As you will know from my website, I am a psychologist and specialise in anxiety disorders and OCD, but I also have lived experience of panic attacks. To be specific, I had panic disorder. I am telling you this at the start because I understand how terrifying panic can feel, as well as knowing from my professional background that recovery is possible.
If you are trying to understand what happened during an attack, why you are frightened of another one, or what treatment involves, this guide will take you through those questions. I will explain the physical sensations as well as the thoughts and changes in everyday life that can come with panic.
If you need help with an attack happening now, go to my step-by-step guide to managing a panic attack.
Panic itself is not life-threatening, but some of its symptoms have other possible causes. New or different symptoms should not automatically be put down to anxiety. If you think you may be having a heart attack or another medical emergency, call 112 or 999. 1, 2
What is a panic attack?
A panic attack is a sudden surge of intense fear or discomfort, accompanied by physical sensations such as a racing heart, trembling, breathlessness or dizziness. It can develop quickly, sometimes when you cannot identify anything that frightened you beforehand. 1
You might be sitting at home, travelling to work or standing in a shop when your body starts to feel very different. Your heart pounds, your breathing feels difficult, and you have an overwhelming need to get away. The experience can seem so physical that anxiety is the last explanation you would consider.
The sensations are real. Understanding them as part of panic does not mean that you imagined them or brought them on deliberately.
An attack is an episode. Panic disorder is a diagnosis involving recurrent unexpected attacks and continuing worry or changes in behaviour because of them. Having one panic attack does not automatically mean you have panic disorder. Attacks can also occur alongside other difficulties, including phobias; for example, fear of vomiting can trigger panic in someone with emetophobia.
People sometimes use “anxiety attack” to describe an experience of intense anxiety. It is not a separate formal diagnosis with the same defined features as a panic attack. I explain the terminology in panic attacks versus anxiety attacks.
What does a panic attack feel like?
Imagine going about an ordinary day and suddenly becoming aware of your heartbeat. Within moments you feel hot, shaky and unable to get a satisfying breath. You start checking your pulse. Your thoughts move quickly from “What is happening?” to “Something is seriously wrong.”
Breathlessness can feel as though you cannot draw air in properly, even though you are breathing. Dizziness can make the floor feel unsteady. You might feel an urgent need to leave, find someone you trust, or get medical help.
After an assessment, being told that it was panic can be difficult to take in. The word can sound too small for what you have just experienced. Understanding the explanation often takes more than hearing it once.
I have written separately about my first panic attack, if it would help to read a personal account.
Expected and unexpected panic attacks
An unexpected attack happens without an obvious immediate trigger. You might be resting or asleep when it begins. An expected attack occurs in response to something you already fear, such as a crowded shop, a journey or a particular bodily sensation.
Both can feel equally frightening. Someone may initially have an unexpected attack, then become anxious in the place where it happened and experience further attacks there. A location becoming associated with panic does not mean the location itself is dangerous.
Panic can occur at work, on public transport, in a car, at home or in bed. Attacks that wake you from sleep are discussed in my guide to nocturnal panic attacks.
How long does a panic attack last?
Panic usually builds quickly. The HSE describes most attacks as lasting between five and thirty minutes, although experiences vary and some episodes last longer. 3, 1
The period of intense panic and the time it takes to feel settled afterwards are not necessarily the same. You may still feel shaky, tired or apprehensive once the strongest sensations have eased. Repeated surges of fear can also make an episode seem to continue. Try not to use a stopwatch as a test of whether your experience is “really” panic; assessment considers the whole pattern.
What can I do during a panic attack?
If this is a familiar pattern that has been assessed as panic, the immediate aim is to get through the episode without adding more fear to every sensation.
If you are somewhere safe, you might pause and remind yourself what you recognise: “This feels like the panic I have experienced before.” Let your breathing be comfortable rather than repeatedly trying to take a huge breath. If focusing on breathing makes you more anxious, notice something ordinary around you instead.
You do not need to perform several exercises perfectly or make the sensations disappear immediately. If you are driving or doing something where impaired concentration would be unsafe, deal with that practical situation first.
My guide to stopping panic attacks explains the immediate steps in more detail. Further down this page, I explain the treatment that can help when the fear of another attack starts affecting your life.
Panic attack symptoms
Panic involves your body, your thoughts and feelings, and sometimes changes in what you do. You do not have to experience every symptom described here. One person may be most frightened by their heartbeat; another by dizziness, nausea or a feeling of unreality. 1
The following explanations describe sensations that can occur with panic. They cannot establish the cause of a new symptom. I have a separate article on medical conditions that can resemble panic attacks.
Physical symptoms
Rapid heartbeat
A racing heart can be one of the first things you notice. It may feel particularly alarming when you are sitting still and cannot see a reason for it.
