Panic Attacks: Symptoms and Treatments to stop them

Dr Elaine Ryan

Retrain Your Brain®

If you want my help with panic attacks please see my online course

Table of Contents

What is a panic attack?

Panic attacks are distinct episodes of extreme fear that start abruptly and characterised by a wave of physiological hyperarousal, catastrophic thinking (e.g., a belief that you are dying), and a powerful urge to escape. These attacks are so powerful that the person may fear another attack and resort to avoidance of situations they believe may trigger another panic attack.

image of counselling session

Components of panic attacks.

Situational triggers.

Most panic attacks do not appear out of the blue, in that they occur in specific situations and the sufferer expected the attack would happen. The situation where the attack occurred could be a shopping centre, driving a car, public transport or any specific situation that the person may see as a trigger; when exposed to the trigger, the panic can occur. As a result, the person with panic disorder may avoid these situations in the future.

Sudden onset of physiological arousal.

Physiological arousal refers to increased heart rate, reduced digestive activity, and increased blood pressure because of activation of the sympathetic nervous system.

Hypervigilance.

Hypervigilance results in close attention to bodily sensations, which may increase the sensation. This monitoring of sensations is important in the fear-avoidance model, as the increased monitoring and increase in sensation may cause avoidant behaviours in the person. Avoidance is one behaviour that keeps the cycle of panic alive.

The belief that a catastrophe will occur.

People with panic attacks expect the worst. For example, a faster than normal heart rate is a sign that something is wrong with their heart. This catastrophic thinking style is common with panic disorder.

Fear of future panic attacks.

Having a panic attack is an all-consuming, terrifying experience, and, understandably, the person fears having another attack. Fear is a key feature of panic attacks and leads to avoidance.

Safety-seeking behaviours and avoidance.

Panic attacks result in an almost uncontrollable feeling to get away from wherever the attack is happening and avoid the place in the future.

Types of panic attacks.

The DSM-5 (1)notes two categories of panic attacks; unexpected and expected.

Unexpected panic attacks appear to come out of nowhere in that there was no notable trigger, although a 24-hour monitoring study suggested that there were subtle cues that occur before a panic attack takes place. Towards the end of this article, I shall give some tips on how to notice and what to do with early warning signs of panic.

Expected panic attacks are what we call situational panic attacks, in that they usually occur when you are expecting a trigger or are exposed to a trigger, such as shopping, driving or other situation where you have experienced a panic attack before.

Specific places.

People can have panic attacks that occur in specific places, such as

  • shops
  • public transport
  • work
  • driving
  • bed

This list is not exhaustive, and you can add your place or situation to help make this article more personal. 

Why do you end up having a panic attacks in the same places?

If you had a panic attack in a shop and then forgot about it, it may not happen again.

However, most people who experience regular panic attacks change their behaviour following the first attack. They avoid the place it happened out of fear of it happening again. Or they may ask someone to accompany them when shopping in case they need help.

If you cannot avoid the shop or place where you had a panic attack, you might worry excessively before you have to return to the place. This worry creates anticipatory anxiety.

These changes; What you do and how you think affect your brain.

What causes panic attacks?

According to cognitive theory, misinterpretations of bodily responses cause panic attacks.

The individual can perceive changes in physical sensations such as heart rate as threatening and become a trigger for panic. This can become a feedback loop.

For example, Colin noticed an increased heart rate and sweating when travelling on a train. He focused on these symptoms and panicked as he thought he was going to die; both the change in heart rate and travelling on a train can become triggers for Colin, and he may avoid train travel in the future.

People who experience recurrent panic attacks are selectively attending to sensations in their bodies, and any change may be frightening.

This hypervigilance to bodily sensations can increase the physical symptoms, which are then catastrophically interpreted by the individual as a threat, further increasing the symptoms and leading to avoidance and other behavioural changes, which are not helpful with panic disorder in the long run.

How do I know if I have a panic attack?

As the physical symptoms of panic attacks are so extreme, you might fear that you are having a heart attack or dying. Part of the diagnostic process for panic disorder is to have medical conditions ruled out.

