All about Panic Attacks

Approximately 8 million people in the UK suffer from some form of anxiety disorder, and sufferers of these disorders can be broken down into the following categories according to the Mental Health Foundation:

• Generalised anxiety disorder 34%.
• Obsessive-compulsive disorder (OCD) 20%.
• Panic disorders 13%.
• Phobias 20%.
• Post-traumatic stress disorder (PTSD) 13%.

This means that in the UK, approximately 1% of people experience panic disorder. However, an occasional panic attack occurs at some point in the lives of almost everyone in the population.

The NHS England ‘Adult Psychiatric Morbidity Survey (2016): Survey of Mental Health and Wellbeing, England’, found that panic disorder was most common in the north-west of England.

What is a panic attack?

A panic attack is an abrupt and intense feeling of fear and acute anxiety. It can happen quite suddenly and feel overwhelming. A panic attack can happen at any time or place, and because it can happen quite quickly, it might feel unexpected. But whilst panic attacks can be very frightening, they are not dangerous.

Panic attacks can occur in almost all generalised anxiety disorders (GADs) and also occur with other psychological problems such as depression.

Types of panic attacks

There are two characteristic types of panic attacks: unexpected and expected. The symptoms can be the same for both types but are classified depending on the trigger and onset.

Unexpected panic attacks appear to have no particular cause or trigger; this doesn’t mean that there is actually no cause or trigger, it is just very hard to identify it. For some, it may be unconscious associations to times when they have felt fear, or it may be the brain picking up on cues in the environment before the conscious self does.

This type of panic attack can happen whilst the person is relaxed and resting, or even when they are asleep. Sometimes, a person may be anxious about events in their life and are doing something to relax, such as listening to music, then unexpectantly they experience a panic attack catching them off guard, leading to even greater feelings of fear and stress.

If these unexpected panic attacks are repeated then a doctor may diagnose panic disorder, which is characterised by either recurrent panic attacks, an intense fear of these attacks, or both.

The other type of panic attack is an expected panic attack. These are usually linked to known stressors and specific triggers, such as a fear of heights or a fear of dogs. The panic attack is linked to that particular object or event and can be situationally cued or predisposed.

If the panic attack is situationally cued, then it will occur immediately after the person is exposed to a similar situation or object; for example, even just being on the ground floor of the very tall building where the person suffered a panic attack previously, could trigger a situationally cued panic attack.

With predisposed panic attacks, they may not happen immediately after being exposed to the trigger; the fear or phobia is consistent, so the panic attack can occur before, during or after the event or exposure.

The trigger is clear, but the onset of the attack can vary. For example, someone with a fear of dogs may experience a panic attack before, during or after visiting a park where dogs are walked, or even from just thinking about visiting a park that might have dogs there. Expected panic attacks are more common for people with a generalised anxiety disorder, such as agoraphobia.

What causes a panic attack?

The experts are not entirely sure why some people experience panic attacks or develop panic disorder. The brain and nervous system play key roles in how we perceive and handle fear and anxiety.

The risk of having panic attacks can increase in people who have:

• Family history – Anxiety disorders, including panic disorders, often run in families; the experts are not sure why this is.
• Mental health issues – People who have anxiety disorders, depression or other mental illnesses are more prone to panic attacks. Phobias, such as agoraphobia (fear of crowded or open spaces), claustrophobia (fear of small spaces) and acrophobia (fear of heights), can often cause panic attacks.
• Substance abuse problems – Alcoholism and drug addiction can increase the risk of panic attacks.

Some people have one panic attack and then don’t ever experience another, or they might find that they have them regularly, or several in a short space of time. For some people particular places, situations or activities seem to trigger panic attacks; for example, they might happen before a stressful appointment such as a visit to the dentist or before a vaccination, when anxiety about the appointment turns to panic.

Panic attacks typically trigger worries or fears related to having another attack. This may have an effect on your behaviour, leading you to avoid places or situations where you think you might be at risk of a panic attack.

Expected panic attacks and anxiety can be triggered by some common factors including:

• A stressful job.
• Driving.
• Social situations.
• Reminders or memories of traumatic experiences.
• Chronic illnesses, such as heart disease, diabetes, irritable bowel syndrome or asthma.
• Chronic pain.
• Withdrawal from drugs or alcohol.
• Caffeine.
• Medication and supplements.
• Thyroid problems.

A 2014 study from the US found a very modern trigger for panic attacks: smartphone “withdrawal”. Researchers studied two groups of people, one with panic disorders and one without. The people with panic disorders exhibited stronger emotional, physical and psychological reactions to being without their devices, compared with the other group.

