem less scary, and thereby prevent a panic episode from escalating.
‘Panic attacks typically develop and are aggravated because you think normal and non-dangerous anxiety symptoms will end in a catastrophe such as a heart attack, stroke or madness,’ says Asle Hoffart, a schema therapist and cognitive therapist based at the Modum Bad Psychiatric Center in Vikersund, Norway. ‘However, anxiety symptoms are not dangerous, on the contrary, they are part of an alarm reaction that is meant to help you.’ Or, as Kevin Gournay, emeritus professor at the Institute of Psychiatry in London notes drily in a blog post for the No Panic charity, where he is president and founding patron: ‘[F]or 33 years I have seen a very large number of patients with panic attacks. Each and every one of them have suffered a large number of episodes. I cannot remember any patient dying during a panic attack.’
Observe and challenge catastrophic thoughts
If reassurance isn’t enough, you might try challenging your own thoughts when you feel the panic rising. David Barlow, founder and director emeritus of the Center for Anxiety and Related Disorders at Boston University, and his colleague Bethany Harris recommend noticing and substituting your fearful thoughts – such as Get out of here immediately or you may die or go crazy – with more rational ones, for example You are probably a little stressed at the moment but this is a normal emotional response to stress that will be over in a few minutes.
Tune in to your body and environment
As a next step, you can use techniques that calm your body, including controlling your breathing (in a sense, giving your parasympathetic nervous system a helping hand). The rapid and/or deep breathing that is common during a panic attack can lead to hyperventilation – a lack of carbon dioxide in the blood, which in turn can cause dizziness, light-headedness and tingling sensations in your hands and feet – all of which could intensify the attack. ‘By learning to slow down the breathing process to as little as 10 breaths per minute (breathe in through your nose for three seconds and slowly exhale through your mouth for three seconds),’ say Barlow and Harris, ‘these symptoms can be minimised.’
It’s worth practising breathing techniques in advance, rather than waiting to try them out in the middle of an attack. A 2010 study involved teaching people with panic disorder about the effects of hyperventilation and the importance of controlling their breathing: each day for four weeks, the volunteers spent just over 15 minutes breathing more slowly and shallowly, while a basic medical device showed them how this maintained lower levels of carbon dioxide in their blood (thus reducing their risk of hyperventilating). Over the course of the study and a week after, their panic-related symptoms reduced, and their feelings of control over their emotions and aversive events increased.
Another technique to calm your body and help increase your feelings of control is known as ‘grounding’. There are various versions but a popular one is the mindfulness-based 5-4-3-2-1 technique: you note and pay attention to five things you can see, four things you can feel, three things you can hear, two things you can smell and one thing you can taste. The idea of the exercise is to relax you, ground you in the present, and put the brakes on any racing negative thoughts.
Stay put and continue what you were doing
The final and perhaps most important step is to resist fleeing the site of the attack – and even being prepared to return. If you ‘physically or mentally escape or avoid the places, activities, or people associated with panic attacks’, says Joanna Arch, a clinical psychologist at the University of Colorado Boulder, they’re more likely to become a problem. Succumbing to the urge to escape and staying away from the same situation increases the risk that you’ll develop a longterm fear and avoidance of future attacks.
Yet if you stay with the panic episode, rather than running from it, then you’ll learn that the associated physiological sensations aren’t in themselves life-threatening or dangerous – which in turn makes it less likely that your fight-or-flight response will be inappropriately activated and spiral out of control. Panic attacks are ‘less likely to become a problem if, during the panic or after it subsides, you continue to engage with whatever you were doing (so long as it’s safe),’ says Arch.
‘Remember,’ add Barlow and Harris, ‘that a panic attack is a normal reaction that will pass in no more than a few minutes.’
The four steps to alleviating a panic attack:
You might also want to make lifestyle changes to reduce the risk of having a panic attack in the first place:
The four steps above provide a way to self-manage a panic attack – and, for many, this will be enough to ease the discomfort and stop the experience from becoming a longer-term problem. However, some people will find that their problems persist and that it’s necessary to seek the advice of a health professional.
