Panic Attacks Explained: What Happens in the Body
A panic attack is one of the most frightening experiences in ordinary medicine, largely because it produces exactly the sensations people associate with a heart attack or with dying. Understanding the physiology reduces the fear, and reducing the fear reduces the attacks.
What an attack consists of
A panic attack is an abrupt surge of intense fear or discomfort that peaks within about ten minutes and includes several of:
- Pounding or racing heart
- Sweating
- Trembling or shaking
- Breathlessness or a feeling of smothering
- A choking sensation
- Chest pain or tightness
- Nausea or abdominal distress
- Dizziness, unsteadiness or faintness
- Chills or heat sensations
- Numbness or tingling, often in the hands, feet or around the mouth
- A sense of unreality or detachment
- Fear of losing control or going mad
- Fear of dying
The symptoms are physically real. Nothing about this is imagined.
The physiology
The sequence usually runs like this. A trigger, which may be a thought, a bodily sensation, a place or nothing identifiable, activates the amygdala. The sympathetic nervous system releases adrenaline and noradrenaline.
Heart rate and stroke volume rise, which produces palpitations and chest tightness as the chest muscles tense. Blood is redirected from the skin and gut to the large muscles, causing pallor, cold hands, nausea and the sensation of a churning stomach. Breathing becomes rapid and shallow.
That last part drives many of the more alarming symptoms. Overbreathing blows off carbon dioxide, so blood becomes more alkaline. This causes cerebral blood vessels to constrict, producing dizziness, blurred vision and unreality, and it alters calcium availability at nerve membranes, producing tingling in the hands, feet and lips and sometimes cramping of the hands.
In other words, the frightening neurological symptoms come from the breathing, not from a brain catastrophe. Adrenaline is cleared within minutes, which is why an attack cannot be sustained indefinitely, however it feels.
The maintaining cycle
Panic disorder develops when the attacks themselves become the feared object. A person notices a normal bodily sensation, such as a skipped beat after coffee, interprets it as dangerous, becomes anxious, which amplifies the sensation, which confirms the interpretation. Two behaviours then lock it in:
Avoidance. Staying away from places where an attack occurred or where escape seems difficult. This prevents learning that the situation is safe, and can progress to agoraphobia.
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Safety behaviours. Carrying medication without using it, always sitting near an exit, insisting on being accompanied, repeatedly checking the pulse. Each one lets the person attribute survival to the behaviour rather than to the harmlessness of the attack.
Ruling out other causes first
A first attack deserves medical assessment, because several conditions mimic panic:
- Cardiac arrhythmia, particularly supraventricular tachycardia
- Angina or heart attack
- Thyrotoxicosis
- Hypoglycaemia
- Asthma exacerbation
- Pulmonary embolism
- Anaemia
- Phaeochromocytoma, which is rare
- Vestibular disorders
- Alcohol or benzodiazepine withdrawal
- Stimulant use, including caffeine, and some decongestants and asthma medications
Once these are excluded, repeated investigation becomes part of the problem rather than part of the solution, because it reinforces the belief that something has been missed.
What helps during an attack
The aim is not to stop the attack, which you cannot do by force, but to stop fighting it.
Slow the exhale. Breathe in through the nose for about four counts and out for six to eight. The long exhale raises carbon dioxide back towards normal and activates the parasympathetic response. Do not breathe deeply and rapidly, which worsens it.
Name it. Saying internally that this is a panic attack, that it peaks in a few minutes and that it cannot harm you, interrupts the catastrophic interpretation.
Let it be there. Resisting the sensations adds a second layer of fear. Allowing them shortens the episode.
Ground yourself. Press your feet into the floor, notice five things you can see, four you can hear, three you can touch.
Stay where you are if you can. Leaving reinforces avoidance. Staying teaches your nervous system that the place was never the threat.
Longer-term treatment
Cognitive behavioural therapy is first-line and highly effective. It has three main elements: education about the physiology, cognitive work on catastrophic interpretations, and exposure. Exposure includes interoceptive exposure, in which the feared sensations are deliberately induced in a controlled way, for example by spinning to create dizziness, breathing through a straw, or running on the spot, until the body learns they are not dangerous.
Medication. SSRIs and SNRIs are the usual first choice, started at a low dose because they can transiently increase anxiety, and continued for six to twelve months after improvement. Benzodiazepines relieve attacks quickly but carry tolerance and dependence risk, and regular use has been shown to reduce the effectiveness of exposure therapy, so they are used sparingly if at all.
Lifestyle. Reduce caffeine, alcohol and nicotine. Regular aerobic exercise has a measurable anti-panic effect. Treat sleep deprivation, which lowers the threshold for attacks.
What to expect
Panic disorder responds well to treatment. Most people improve substantially, and improvement usually begins once avoidance starts to reverse rather than once the attacks stop.
This is general information about a treatable condition, not a substitute for assessment. A first episode of chest pain or breathlessness should be medically evaluated, and if you are struggling with anxiety or low mood, speaking to a doctor is a reasonable and useful step.