Panic attacks have particular signs and symptoms, which are as follows:

What are the symptoms of panic attacks?

Physical symptoms

  • Chest pain
  • Difficult breathing, smothering sensation
  • Numbness, tingling, pins and needles

Emotional symptoms

Do I need to see a doctor?

If you have panic attacks, you have probably already met with your doctor or attended A&E if your attack was severe.

If you have not met with your doctor, I recommend making an appointment to rule out medical health conditions. Once ruled out, your GP will refer you to someone like me, a psychologist, or other mental health professionals to undertake an assessment.

How is panic disorder diagnosed?

Your psychologist will use a manual called the DSM5 to help with diagnosis. DSM5 stands for Diagnostic and Statistical Manual of Mental Disorders, fifth edition.

The psychologist will take a complete history and may perform other assessments to rule out other anxiety disorders.

Once you have a diagnosis, you will have the assurance that the startling physical symptoms you experience result from panic and not a medical emergency.

I had panic disorder myself, and it can take time to accept that there is nothing physically wrong with you.
Your psychologist will then discuss treatment options with you.

How to stop panic attacks.

Recovery involves the following;

  • Reduction in hypervigilance.
  • More balanced thinking to replace catastrophic interpretations of symptoms.
  • Removal of avoidance and other safety-seeking behaviours.

Treatment and self-help.

If you have been diagnosed with panic attacks, your GP will normally refer you for talking therapy, specifically for cognitive behavioural therapy, or they may discuss medication options with you.

Start with self-help.

I recommend a stepped care model of therapy, which means starting small, and, if not successful, moving to the next stage of the model.

Step 1–self-help. This does not have to be my course; you can use self-help books or information freely available on my site or the internet.

Step 2. If self-help was not enough, meet with a therapist for individual therapy.

What does a panic attack feel like?

One minute you are going about your business, and the next, you might break into a sweat, your heart is pounding out of your chest, and it’s getting hard to breathe.

It might feel like someone has placed a cushion over your mouth and nose, where it feels like you are getting smothered or suffocated, even though there is nothing on your face.

Terrified and convinced that you are not breathing, there’s not enough air getting into your lungs.
You check your pulse, and it may be rapid, or you might not feel it at all.

Shaking, sweating and feeling complete and utter terror, you may think (maybe for the first time in your life) that you are dying.
You may have had different symptoms, but if you have had a panic attack, you will relate to what I have just said.

Ending up in the hospital and getting a series of tests, to be told
“It’s okay; there’s nothing wrong with you. You just had a panic attack.”

If you are very accepting of this information, or if it gives you some sort of relief or explanation regarding what has just happened to you, you may never experience an attack again or as severe.

More than likely, though, it is tough for your brain to understand that what you have just experienced is “just a panic attack.”

Panic attacks and fear.
Without fear; your panic attacks will stop.

Any sensation in your body can spark thought processes you would rather not have. You might feel your heart beating and think you will have a heart attack.

Afraid of the sensations in your body. This is one of the most uncomfortable fears. You become terrified of what is happening in your body. Scared when it is happening and living in fear of it happening again.

Afraid to go to bed
If you have panic attacks in your sleep, you wait until they exhaust you before going to bed. When you lie down, you may feel your heart pounding and hear it beating in your ear against the pillow.

All your thought processes are then focused on your heart. Being exhausted, your body relies on adrenaline to keep you going, causing more anxiety.

You get out of bed, and the cycle begins again.

Afraid to go out
You might feel safer at home and be terrified of going outside, worried that you might have a panic attack.

Even thinking about going out can cause you to feel fear.

Afraid to stay at home alone. Being at home alone can be too much for some people. You are left alone with your thought processes and may have nothing to distract you from what is going on in your body and mind.

As your mind is racing, you might not kick back and watch TV or do what you need to do around the house.

There will be nothing in your home that is causing the anxiety.

A habitual response you have developed will cause the anxiety –
– fear of thought processes,
– fear of what may happen,
– fear that there is no one there to help you if you need it.

Your thoughts will keep this going–maintaining the fear.