If a physician rules out other possible causes (see below), he or she might prescribe a drug treatment such as a mild sedative, an antidepressant or a betablocker, which is a drug that reduces the body’s fight-or-flight response by blocking the effects of adrenaline. Alternatively, the physician might make a referral to a counsellor or another kind of therapist who can teach relaxation and other coping techniques. If you’re still suffering, you should discuss treatments with your own doctor and find an approach that works for you.
As a counterpoint to mainstream approaches to managing anxiety, some professionals believe that both self-managed relaxation techniques and drug interventions act as a form of avoidance of panic symptoms. As with any kind of fear, avoidance can increase the risk of longer-term disorders taking hold. ‘Trying too hard to resist and suppress catastrophic thoughts and images can sometimes make them worse,’ says Asle.
A potential problem with any techniques intended to suppress panic, explains Nick Wignall, a licenced psychologist at the Cognitive Behavioral Institute of Albuquerque, ‘is that, while you may get some temporary relief, you could be perpetuating the core misattribution of panic – that sympathetic nervous system activation is dangerous, something to be avoided or eliminated. This creates fear learning in which you’re essentially training your amygdalae [part of the brain involved in fear learning] to be more sensitive and reactive to future bouts of anxiety.’
Wignall’s approach is to provide his clients with some basic ‘psychoeducation’ about the body’s stress response. He then helps them pay attention to and describe the very symptoms of panic that they find alarming or uncomfortable, rather than trying to interpret or attenuate them. ‘It’s basically mindfulness plus interoceptive exposure therapy,’ he explains. (The latter involves gradually and deliberately inducing the bodily sensations associated with panic, which is usually best undertaken with the support of a therapist.) ‘Observe what’s happening and be willing to experience it. Just because something feels bad doesn’t mean it’s dangerous. The willingness to have panic is really the only way to teach your brain that it’s not dangerous.’
Asle agrees: ‘Try to observe the thoughts and feelings,’ he says, ‘let them develop as they may, knowing that they ultimately will abate.’
An exercise in acceptance
Learning to accept racing and panic-stricken thoughts is easier said than done. One practical approach comes from a branch of psychotherapy known as acceptance and commitment therapy (ACT), which is one of Arch’s areas of focus. ‘Remind yourself,’ she says, ‘that when the human mind gets scared, such as during a panic attack, its job is to come up with all kinds of reasons why the panic attack is happening and what to do about it – I am going to die. This must mean something terrible and dangerous is happening – and what you should do about it: I can’t stand this a second longer. I must make it stop!’
Arch says these thoughts are simply the mind’s way of reacting when it gets scared – nothing more. Your job is simply to notice the mind doing its job, see it as such, and then get on with whatever you were doing. ‘You can even respond with humour,’ she suggests. ‘Thanks, mind … that’s really what I needed to hear right now. And then draw on your own experience: I’m going to remind myself that you’re just feeling scared, and remember all of those times when I had panic symptoms and survived just fine. I’m going to let you keep doing your job while I keep doing what’s important to me right now (eg, board the plane, go on the date, give the speech, etc).’
One complication is that panic attacks and disorders can exacerbate and interact with underlying health problems, including asthma and heart conditions. Stress and panic symptoms can provoke an asthma attack in some people, for example, which can then cause an even more intense panic. Also, while it’s extremely unlikely that a panic attack will induce a heart attack, panic-related symptoms such as chest pain and breathing difficulties can be indicators of a heart attack. People with diagnosed heart conditions are in fact at increased risk of developing panic disorder – 6 to 10 per cent of them have panic disorder – as are patients with asthma. If you have an underlying health condition and are worried about panic-related symptoms, you should seek professional medical advice.
Psychologists have developed tailored approaches for patients with panic disorder and underlying health problems. For the treatment of cardiac patients with panic disorder, there’s an approach known as PATCHD or ‘panic attack treatment in comorbid heart diseases’ – this involves psychoeducation; mindfulness-based relaxation techniques; gentle exposure to bodily sensations via tailored exercise; together with ‘chest pain action plans’, in which it’s agreed that if any alarming symptoms persist for longer than a pre-agreed period of time (eg, five minutes), the client or someone with them will call an ambulance. Preliminary evidence suggests that this approach can reduce patients’ anxiety and their visits to emergency services based on ‘false alarms’. The authors of the PATCHD programme caution sensibly that more research is needed – but their creative approach gives hope that there are ways to bring relief to people living with panic disorder even in the context of challenging health conditions.