Fear activates physical responses that include an increase in heart rate. The meaning you give that change matters too. If your heart beats quickly after running for a bus, you have an explanation for it. The same sensation during a meeting can feel much more threatening because it seems to have arrived without a reason.
Repeatedly checking your pulse can keep your attention fixed on it. Treatment can help you become less frightened of the sensation and less dependent on checking for reassurance.
Palpitations
Palpitations are the experience of noticing your heartbeat unusually strongly. People describe pounding, fluttering or the feeling of a missed or extra beat. They can occur during anxiety, but anxiety is not their only possible explanation.
In my clinical work, I made sure that people attending for panic had received appropriate medical assessment. That helped establish what we were working with.
With panic, the difficulty often becomes the interpretation: “My heart cannot cope with this.” Learning about that pattern and reducing repeated checking can be more useful than trying to make yourself unaware of every heartbeat.
Chest pain or tightness
Panic can involve chest discomfort, tightness or pain. Muscle tension and changes in breathing may contribute. The sensation can then provoke a frightening thought, which adds to the tension and fear.
This explanation is not a way to diagnose chest pain at home. If you suspect a heart attack, seek emergency help. For a familiar pattern that has been assessed, treatment can address the fear of the sensation and the habits that keep your attention on it.
If muscle tension is part of your experience, the gentle relaxation exercise later in this guide may be useful. There is no need to force a stretch, tense painful muscles or keep checking whether the discomfort has gone.
Shortness of breath and air hunger
Up until I had panic attacks, breathing was not something I thought about, or felt. With panic, you can become aware of every breath. It can feel as though you are not getting enough air; some people call this air hunger.
The understandable response is to try harder to get a satisfying breath. You may repeatedly sigh, take very large breaths or consciously manage a process you previously barely noticed. This can make breathing occupy more and more of your attention.
Changes in breathing can contribute to panic sensations, although anxiety or overbreathing does not explain every episode of breathlessness. When panic makes you struggle to take the perfect breath, a gentler approach is often more workable. I describe that approach in the practical section below.
Hyperventilation
Hyperventilation means breathing more than your body needs at that moment. It involves the depth of breathing as well as its speed; it is not simply another word for breathing quickly.
Overbreathing can lower carbon dioxide and contribute to dizziness, tingling and other uncomfortable sensations. Those sensations may then seem like further evidence that something is wrong, adding to the panic. This can be part of an attack, but it does not explain every attack or every symptom. 4
Repeatedly gulping in air may therefore be unhelpful. Comfortable, unforced breathing is a better starting point than trying to take the largest possible breath. I also explain why breathing into a paper bag is not recommended.
Nausea or an upset stomach
Anxiety can affect your digestive system, leaving you feeling sick, unsettled or as though you urgently need the toilet. Nausea can be particularly difficult if being sick is itself something you fear.
For example, you might notice your stomach turning before a presentation. Your attention moves from what you want to say to whether you are going to vomit. That feared possibility can become more distressing than the original sensation.
The nausea may ease as the episode settles. If it is a recurring part of panic, it can help to separate the sensation from the prediction you attach to it. My article on fear of fainting, vomiting or losing control during panic explores these fears in more detail.
Dizziness or light-headedness
Dizziness can feel like unsteadiness, light-headedness or a sense that you might faint. Changes in breathing can contribute during panic, and fear can make the sensation more alarming.
Feeling faint does not necessarily mean you are about to lose consciousness. Equally, it would be wrong to promise that anyone who experiences panic can never faint.
If you feel unsteady, sit somewhere safe. Taking a sensible precaution is different from building your whole day around preventing an imagined collapse. If dizziness is new, persistent or accompanied by actual fainting, it needs medical assessment rather than an assumption that it is anxiety.
Tingling or numbness
You may notice pins and needles, tingling or numbness, particularly in your hands or around your mouth. Changes associated with overbreathing can contribute to these sensations during panic.
The sensation can draw you into repeatedly testing your fingers or comparing one side with the other. That repeated checking can keep the symptom at the centre of your attention.
You might instead let your attention include what you are doing and what is around you. The grounding exercise later in this guide offers one way to practise that, without having to make the tingling disappear first.
Trembling or shaking
Your hands, legs or whole body may shake during panic. Physical arousal and muscle tension can make you feel visibly unsteady, which can be especially uncomfortable around other people.
Trying very hard to hold yourself completely still can add another task at a moment when you are already frightened. If it is practical, you might let your hands rest or allow some gentle movement. You do not have to exercise until the shaking stops.
Some people remain shaky after the most intense fear has passed. I discuss this period in what to do after a panic attack.
Sweating
You may notice damp palms, a warm face or sweating even when the room is not hot. Sweating can occur as part of the body’s response to fear.