Panic Attacks take a severe toll on your body. You may well feel physically and emotionally exhausted afterwards and feel “hyper” because of the rush of adrenalin in your body.

With this in mind, it is challenging to “just relax” and accept that there is nothing seriously wrong. More than likely, it is playing on your mind,
“what has just happened to me?”.

If this were your first attack, there would have been a slow build-up of anxiety in your body to cause the anxiety attack.

This will not disappear because someone has informed you that nothing is wrong with you. The high levels of anxiety will still be there.

By the time you have had a few attacks, you may fear having another. You might decide to cope by avoiding the situations that you think may lead to your attacks.

You may not get a break from this in the security of your bed, as many individuals experience attacks in their sleep.

When you retire at night, your heart is pounding, and you are frightened of falling asleep, as waking up in a panic is complete terror.

Jumping out of bed, going through all the symptoms already mentioned, only now it is the middle of the night when everyone else is sleeping.

Panic Attacks, if left untreated, can overshadow every aspect of your life and turn into Panic Disorder.

Panic disorder is an anxiety disorder.

If a mental health professional has advised that you have Panic Disorder, you have repeated anxiety attacks, and when not having an attack, you live in fear of the next one.

You also recognise that you may do things differently since your initial attack.

For example, to cope, you might avoid things. You might bring water everywhere if your mouth or throat becomes dry (as having a dry mouth is a symptom of panic.)

Needing people to come with you when you go out if something happens to you.

Tips

Self-help checklist.

What you think.
Do you worry about getting another panic attack? 
Are your thoughts taken up with;

“How will I cope?”,
“What if I get anxious?”
“I am going crazy?”
“I’m having a heart attack.”

What you feel.
Anxious. On edge. Irritable. Worried.

What you do.
Are there things you do that act as “safety blankets” or “crutches”? These might be bringing water with you every- where in case your mouth is dry.

Do you do quick check-in places to get a route out if you have an attack?
Do you sit nearest the door to get out?
Are you avoiding things?


If the checklist seems familiar to you,
what you are thinking, feeling, and doing are maintaining your panic attacks.

The remaining parts of this article will help you identify early warning signs and how to ground yourself.

Early warning signs of panic.

Even though it can feel like panic attacks come out of the blue, there are usually early warning signs that, with practice, you can learn how to stop a panic attack.

Possible early warning signs include:
feeling a tightness in your chest, noticing a change in your breathing, feeling your heart beat faster.

When you have developed a list of early warning signs, you are better positioned to stop your anxiety from developing.

What to do if you spot your early warning signs of anxiety?

Remind yourself you are experiencing the effects of anxiety and that it will not harm you.

Start a mindfulness exercise such as the following one:
Start by noticing your breath.

This may be difficult at first, but this is why it is called a mindfulness practice.

It does not have to be perfect each time you try it: you practice.

If your breathing feels laboured, fast, or uncomfortable, just notice it, and try not to engage your thought process, as anxiety-related thoughts may increase your anxiety.

Count each out-breath
breathe in, breathe out 1 breathe in, breathe out 2 breathe in, breathe out 3 breathe in, breathe out 4 breathe in, breathe out 5

Repeat this until the number 10 and start again with the number 1 through 10.

Focusing on your breathing with no judgement and letting your thoughts come and go as they please will eventually calm your body and mind.

If you feel other anxiety symptoms while doing this, notice them and keep bringing your attention back to your breathing.

If your heart is racing, just notice it racing, and bring your attention back to counting your out-breaths.

At first, this may feel difficult, but you will lower your anxiety with practice.

This is an excellent exercise to do daily, not just when you feel your early warning signs of anxiety.

Developing a daily practice will help you lower your overall anxiety levels and make you less likely to experience a panic attack.

To calm down, whatever you feel in your body, you need to activate your relaxation response.

Different rates of breathing result in other emotions and feelings in your body.

You breathe too much during a panic attack, resulting in hyper-ventilation.

What happens when you breathe too much?
– Your heart rate speeds up.
– You take in too much oxygen, and your carbon dioxide levels
lower.

