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Panic attacks and panic disorder

A panic attack is a sudden surge of intense fear which might feel as though it appears out of the blue. Panic attacks make you feel strong feelings in your body such as your heart beating rapidly, or the sensation of finding it hard to breathe. Panic attacks are accompanied by catastrophic thoughts that something terrible is happening or will happen, such as thinking that you will lose control or die. Panic attacks are not dangerous, but they do feel terrifying. People who worry about their panic and who take steps to prevent the possibility of having another panic attack are said to suffer from panic disorder. It is thought that between 1 and 3 people out of every 100 will experience panic disorder every year [1, 2]. Cognitive behavioral therapy (CBT) is an extremely effective treatment for panic disorder, with about 80% of people with panic disorder panic-free at the end of treatment [3].

What is it like to have panic attacks?

Ted’s fear that he would pass out

Ted experienced his first panic attack during a stressful time of his life. He had been rushing to get a job completed at work so that he could leave on time to visit his mother in hospital. He got stuck in traffic on the way to the hospital and worried that he would miss visiting hours. At the hospital he suddenly began to feel lightheaded and felt that he couldn’t breathe properly. Ted felt a wave of fear come over him, noticed himself getting hot and sweaty, and thought that he might pass out. He left the hospital and took deep breaths of fresh air which helped to calm him down. The sensations had only lasted a couple of minutes but to Ted it had felt like forever. Ted experienced more panic attacks over the next week. Each time they would come completely out of the blue and he would experience an overwhelming sensation of dread and fear. He could feel his heart race and his throat getting tight. He worried that he wouldn’t be able to get enough air and would pass out, and only felt better when he got out in the open. Ted tried to manage by avoiding going to places where he had panicked before. He avoided crowds and anywhere busy. He took to doing his shopping at night when it was less busy.

Aspects of treatment that Ted found helpful

Ted approached his doctor who referred him to a psychologist. Some aspects of treatment that Ted found most helpful were having an understanding of why his body was reacting in such an extreme way – learning about the fight or flight response helped to take some of the sting out of his conviction that he was going to pass out. The other part of treatment that Ted found helpful was approaching his panic directly. He and his therapist did experiments in session where they would deliberately bring on the symptoms of a panic attack by hyperventilating. They deliberately approached situations that made him feel uncomfortable. By the end of therapy Ted’s belief that he was in danger of passing out had completely turned around. He felt more in control of his life and no longer avoided crowded or enclosed spaces.

What is panic disorder?

Panic attacks are an abrupt surge of intense fear or discomfort that reaches a peak within minutes, and which involve feeling at least four of the following symptoms:

  • Palpitations, pounding heart, or accelerated heart rate
  • Sweating
  • Trembling or shaking
  • Sensations of shortness of breath or smothering
  • Feeling of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, unsteady, lightheaded, or faint
  • Chills or heat sensations
  • Paresthesias (numbness or tingling sensations)
  • Derealization (feelings of unreality) or depersonalization (being detached from oneself)
  • Fear of losing control or going crazy
  • Fear of dying

Some people might just have a one-off panic attack and not experience any more. People who go on to develop panic disorder take steps to prevent the possibility of having another panic attack.

How you might think How you might feel How you might act
  • Thoughts that something terrible is about to happen
  • Thoughts that you are going to die
  • Thoughts that you have to escape right now
  • A feeling of impending doom
  • Anxious
  • Afraid
  • Terrified
  • Scared
  • Worried
  • Short of breath
  • Heart racing
  • Sweating
  • Shaking
  • Escape situations that you perceive as dangerous
  • Take protective action (safety behaviors) to help you to manage in situations you are afraid of
  • Avoid situations where you have panicked before, or where you worry you might panic
  • Stay vigilant for body sensations or cues that could indicate the onset of a panic attack

What causes panic disorder?

There is no single cause for panic. Some of the factors that make it more likely that you will experience panic attacks and panic disorder include:

  • Strong biological reactions to stress. Some people’s bodies are more responsive to stressful events and produce more stress hormones such as adrenaline and cortisol.
  • Anxiety sensitivity. Some people are more sensitive than others to the feelings in their bodies. They are more likely to notice them, and to misinterpret them as being dangerous [4].
  • Cognitive biases including catastrophizing. These ‘thinking habits’ can be learned, sometimes through exposure to caregivers who were catastrophizers. [5, 6].
  • Other psychological problems. People suffering from a wide range of psychological problems often experience panic attacks. For example, people with post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), or depression may experience panic attacks.
  • Genetic factors. There may be genes which predispose people to developing emotional problems in general, but no specific genes which predispose people to developing panic.

As we will see in the next section, no matter what causes panic it is what keeps panic going that tends to be more important – and these maintenance factors are the focus of treatment.

What keeps panic disorder going?

Cognitive behavioral therapy (CBT) is always very interested in what keeps a problem going. This is because if we can work out what keeps a problem going we can treat it by intervening to interrupt this maintenance cycle. A psychologist called David Clark identified the key maintenance process in panic attacks: people with panic tend to misinterpret their body sensations [7].