The worry may become “Everyone can see that something is wrong with me.” That thought can increase self-consciousness and make you watch for other people’s reactions. Other people may notice less than you expect, and a visible sign of anxiety does not mean you have failed to cope.
It is fine to make yourself comfortable or have a drink. You do not need to turn having water immediately available into a condition for feeling safe.
Chills or hot flushes
Panic can involve sudden heat, chills or a change between the two. These sensations can feel strange when there has been no obvious change in the temperature around you.
You can make an ordinary adjustment, such as loosening a layer of clothing, without treating every temperature change as a sign that the panic is becoming dangerous.
Dry mouth
A dry mouth can be particularly noticeable when you are speaking. It can make you worry that your voice will fail or that other people will realise how anxious you feel.
This happened to me many years ago when I was interviewing for a psychology position in a large university, in front of a panel of psychologists. I kept going. Looking back, acknowledging what was happening might have taken some of the pressure off me.
A sip of water or a pause is an ordinary response to a dry mouth. The longer-term work is often around the meaning attached to someone noticing your anxiety, rather than ensuring your mouth never feels dry again.
Throat tightness or a lump in the throat
Some people feel tightness or a lump in the throat during anxiety. A lump sensation when swallowing is otherwise normal is often described as globus. Stress can make this sensation more noticeable. 5
Repeated swallowing or throat clearing may become a way of checking that everything is still working. That can keep your attention on a sensation you want to forget about.
A comfortable sip of water may help, but it is not a test you need to repeat. Actual difficulty swallowing or breathing is different from a familiar lump sensation and should not simply be labelled panic.
Blurred vision or tunnel vision
Some people notice changes in vision during intense anxiety, including a sense of looking through a tunnel or difficulty focusing. These experiences can make surroundings feel unfamiliar and increase the fear that you are about to lose control. 6
If this happens, attend to your immediate safety. You should not continue driving while your vision is impaired. New, persistent or unexplained visual changes need assessment; a history of panic does not establish their cause.
Thoughts, feelings and changes in perception
Fear of losing control or “going crazy”
An attack can create a strong feeling that something terrible is about to happen to your mind or behaviour. You may fear that you will scream, run away, embarrass yourself or no longer be able to control what you do.
A feeling of losing control is not the same as actually losing control. During panic, a frightening prediction can feel unusually convincing because your body is already in a state of fear.
Later, when the episode has passed, it can be useful to compare what you feared with what actually happened. You do not have to argue with every thought while the attack is at its strongest.
Fear of dying or having a heart attack
A pounding heart, chest discomfort and breathlessness can lead to the thought that you are dying. This is one reason an initial panic attack can be so frightening and why appropriate medical assessment matters.
After a familiar pattern has been assessed, repeatedly searching for a new explanation or asking for absolute certainty can bring brief relief without resolving the fear. Panic treatment helps you work with that uncertainty and the interpretation of sensations. It does not ask you to ignore new symptoms or avoid necessary care.
Derealisation: when your surroundings feel unreal
Derealisation is a feeling that the world around you is distant, dreamlike or unreal. You might recognise where you are while feeling strangely disconnected from it. 7
The unfamiliar feeling can itself become frightening: “Why does everything look odd?” You may then monitor it closely, waiting to feel normal before continuing with anything else.
Gently returning your attention to an ordinary activity can be useful. You do not need to keep testing whether the room feels completely normal yet.
Depersonalisation: feeling detached from yourself
Depersonalisation describes detachment from yourself or your body. You might feel as though you are watching your actions from a distance, or that your body or emotions feel unfamiliar. It is different from derealisation, although they can occur together. 7
These experiences can happen with intense anxiety. Their presence during panic does not, by itself, establish a separate dissociative disorder. If they are persistent, new or happening outside your usual pattern, discuss them with a clinician.
Overwhelming fear or terror
Sometimes the strongest part of an attack is the sheer intensity of fear. You might be doing something ordinary, such as buying groceries, and suddenly feel as though you need to escape immediately.
There may be no danger in the supermarket, but your experience of fear is still real. Naming it as a familiar feeling can create a little room between the sensation and the action you feel compelled to take.
The aim is not to criticise yourself for feeling frightened. It is to learn, over time, that the feeling does not have to decide everything you do.
Irritability or agitation
Irritability is not one of the defining features of a panic attack, but the strain of ongoing anxiety can leave you feeling on edge. You may become impatient with interruptions or find ordinary demands harder to tolerate.
Someone close to you may see the irritation without knowing how frightened or exhausted you feel. A straightforward explanation can help: “I have been very anxious, and I am finding things harder to manage today.” This gives them something more useful to respond to than having to guess.
Feeling overwhelmed
Busy places, several demands at once or the thought of getting through a whole day can feel difficult when much of your attention is already occupied by panic.