People who experience anxiety are at an increased risk of experiencing panic attacks. However, having anxiety does not mean you will experience a panic attack. For some people who experience unexpected panic attacks, there is often no obvious external factor triggering the attack.

What is the difference between panic attacks and anxiety attacks?

These two conditions have many similarities but they also differ. These are best described in terms of the intensity of the symptoms and the length of time the main symptoms occur. Panic attacks usually peak at around 10 minutes whilst anxiety can last for months.

Panic attacks are more often connected with fear that is more often associated with surges of autonomic arousal necessary for fight or flight, thoughts of immediate danger, and escape behaviours. Our bodies have an in-built defence mechanism to help them deal with a perceived threat, the “fight or flight mechanism”.

Once this is triggered, chemical messages are sent via the “sympathetic” side of our autonomic nervous system (ANS) to stimulate our heart rate, restrict the size of our blood vessels etc. When we deal with a threat, for example a wild animal charging, we either face the threat and fight or we run away. This engages the “parasympathetic” side of the ANS which is designed to bring things back into balance, rather like a seesaw.

Anxiety disorders include disorders that share features of excessive fear and anxiety and related behavioural disturbances. Fear is the emotional response to a real or perceived imminent threat, whereas anxiety is the anticipation of a future threat.

Anxiety is more often associated with muscle tension and vigilance in preparation for future danger and cautious or avoidant behaviours. Sometimes the level of fear or anxiety is reduced by pervasive avoidance behaviours. Anxiety is distinguished from a panic attack in that it includes symptoms such as apprehension and worry, but without the extreme fear and sense of detachment that occurs during a panic attack.

Panic attacks feature prominently within anxiety disorders as a particular type of fear response. But panic attacks are not limited to anxiety disorders; they can be seen in other mental disorders as well.

What do panic attacks feel like?

People experiencing a panic attack have a feeling of sudden and intense fear, often described as the impending sense of doom or danger.

When experiencing a panic attack, many people feel as though their heart is pounding; these heart palpitations are often fearfully perceived and some people report that a panic attack feels like they are having a heart attack or are going to collapse. For many people, this can feel quite distressing.

However, an accelerated heart rate is normal when it comes to panic attacks or even when people are nervous or excited; it is associated with the fight-or-flight response. Heart rate typically returns to normal as the panic attack subsides.

Panic and anxiety attacks may feel similar, and they share a lot of emotional and physical symptoms. People experience breathlessness or feelings of struggling to breathe or choking. Others describe unnaturally deep or fast breathing, which is associated with hyperventilation, which causes an increased loss of carbon dioxide from the blood.

This leads to chemical changes in the blood that can result in light-headedness, dizziness and trembling, as well as tingling in the hands. As breathing begins to return to normal these feelings will gradually subside.

Panic attack sufferers reported to MIND, the mental health charity, their experiences of a panic attack as follows:

• “My teeth would chatter uncontrollably and my whole body would tremble, I’d hyperventilate and cry with panic as the feeling that I was going to fall unconscious was so convincing.”
• “I felt like I couldn’t breathe, I just wanted to get out, to go somewhere else, but I couldn’t because I was on a train.”
• “My panic attacks seem to come out of the blue now. But in fact, they seem to be triggered mainly at night when I want to go to sleep but cannot stop my mind racing, experiencing worry and panic about anything that may be on my mind.”
• “Never knowing when I was going to have a panic attack was the worst feeling in the world.”

How long do panic attacks last?

As the symptoms of panic attacks differ in different people, so too do the intensity and length of the attack. For some people an attack might last a few minutes; in others, a panic attack could last for 30 minutes or more.

A typical panic attack lasts up to 30 minutes, with the symptoms reaching peak intensity within the first 10 minutes before easing up, with some people still feeling somewhat unsteady, dizzy, and experiencing a fear of losing control hours after the actual panic attack has ended.

In some cases, a person might experience panic attacks daily over a period of time; the attack coming in waves of intensity over time. Others might experience one attack and then go months or even years before experiencing another or even never experiencing another.

Panic attack symptoms

The physical symptoms of a panic attack can build up very quickly and can include:

• Chest pain.
• Chills or hot flushes.
• Derealisation or depersonalisation.
• Excessive sweating.
• Fear of dying.
• Fear of losing control or going crazy.
• Feeling dizzy, unsteady, light-headed or faint.
• Feeling of choking.
• Feelings of numbness or tingling sensations.
• Heart palpitations or accelerated heart rate.
• Nausea or abdominal pain.
• Shortness of breath.
• Trembling or shaking.

Panic attack diagnosis

The Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition (DSM-5), lists a set of distinct criteria for diagnosing panic attacks. According to the DSM, a panic attack involves a sudden fear accompanied by four or more of the symptoms that are listed above.

