Panic attack: what to do right now, and how to stop them coming back

It can arrive in a bus, in a meeting, at home, or even in your sleep. Your heart pounds. Your chest feels tight. You cannot get enough air. You may feel sure you are about to faint, lose control or die. That is a panic attack, and if you are in the middle of one right now, please read the next section first.

What to do right now

The NHS gives simple advice for the moment of an attack. These steps do not make the attack vanish at once, but many people find they help it feel less frightening.

1. Stay where you are, if it is safe.
2. Breathe slowly and deeply.
3. Remind yourself: this is a panic attack, it is not life threatening, and it will pass.
4. Focus on peaceful, relaxing images, or look around the room and rest your eyes on something calm.

What a panic attack is

The National Institute of Mental Health (NIMH) in the United States describes a panic attack as a one-time or occasional episode of intense fear with physical and emotional symptoms. It also says an isolated panic attack is not a mental disorder.

The NHS says most attacks last 5 to 20 minutes, though some have been reported to last up to an hour. NIMH notes that attacks can happen several times a day or only a few times a year, and can happen during sleep.

What it feels like in the body and mind

Symptoms described by the NHS and NIMH include:

• A pounding or racing heart, and chest pain
• Sweating, chills or hot flushes, and trembling
• Shortness of breath or a feeling of choking
• Dizziness, feeling faint, nausea or stomach pain
• Numb or tingling hands
• A feeling of dread, losing control, or fear of dying
• Feeling cut off or disconnected from your body

The sensations are real, and they are strong. The body is reacting as if there were danger, even when there is none.

Why it happens

The exact cause is not known. MedlinePlus says researchers suspect a mix of genes, brain biology and chemistry, environment and major stress. MedlinePlus adds that people who have had trauma, especially in childhood, are more likely to develop panic disorder. NIMH says panic attacks often begin in the late teens or early adulthood, and are more common in women.

In simple terms, the body's alarm system fires too strongly. It releases stress hormones, the heart speeds up and breathing changes. Those sensations are frightening, which can make the alarm louder. This is a simplified picture, not a full explanation.

A panic attack or panic disorder?

MedlinePlus says having panic attacks does not mean you will develop panic disorder, and many people have one or two attacks and recover without treatment.

According to NIMH and the NHS, panic disorder is usually considered when you have repeated, unexpected attacks followed by at least a month of ongoing worry about having more, fear of what the attacks mean, or changes in behaviour to avoid them. Only a professional can tell you whether this applies to you.

NIMH also notes that panic can come alongside other conditions, such as other anxiety disorders, depression, thyroid problems, heart or breathing conditions and alcohol or substance misuse. A doctor can check for these.

The trap: fear of fear

After an attack, it is natural to avoid the place where it happened, to keep checking your pulse, or to stay close to an exit or to a family member. This feels safer. But the NHS warns that avoiding situations can leave you living in fear of fear, which can bring on more attacks. For anxiety in general, the NHS advises gradually facing situations that make you anxious instead of avoiding them.

What helps over time

Talking therapy

Cognitive behavioural therapy (CBT) is the main talking therapy for panic. NIMH describes CBT as the commonly used gold standard psychotherapy. It helps you understand the panic cycle and change how you react to the sensations. It often includes exposure, where you practise facing feared situations or body sensations in a safe, planned way.

A 2018 review of 72 trials with 4,064 people, published in Psychological Medicine, looked at which parts of CBT for panic work best. It found that exposure to body sensations (called interoceptive exposure) and face-to-face sessions were linked to better results. Muscle relaxation was linked to lower effectiveness. The authors noted that many of the estimates were uncertain, so this is a pointer and not a rule. Please do not try to treat yourself with exposure on your own. A therapist can plan it with you.

Medicine

Medicine is another option that a doctor may discuss. The NHS says antidepressants can take 2 to 4 weeks to begin working and up to 8 weeks to work fully, and should not be stopped unless your doctor advises it. NIMH notes that some fast-acting medicines can lead to tolerance and dependence and are usually prescribed for short periods. Whether and which medicine suits you is a decision for you and your psychiatrist or doctor.

Everyday habits

MedlinePlus and the NHS suggest regular exercise, regular meals, enough sleep, and cutting back on caffeine and alcohol. The NHS also advises stopping smoking, as caffeine, alcohol and smoking can all make attacks worse. These can help alongside treatment, but they do not replace it.

Getting started with a professional

NIMH suggests starting with a primary care provider, who can refer you to a mental health professional, and seeking help when anxiety disrupts school, work or relationships. Talking openly with someone you trust, and being patient with yourself, are also part of recovery. Setbacks are normal and do not mean treatment has failed.

Myths and the Indian context

Because panic feels so physical, many people first think of a heart or breathing problem. That is understandable, and it is sensible to have a doctor rule out other causes. If the checks are clear and the attacks continue, it may help to talk about anxiety with a doctor.

Worry about what family or colleagues will think can stop people from asking for help. The National Mental Health Survey of India (2015-16) estimated that the overall treatment gap for mental disorders was 84.5 percent, so most people who may need care are not receiving it. You are not alone in hesitating.