A manageable routine and some space to recover can help. It need not become a strict set of rules about sleeping, eating or organising every hour perfectly. If your activities are steadily shrinking, that is a reason to seek help with the panic rather than continually reorganise life around it.
Changes in behaviour
Avoiding places or activities
After an attack in a shop, on a train or during a meeting, it is understandable to feel reluctant to return. Leaving or avoiding the situation may give immediate relief.
Over time, however, avoidance can prevent you from discovering what would happen if you stayed or returned with an appropriate plan. More places may begin to feel difficult, even though the original problem was the fear of another attack.
Some people develop agoraphobia, involving fear of situations where escape or help might seem difficult. This can include public transport, queues, enclosed spaces or being away from home. It is not simply a dislike of open spaces.
Seeking reassurance
It is reasonable to want support when something has frightened you. Reassurance becomes a difficulty when you need the same question answered repeatedly and the relief never lasts.
For example, after appropriate assessment, you might repeatedly ask whether a familiar heartbeat sensation is safe. Each answer helps briefly, but soon you need another one. The underlying fear has not had a chance to change.
Treatment can help you reduce this repeated search for certainty while keeping ordinary emotional support. You do not have to cope alone to demonstrate that you are recovering.
Safety behaviours
Safety behaviours are actions used to prevent a feared outcome or make you feel certain you can cope. Examples might include repeatedly locating exits, monitoring your pulse or believing you can enter a shop only if a particular person is available by phone.
The purpose matters. Carrying water is an ordinary action. Believing that you will collapse unless that exact bottle is within reach creates a different relationship with it.
Prescribed medication, disability support and sensible precautions are not things to remove as a test of recovery. The work is to identify additional rituals that keep you believing you are unable to cope, and consider gradual changes that fit your circumstances. My article on safety behaviours explains this distinction further.
What causes panic attacks?
There is no single explanation for every person’s panic. Biological vulnerability, stress, learned associations and the way bodily sensations are interpreted can all contribute. Sometimes you can identify a trigger; sometimes you cannot. 1
It is useful to separate what may have contributed to the first attack from what is keeping the difficulty going now. The first episode might have happened during a stressful period. Months later, the main problem may be the fear of another attack and the changes you have made to avoid it. I discuss panic after illness, burnout or prolonged stress in more detail in a separate guide.
Biological factors and the body’s response to fear
When you are frightened, your body prepares to respond. Changes can include a faster heartbeat, altered breathing, sweating and muscle tension. During panic, those responses may occur when there is no immediate external danger.
Panic disorder sometimes runs in families, although having a relative with it does not mean you will develop it. Research considers several brain systems and biological processes alongside psychological and environmental influences. It is too simple to explain an individual’s experience as a single chemical imbalance or to conclude that an unexpected attack was caused by one particular part of the brain. 1
Your symptoms also cannot tell you, by themselves, exactly which process started an episode. Understanding the pattern of fear and response is often more useful for treatment than trying to identify one part of the brain to blame.
Learned associations and fear of bodily sensations
After panic in a particular setting, that setting may become linked with the experience. A lift, train or supermarket can begin to bring back the expectation of panic before anything else has happened.
The same can occur with bodily sensations. A faster heartbeat after climbing stairs may remind you of an attack. You notice it, become frightened of what it could mean, and then experience more of the sensations associated with fear.
Paying close attention to your body can make ordinary changes easier to notice. This does not mean the sensations are imaginary. It means your attention and interpretation can influence how threatening they feel. I discuss this process in more detail in body monitoring and selective attention.
Anticipating an attack can also raise anxiety. This is an understandable response to a frightening experience, not a choice to make yourself panic. The train example in the next section shows how anticipation, sensations and avoidance can become connected.
Stress, difficult experiences and life changes
Panic can begin during a period of pressure, after a frightening event, or around a significant change in life. Sometimes the connection becomes apparent only afterwards; sometimes there is no clear event to point to.
Earlier experiences and what we have learned about danger or physical symptoms may influence how we respond to anxiety. That does not mean that every person with panic has experienced trauma, or that a family member is to blame.
Looking at stress can be helpful, but searching indefinitely for the one perfect explanation can become frustrating. Treatment can still help when you do not know precisely why the first attack happened.
Caffeine, alcohol, other substances and medication
Caffeine and other stimulants can make physical sensations of anxiety more noticeable. Alcohol or other drugs may seem to offer short-term relief while contributing to difficulties later. The effect varies between people and circumstances.
Medication effects and withdrawal can also be relevant to an assessment. Tell your GP what you take, including non-prescription products. If you are concerned about prescribed treatment or dependent on alcohol, seek advice about changes rather than stopping abruptly.
Sleep and physical health
Poor sleep can leave you feeling more strained and less able to manage anxiety. Fear of panic can then interfere with sleep, creating a difficult pattern in both directions. My article on sleep and panic disorder looks at that relationship.