This is known as hypocapnic alkalosis–or, more simply put, your blood is too alkaline and makes you
light-headed
dizzy
feel unreal
suffocating or smothering feelings and a host of other symptoms.

When feeling unreal, light-headed and dizzy, you panic, making you feel worse, and your symptoms increase.

Breathing is something that your brain takes care of; it is outside your control.

If you have a panic attack, you breathe more than you should be, and you need to take control.

Taking control of your breathing will allow the anxiety to melt away.
Controlling your breathing will
Calm your heart rate
Restore the carbon dioxide levels, and your uncomfortable symptoms will go away.


How to take control.

If it feels like you are gulping in air or notice that your belly expands when you breathe, you are taking in too much air.

The uncomfortable feeling of panic breathing will make you want to breathe more deeply but don’t.

Your over-breathing is the problem.

Breathe in through your nose, do not gulp.
Breathe out through your mouth as if you were blowing up a balloon. Make sure your exhale is longer than your inhale.

Each time you breathe out, relax your shoulders and let them drop.

Wait for the next breath to come. If you are gulping in air, you start to breathe in before you need to.
Wait
Wait for the next breath to come.

What to do if you control your breathing and your mind is racing?
It is normal to have scary thoughts during a panic attack. Besides taking control of your breathing, you need to ground yourself.
This will take your attention away from your thoughts.

Grounding technique.

Focus on something else. I would recommend focusing on something else in your body, as your body is always with you!

  • – Focus on the soles of your feet.
  • – Shift them about a bit.
  • – How do they feel on the ground?
  • – Walk around, paying attention to your heel coming into contact with the ground, followed by the rest of your foot.
  • By doing this, you are taking your attention away from scary thoughts that add to your anxiety and focusing on something neutral — something real. Your feet are on the floor.
  • Talk Slowly

Talking to yourself slowly will calm down your racing heartbeat, blood pressure, and fear.

There is too much adrenaline in your system, speeding everything up, including your thoughts – slow it down.

Read it slowly if you refer to this guide during a panic attack. It takes practice as you will want to skim through it, but slowing everything down on purpose, is you taking control?

Does all of this sound too simple for you? It may sound simple but remember.

You experience a panic attack because of your sympathetic nervous system; your stress response.

Your brain controls this; you did not choose to activate it.

Controlling your breathing is your choice. You are activating your parasympathetic nervous, your relaxation response, which will restore balance in your body.

Focus on your feet too simple for you?

If you continue to focus on panic-filled thoughts, you will spiral more into a panic.

Focusing on your feet is where you choose to focus on thoughts that are not adding to your panic.

Remind yourself that you only feel this because you are hyperventilating and will be okay, or by using coping statements.

Coping statements.

This will pass.

I have felt this before, and it goes away.

The sensations are because I am over-breathing, nothing else.

If my thoughts are scary, I know they are not real. My thinking is irrational when I have a panic attack.

Pay no attention to my thoughts–I choose to focus on something else.

So what? If I have a panic attack. It will pass. You can add some coping statements of your own.

Accept your feelings.
Don’t run away from panic, but do not fight it either–just accept it.

Accept it for what it is–your nervous system is overstimulated.

Accept your feelings of panic without your spin on what is happening. I mean thoughts such as “I am going to die, I can’t handle this”, etc.

Accepting your feelings is just describing them. For example,
My heart is beating fast–as opposed to–I am going to have a heart attack.

My breathing is fast as opposed to–I am suffocating

Acceptance statements.
My heart is beating fast. I feel pins and needles. I am sweating.

This way, you accept what is happening without adding fuel to the fire.

Take control of your panic attacks by

  • Controlled breathing
  • Grounding yourself
  • Acceptance.
  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington D.C.: 2013.
Dr Elaine Ryan

Dr Elaine Ryan

Dr Elaine Ryan is a Counselling Psychologist with 20 years experience. She specialises in OCD and anxiety related conditions. She worked in the National Health Service before setting up private practice. Dr Ryan obtained her PsychD from The University of Surrey.