Other things done by people who panic which inadvertently prolong their panic disorder are:

  • Being on the lookout for ‘dangerous’ body sensations. Vigilance for body sensations is problematic because the more we focus our attention on something the more that we are likely to notice.
  • Misinterpretation of body sensations. In panic, harmless body sensations are often misinterpreted as indicating an impending catastrophe.
  • Avoidance of feared situations or body sensations. Avoiding things to do with panic means that you never get to learn how dangerous they really are, or how well you would really be able to cope. Avoidance of situations associated with panic, or the use of safety behaviors intended to prevent catastrophe are problematic because they maintain (or fail to challenge) unhelpful panic-related beliefs.
  • Safety-seeking behaviors. Safety-seeking behaviors are things that you to to try to prevent a catastrophe from occurring. Like avoidance, safety behaviors prevent you from learning how dangerous that situation really is, or how well you could really cope.

Treatments for panic disorder

Psychological

The treatment of choice for panic disorder is cognitive behavioral therapy (CBT). If CBT is delivered face-to-face then the optimal range is between 7 and 14 hours of therapy, typically in the form of weekly sessions of 1-2 hours. Guided and non-guided self-help also appropriate treatment interventions for panic disorder [8].

Medical

The UK National Institute of Health and Care Excellence (NICE) guidelines for panic disorder [8] recommend that the only medicines that should be used in the longer-term management of panic disorder are selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). Benzodiazepines are associated with a poorer long-term outcome and should not be prescribed for the treatment of panic disorder.

How can I overcome my panic?

There are lots of things that you can do for yourself that will help you to overcome panic. These include:

  • Understand your body’s natural fight and flight response
  • Understand your panic symptoms and thoughts
  • Face fears of your body sensations with interoceptive exposure
  • Confront your fears by overcoming avoidance

Understand about fight and flight

Like other animals, people have a fight or flight response. This is a system built into the body which is designed to keep it safe from danger. This system is always on the lookout for dangers in the world around you. If it detects a threat it sets off a cascade of reactions in the body which are designed to increase your chances of surviving the danger. All of this can happen quickly and automatically, before the conscious ‘you’ even has a chance to think about it. Some of the things we know about the fight or flight system are:

  • It has many triggers. It can be set off by real dangers in the world around us, or by things we think about.
  • It is quick and automatic. It can go off before the conscious ‘you’ even has a chance to think.
  • It is very sensitive. Psychologists often say that it has a ‘better safe than sorry’ attitude.

Psychology Tools has a selection of information handouts which will help you to learn more about you body’s responses to threat:

Understand the catastrophic thoughts that are central to your panic

The CBT model of panic tells us that catastrophic thinking is responsible for triggering a panic attack. Not everyone who panics catastrophizes about the same things though. To learn more about your experience of panic you can use a panic attack record form to notice and record symptoms, and to catch your catastrophic thoughts. You will find it helpful to get into the habit of asking yourself at anxious moments “What is it that I think is going to happen?”.  By examining specific events you will gain a much better understanding of your panic.

Face your fears of body sensations with interoceptive exposure

People with panic misinterpret what particular body sensations mean. For example, Jennifer thought that a tightness in her chest meant that she was likely to pass out, and David thought that his racing thoughts would get worse until he ran amok and hurt somebody. One of the best ways to learn about the true nature of your body sensations is to exposre yourself to them, and to feel them without avoidance: psychologists call this interoceptive exposure. The Psychology Tools interoceptive exposure exercise will guide you through the steps you need start confronting uncomfortable body sensations.

Confront your fears by overcoming avoidance

People who panic often find that their life ‘shrinks’ when they start to avoid situations or places that they associate with panic. Avoiding is problematic because it perpetuates the idea that panic is dangerous, and you forego the opportunity to learn that you can cope and are not in danger. Facing the situations that you are afraid of is called exposure and it is the most effective treatment for anxiety. You can think of exposure as the process of reclaiming your life from panic. Psychology Tools worksheets and handouts to support exposure therapy include What Is Exposure Therapy?, Habituation, and Behavioral Experiments.

References

[1] Rees, R., Stokes, G., Stansfield, C., Oliver, E., Kneale, D., & Thomas, J. (2016). Prevalence of mental health disorders in adult minority ethnic populations in England: a systematic review. Department of Health.

[2] Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617-627.

[3] Clark, D.M. and Salkovskis P. (2009) Cognitive Therapy for Panic Disorder: Manual for IAPT high intensity therapists. Retrieved from: https://web.archive.org/web/20190704101855/https://www.kss-ppn.nhs.uk/resources/publications/12-cognitive-therapy-for-panic-disorder-iapt-manual/file

[4] Schmidt, N. B., Zvolensky, M. J., & Maner, J. K. (2006). Anxiety sensitivity: Prospective prediction of panic attacks and Axis I pathology. Journal of Psychiatric Research, 40(8), 691-699.

[5] Ehlers, A. (1993). Somatic symptoms and panic attacks: a retrospective study of learning experiences. Behaviour Research and Therapy, 31, 269-278.

[6] Cox, B. J. (1996). The nature and assessment of catastrophic thoughts in panic disorder. Behaviour Research and Therapy, 34(4), 363–374.

[7] Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24(4), 461-470.

[8] National Institute for Health and Care Excellence (2011). Generalised anxiety disorder and panic disorder in adults: management. Retrieved from: https://www.nice.org.uk/guidance/cg113/resources/generalised-anxiety-disorder-and-panic-disorder-in-adults-management-pdf-35109387756997