Waking with breathlessness is not always nocturnal panic. For example, sleep apnoea is a separate condition that may need assessment. I discuss the distinction in panic attacks and sleep apnoea.
Other physical conditions can produce symptoms that resemble panic. A GP can consider those possibilities alongside your history, medication and pattern of symptoms. Medical assessment and psychological treatment can complement one another.
What about the gut and the microbiome?
There is research into connections between the gut, stress and mental health. It is an area of continuing investigation, rather than a reason to assume that gut bacteria explain your attacks or that a probiotic is an established treatment for panic disorder.
I have written about panic disorder and the microbiome for readers interested in the topic. It should be considered alongside the stronger treatment evidence for approaches such as CBT.
What is panic disorder?
Panic disorder involves recurrent unexpected panic attacks, with at least one followed by a month or more of persistent concern about further attacks or their consequences, or significant changes in behaviour because of them. Assessment also considers other explanations for the symptoms. 1
The difficulty therefore extends beyond the time spent having an attack. You might spend much of the day wondering when the next one will happen, checking how your body feels or deciding which activities are safe enough to attempt.
I had panic disorder myself, and I understand that it can take time to accept the explanation. Being told that symptoms are part of panic may make sense intellectually before it feels convincing when your heart starts racing again. That is something treatment can work with.
Panic disorder can also occur alongside other anxiety difficulties. A useful assessment considers the whole picture, including low mood, physical health, sleep and the effect on daily life.
How fear of another attack can keep the cycle going
In my clinical experience, and personally when I had panic attacks, the fear of another attack could make life smaller. You begin avoiding things that you believe might bring it on. The anticipation itself can make you anxious before you reach the situation you fear.
Consider this illustration. You have a panic attack on a crowded train. The next time you need to travel, you remember how frightening it was. Before leaving home, you begin checking how you feel.
At the station, you notice your heart beating faster. You interpret that as the start of another attack and think, “If I get on, I will be trapped and unable to cope.” You decide to go home. The relief is immediate.
That relief is understandable, but you have not had an opportunity to discover what might have happened if you had taken the journey with a manageable plan. The train may feel even harder to approach next time. You might begin avoiding other situations where leaving seems difficult.
Several parts of the experience have become connected:
- A sensation, such as a faster heartbeat.
- A frightening interpretation of what it means.
- Increased fear and more noticeable sensations.
- An action, such as escaping, checking or seeking reassurance.
- Brief relief, followed by continued concern about another episode.
This pattern is not a criticism of how you coped. It helps explain where treatment can make a difference. You can learn different ways to respond to the sensations and gradually revisit activities that fear has restricted.
You can read more about anticipatory anxiety and the cycle of fear and avoidance in panic.
How panic can affect everyday life
The effects of panic are sometimes less visible than the attacks themselves. You might continue working and seeing people while quietly changing how you travel, where you sit or how long you stay away from home. If panic is affecting your working or study day, see the practical guides to panic attacks at work and panic attacks at college.
Work, relationships and ordinary activities
Concentration can be difficult when part of your attention is monitoring your body. Meetings may feel harder if you worry about needing to leave. A journey that used to be routine may require a great deal of planning.
Other people may notice cancelled plans or reluctance to go somewhere without understanding the reason. You may feel embarrassed to explain, especially if you worry that the experience will sound unreasonable when described aloud.
The more you organise life around avoiding panic, the fewer opportunities you may have to enjoy things or discover that you can manage them. Help can focus on those practical restrictions as well as the frequency of attacks. I explore this in living with panic disorder.
Fear of being alone or going out
You may feel safer with someone nearby because you believe they could help if you panicked. Alternatively, going out may feel difficult because you are unsure where you could leave or find support.
Neither response means you are weak. It gives useful information about what you fear will happen. A treatment plan can work with that specific concern and the activities you want to regain, without making independence from every form of support the goal.
Fear of going to bed
If you have experienced panic around sleep, bedtime can become difficult. You might lie awake, aware of your heartbeat, worrying that you will fall asleep and wake in panic.
This is where I experienced the worst of my panic. It is an experience that makes the phrase “tired and wired” very understandable: exhausted, but finding it hard to settle.
Anxiety while lying awake and an attack that wakes you from sleep are not exactly the same experience. I explain both in why anxiety can feel worse at night and nocturnal panic attacks.
Tiredness and the longer-term effect of panic
You may feel drained after an attack or after a day spent anticipating one. Resting afterwards is reasonable. You do not need to analyse every sensation while you recover from a frightening episode.
Over time, the impact on sleep, relationships, work and confidence can become substantial. This is a reason to seek support, rather than a prediction that panic will permanently damage your life. My article on the longer-term effects of panic attacks discusses these wider difficulties.