When diagnosing, a doctor will also want to rule out the possibility of any separate medical conditions or related and co-occurring conditions, so medical professionals may carry out tests to rule out an underlying physical condition, an earlier injury, or a substance used.

Such as the symptoms of:

• A thyroid condition.
• Abnormal hormone activity.
• Asthma.
• Cerebrovascular disease.
• Disturbances in some blood chemical levels.
• Epilepsy.
• Heart disease.
• Infections.
• Alcohol use.
• Cannabis use.
• Cocaine use.
• Amphetamines use.
• Hallucinogens use.
• Prescription medications, regardless of whether they are taken under a doctor’s supervision.

Ruling out any physical causes can help to reassure the person that the symptoms they are experiencing are not fatal. Once possible physical causes are ruled out, a mental health professional will be able to help the person to understand the panic attacks. They will investigate any overlap with symptoms of other mental health conditions.

Including:

• Agoraphobia.
• Anxiety.
• Depression.

Treatment for panic attacks

Having assessed the individual’s situation, there are a number of treatments that a GP might recommend should they diagnose a person with having panic attacks.

These include:

• Talking therapies.
• Cognitive behavioural therapy (CBT), either group or one-to-one sessions.
• Guided self-help, including workbooks.
• Applied relaxation therapy.
• Medication such as antidepressants, pregabalin, beta blockers, benzodiazepine tranquillisers.

Working with a therapist can help the person to gain an understanding of the root causes of the panic attacks as well as learn invaluable coping mechanisms for managing them as and when they come along.

Medications can also be useful in helping prevent future panic attacks and lessening the symptoms associated with anxiety.

How to manage panic attacks

There are some strategies that you can try if you feel a panic attack coming on to help to manage the situation:

• Focusing on breathing slowly and deeply can help you manage rapid breathing or anxious feelings. Practise breathing exercises regularly, as they can help prevent panic attacks and also help while they are happening too. Calm has an animation that can help to slow breathing.
• Focusing on an object that you can see and noticing everything about it, can help your panic to subside as you focus all your energy on the object and describe it in detail to yourself.
• Putting your hands in water – Focus on the water’s temperature and how it feels on your fingertips, palms and the backs of your hands. Does it feel the same in each part of your hand? Use warm water first, then cold. Next, try cold water first, then warm. Does it feel different to switch from cold to warm water versus warm to cold? This grounding exercise helps to concentrate the mind.
• Taking a short walk – Concentrate on your steps, you can even count them. Notice the rhythm of your footsteps and how it feels to put your foot on the ground and then lift it again.
• Listening to your surroundings – Take a few moments to listen to the noises around you. Do you hear birds, dogs barking, traffic? If you hear people talking, what are they saying? Do you recognise the language? Let the sounds wash over you and remind you where you are.
• Trying the 5-4-3-2-1 method – Working backwards from five, use your senses to list things you notice around you. For example, start by listing five things you hear, then four things you see, then three things you can touch from where you are, two things you can smell, and one thing you can taste.
• Listening to some of your favourite music or watching your favourite TV show. This can help you switch off from your anxious thoughts and help you to calm down.
• Drinking some water can help if you were breathing quickly, felt out of breath or were crying a lot during your panic attack, as your throat might feel dry or you may feel dehydrated.

How to help someone having a panic attack

The old-fashioned advice was that if someone was having a panic attack or hyperventilating, then you would give them a paper bag to breathe into. The British Red Cross and St John Ambulance strongly recommend against this, as they caution that if the person rebreathes their own air from a paper bag, it may aggravate a more serious condition.

If someone is experiencing a panic attack, speak to them calmly and be reassuring. If possible, lead them to a quiet area where they can gain control of their breathing. Ideally, get them to sit on the floor with their back against the wall and their knees drawn up towards their chest. If you can, stay with the person during their panic attack.

Keep talking to them in a composed manner, which will help to take their mind off their panicky thoughts, helping them to feel calm and to slow down their breathing. Just by you being there, you can help them to calm down and remind them that help is available. As they begin to recover, suggest that they seek medical advice.

Final thoughts

Anyone who suffers panic attacks or who knows someone who does may benefit from contacting any of the following organisations and/or helplines:

• The No Panic Helpline 0300 772 9844 provides a helpline, step-by-step programmes and support for people with anxiety disorders.
• The No Panic Youth Helpline 0330 606 1174.
• You can also access the No Panic crisis message 24hrs a day by calling 01952 680835.
• No More Panic provides information, support and advice for those with panic disorder, anxiety, phobias or OCD, including a forum and chat room.
• Mind – 0300 123 3393.
• Young Minds – 0808 802 5544.