Treatment for panic attacks and panic disorder in Ireland
Treatment should take account of how often attacks happen, what you fear about them, how much your life has changed, your physical health and your preferences. The main options include psychological treatment, CBT-based self-help and, for some people, medication. 1, 8
You do not have to wait until panic has become severe before asking for help. Equally, you do not have to work through self-help on your own before you are allowed to discuss professional treatment.
Cognitive behavioural therapy: understanding and changing the panic pattern
CBT is a well-established treatment for panic disorder. It considers the relationship between bodily sensations, the meaning you give them, the fear that follows and what you do in response. 1
The starting point is your particular experience. Fear of fainting in a queue may call for different work from fear that a racing heart means a heart attack, or fear of vomiting in front of other people.
For example, suppose you notice your heart beating quickly and immediately think, “I am going to lose control.” You check your pulse repeatedly and leave what you are doing. The immediate relief may leave the original prediction untested.
CBT can help you examine that prediction and plan a different response. That includes learning from experience, not only discussing thoughts. A less frightening interpretation may become more believable when you have opportunities to see what happens without the usual checking or escape.
My guide to CBT for panic attacks explains the process in greater detail. If you are new to the approach, you can also read my introduction to cognitive behavioural therapy.
Working with catastrophic thoughts
“Catastrophic” describes a prediction of a terrible outcome. During panic, the prediction can arrive so quickly that it feels like a fact.
It can be useful to separate three things afterwards: what you noticed, what you feared it meant, and what you did next. For example: “My heart beat quickly; I thought I would collapse; I sat checking my pulse.” That is more specific than recording only “I felt awful.”
You can then consider another interpretation that fits what you know: “I have experienced a racing heart with panic before. I felt frightened, but the collapse I predicted did not happen.” The wording needs to fit your actual experience, rather than becoming a sentence you repeat to force certainty.
I explain this further in my articles on negative automatic thoughts and catastrophic thinking.
Gradually returning to situations you avoid
Exposure is part of CBT. It involves planned opportunities to approach situations you have been avoiding and learn from what happens. The plan should fit the fear you want to address and the activities that matter to you.
Returning to the train illustration, you might work towards a manageable journey rather than setting a first task of travelling a long distance at the busiest time. Before the practice, identify the prediction: “If my heart races, I will be unable to stay on the train.” Afterwards, consider what happened and what you learned.
You may still have felt anxious. That does not mean the practice was useless. Learning can include finding that you were able to make a choice and continue with an activity while anxiety was present. Feeling completely calm is not the only measure of progress. 9
The aim is not to stay in an unsafe situation or disregard medical advice. It is to reduce restrictions created by fear through suitable practice. I explain the approach in exposure therapy for panic and behavioural experiments for anxiety.
Interoceptive exposure: working with feared bodily sensations
Sometimes the main thing you fear is a bodily sensation itself: a faster heartbeat, dizziness or breathlessness. Interoceptive exposure involves planned practice with bodily sensations to address the predictions attached to them. 1
The purpose is to learn about the sensation and your response to it. It is not a test of how much discomfort you can endure, and a list of exercises is not a personalised prescription.
Suitable practice depends on your health, the sensation and the feared outcome. A clinician can help choose an approach when you are unsure, have relevant medical conditions or find self-directed practice difficult. I explain the principles in body sensation practice for panic attacks.
Self-help based on CBT
Structured self-help can be useful, particularly when difficulties are less severe. It usually involves more than reading about symptoms. You learn about your pattern, consider fearful interpretations and practise changes in the things you have begun doing to avoid panic. 8
It helps to choose a manageable focus. For example, you might work on the habit of repeatedly checking your pulse for reassurance, or on returning to an ordinary activity you have been avoiding. Trying to change every habit at once can make it hard to tell what you are learning.
You can read my guide to working on panic attacks through self-help. If panic is seriously restricting your life, or you are unsure how to proceed, professional support can help you develop a more individual plan.
Can CBT for panic be delivered online?
Psychological treatment can be delivered in person or online. What matters is receiving an appropriate approach from someone with relevant training and experience, in a format that works for your circumstances. 1
Live appointments with a therapist, guided self-help and an independent educational resource involve different levels of support. It is worth being clear about which you are choosing. My article on online therapy for panic attacks explains the format in more detail.
Mindfulness, acceptance and other approaches
Mindfulness and acceptance approaches can help you notice sensations and thoughts without immediately treating them as instructions to escape or check. For some people, this is a useful part of their work on panic.
Relaxation may also be helpful for tension or general wellbeing. It does not have to become something you must achieve before leaving home or entering a difficult situation.
The evidence and purpose of different approaches are not identical. CBT has a well-established place in panic disorder treatment; other approaches can be considered according to your needs and the clinician’s assessment. I discuss one of these approaches in mindfulness-based cognitive therapy and panic.
Medication
Your GP may discuss medicine as one of the treatment options. Antidepressants, including some SSRIs and SNRIs, are used for panic disorder even when someone is not depressed. The choice depends on your circumstances, possible benefits, side effects and other medicines. 1, 10
Medication can take time to help, and progress should be reviewed with your prescriber. Ask what to expect, what difficulties to report and how any future changes would be managed. Changes to prescribed treatment should be discussed with the person prescribing it.
Taking medication does not prevent you from learning psychological skills. Treatment decisions can include psychological help, medication or both, according to what is appropriate for you.
Choosing the right level of help
If panic is occasional and you are still able to manage everyday activities, a structured self-help approach may be a reasonable option. If attacks are frequent, avoidance is increasing or work, sleep and relationships are being affected, discuss a fuller assessment and treatment plan.
If one approach has not helped enough, that is useful information for reviewing the plan. It does not mean you have failed. The review might consider the specific fear being addressed, the support available, other difficulties and whether a different form of treatment would suit you better. 8
Progress varies. It may show up as less checking, a journey you can take again or less time spent planning around panic, as well as fewer attacks. I would not give everyone the same deadline for improvement.
Finding help in Ireland
Your GP is a useful starting point for assessment and a discussion of available treatment. They can explain relevant services or referral options, although availability and waiting times vary. The HSE provides information about panic disorder and treatment. 10
If you are considering a therapist independently, ask about their qualifications, professional registration or accreditation, and experience treating panic. You can ask specifically whether their approach includes CBT for panic and work with avoidance and feared bodily sensations.
Practical questions matter too: the fee, appointment availability, online or in-person format, and what support is included between appointments. If you have health insurance, check the terms of your own cover.
Professional directories can help you check credentials and find practitioners. The Irish Association for Counselling and Psychotherapy is one such resource. If you are looking in the UK, the British Association for Counselling and Psychotherapy has a directory. A directory entry alone does not establish experience with panic, so ask about that directly.
My guide to different mental health professionals explains their roles, and my introduction to psychotherapy may help if you are unsure what talking treatment involves.
Sleep, activity and support alongside treatment
Regular meals, adequate rest and physical activity suited to your health can support wellbeing. It may also be helpful to consider whether caffeine, alcohol or other substances are making your symptoms harder to manage. These changes can support treatment; they do not have to become a perfect daily routine. 1
Relaxation or mindfulness may make space in a stressful day. Family, friends and peer support can reduce the sense of having to keep the difficulty to yourself. You can explain the kind of help you find useful, such as company, practical support or encouragement with a planned activity. For partners, friends and colleagues, I have a guide to helping someone having a panic attack.
If you are interested in a support group, your GP or the HSE may be able to point you towards available options. Support can sit alongside CBT, self-help or medication without replacing an individual assessment when one is needed.
Practical ways to respond to familiar panic
You do not have to predict every attack or keep checking your body for an early warning. It can be more useful to notice whether fear is changing what you do: avoiding a journey, repeatedly asking for reassurance or spending a long time checking how you feel.
The following practices are options. They are not a checklist you must complete during every attack, and they do not replace the longer-term work with fear and avoidance.
Gentle, comfortable breathing
If your breathing has become fast or forced, allow it to become gentler. Sit or stand comfortably, with your body supported where that helps. Let the breath come in and out without repeatedly filling your lungs as much as possible.
Some people find a comfortable count useful; others find that counting adds pressure. You do not need to reach a particular number or hold your breath. The NHS breathing guidance emphasises a gentle, regular rhythm without forcing the breath. 11
If concentrating on breathing makes you more anxious, you can turn your attention towards an ordinary activity or your surroundings instead. The aim is not to monitor every breath until you can prove that it is normal.
Grounding through your surroundings
Grounding gives your attention something concrete to rest on. One option is to notice five things you can see, four things you can hear, three things you can feel through touch, two things you can smell and one thing you can taste. Adapt the exercise to the senses available to you. 3
You need not complete the sequence perfectly. If you are in a supermarket, for example, you might notice the weight and texture of a tin of beans in your hand and return your attention to choosing what you need.
This is a way to widen your attention beyond the frightening sensation. It does not have to become a ritual you perform before you are allowed to carry on.
Easing muscle tension
If you notice tension, first see whether you can let your jaw, shoulders or hands soften a little. You can also try a gentle version of progressive muscle relaxation when you are somewhere comfortable.
For example, lightly tense your hands for a few seconds, then release them and notice the difference. You can do the same with other comfortable muscle groups, such as your shoulders or legs. Keep breathing normally and skip any area that is painful or where you have been advised against tensing.
The exercise is for comfort and awareness of tension. It is not necessary to relax every muscle before you can cope with anxiety.
Responding to frightening thoughts
A short, believable response may be more useful than trying to persuade yourself that you feel perfectly calm. During panic, examples might be:
- “I recognise this feeling from previous panic attacks.”
- “The thought that I will lose control is a prediction.”
- “I can take a moment and decide what to do next.”
- “I do not have to make every sensation disappear before continuing.”
Choose words that fit your experience. Repeating a statement until you feel completely certain can turn into another form of checking. The longer-term aim is to become less governed by the frightening interpretation, even when some uncertainty remains.
For a fuller explanation of responding in the moment, see how to stop panic attacks.
When should I speak to my GP?
Speak to your GP if you are unsure what is causing your symptoms, if attacks are recurring, or if fear is making everyday activities difficult. A first assessment is also an opportunity to discuss physical health, medication, sleep and other possible contributors. 10
If you already have a panic diagnosis, new or significantly different symptoms still deserve appropriate attention. The purpose of assessment is to understand what is happening, not to provide a rule that every future sensation must be anxiety.
For suspected medical emergencies, including a possible heart attack, call 112 or 999. You do not need to establish the diagnosis yourself before seeking emergency help. 2
How is panic disorder diagnosed?
The clinician will ask about the attacks, how they begin, what symptoms occur, whether there is an obvious trigger, and what happens between episodes. They will also consider worry about further attacks, avoidance and the impact on your life. 1
Your GP may carry out an examination or arrange investigations where appropriate. A mental health assessment considers whether panic disorder or another difficulty best explains the pattern. The diagnosis is based on that assessment, rather than on counting symptoms from a web page.
You can prepare by noting a few examples: what happened, roughly how long it lasted, what you feared and what you have changed because of it. You do not need an exhaustive record of every heartbeat or every anxious thought.
Frequently asked questions
Try to let your breathing stay comfortable and give yourself time to decide what to do next. Repeatedly checking your pulse for reassurance can keep you focused on the sensation. New or different symptoms need appropriate medical advice; a racing heart does not establish its own cause.
Chest pain can occur during panic, but an article cannot distinguish its cause for you. If you think you may be having a heart attack, call 112 or 999. Once a familiar pattern has been assessed as panic, treatment can help address the fear and repeated checking around it.
Changes in breathing can contribute to dizziness during panic, and fear can make the sensation more distressing. Sit somewhere safe if you feel unsteady. New, persistent or unexplained dizziness, especially with actual fainting, needs assessment rather than an assumption that it is panic.
For overbreathing during panic, aim for comfortable, gentler breaths rather than repeatedly taking very large ones. Counting is optional; forcing a particular count or long hold is unnecessary. If breathing exercises increase your anxiety, turn your attention towards your surroundings instead.
Tension and anxiety can make a lump or tight sensation in the throat more noticeable. Repeated swallowing or checking may keep your attention on it. Actual difficulty breathing or swallowing is different from a familiar globus sensation and requires medical attention.
These feelings can be very unsettling, but experiencing them during panic does not, by itself, mean you are losing your mind. Derealisation concerns your surroundings feeling unreal; depersonalisation concerns feeling detached from yourself. If these experiences are new, persistent or happening outside your usual panic pattern, seek an assessment.
Feeling faint is not the same as actually fainting. Sit or lie somewhere safe if you feel unsteady. If you lose consciousness, or faintness is new or unexplained, seek medical advice. Treatment can also help with a persistent fear of fainting during panic.
Focus on one manageable next action. You do not have to resolve every frightening thought immediately. CBT can help you understand the feared outcome and test the predictions that keep the fear going.
Anxiety can affect your digestive system and leave you feeling sick. The sensation may ease as the episode settles. If vomiting is a particular fear, the anticipation of it can add another layer of anxiety; that specific concern can be addressed in treatment.
They are actions intended to prevent a feared outcome or make you feel certain you can cope. Some can keep panic-related fear going, particularly when you believe you are safe only because you performed them. Identify their purpose before changing them. Prescribed treatment, necessary support and ordinary precautions should not be removed as a test of recovery.
Sources
- National Institute of Mental Health: Panic Disorder—What You Need to Know.
- HSE: Heart attack symptoms and when to seek emergency help.
- HSE: Panic attacks.
- Centre for Clinical Interventions: Breathing retraining.
- NHS inform: Feeling of something in your throat—globus.
- NHS inform: Panic self-help guide.
- NHS: Dissociative disorders—definitions of depersonalisation and derealisation.
- NICE CG113: Generalised anxiety disorder and panic disorder in adults—management.
- Craske and colleagues: Maximizing exposure therapy—an inhibitory learning approach.
- HSE: Panic disorder.
- NHS: Breathing exercises for stress.
Further reading
If you would like to explore the wider context, I have also written about the cultural context of panic attacks and living with panic disorder in the digital age.