Panic Attacks

A panic attack can feel like a heart attack, loss of control or another immediate catastrophe, but the sensations do not reveal their cause by themselves. Clinicians first consider the symptom pattern, previous episodes, physical warning signs and whether another medical condition needs assessment.

A panic attack is a sudden surge of intense fear or distress accompanied by strong physical or mental symptoms. It can develop rapidly, sometimes without an obvious trigger. The experience can feel overwhelming even when no external danger is present. You may feel certain that you are having a heart attack, fainting, suffocating or losing control. These fears are part of the experience for many people. They do not mean that you are imagining the physical sensations. A panic attack is an episode, not a diagnosis by itself. One attack does not automatically mean that you have panic disorder. Panic attacks can occur with several anxiety conditions, trauma related problems, depression, substance use, physical illness or severe stress. What a panic attack can feel like Physical symptoms may include a racing or pounding heartbeat, sweating, trembling, chest discomfort or shortness of breath. You may feel dizzy, faint, hot, cold, sick or unsteady. Your fingers, lips or face may tingle. You may experience numbness, dry mouth, stomach discomfort or a choking sensation. Symptoms differ between people and between separate attacks. Mental symptoms may include intense dread, fear of dying, fear of losing control or a feeling that something terrible is happening. You may feel detached from yourself or as though your surroundings are unreal. Clinicians call feeling detached from yourself depersonalisation. Feeling that your surroundings are unreal is called derealisation. These sensations can be frightening but can occur during intense anxiety. Panic attacks usually rise quickly A panic attack usually develops quickly and reaches its most intense point within minutes. Most attacks last between five and twenty minutes, although some last longer. The most intense symptoms may settle before you feel fully recovered. You may remain shaky, tired or worried afterwards. Fear of another attack can continue long after the physical surge has passed. Symptoms that continue for many hours at the same intensity, steadily worsen or follow a different pattern may require assessment for another explanation. Duration alone cannot identify the cause. The body's alarm response During possible danger, your nervous system prepares your body to respond. Your heart may beat faster, your muscles tense and your breathing change. This is often called the fight or flight response. During panic, the alarm response may activate when there is no immediate external threat. The sensations are still genuine. They reflect changes in breathing, circulation, muscle activity, attention and stress hormones. Rapid, deep breathing, known as hyperventilation, can contribute to dizziness, tingling and feelings of unreality. These sensations can increase fear and intensify the panic cycle. This creates a feedback cycle. A sensation causes a frightening interpretation, which increases the alarm response and makes the sensation stronger. Not every panic attack begins with breathing changes, and not every episode of rapid breathing is caused by panic. Panic attacks and panic disorder are different You may experience an isolated panic attack during acute stress or another anxiety condition. You may never experience another one. Panic disorder involves recurring, unexpected panic attacks followed by at least one month of continuing worry about further attacks or changes in behaviour because of them. You may avoid exercise, travel, crowded places or being alone because you fear that another attack will occur. The attacks are described as unexpected when they are not consistently limited to one predictable situation. Panic attacks that occur only in one particular setting may fit another anxiety pattern, such as a specific phobia or social anxiety. Panic disorder can occur with agoraphobia. Agoraphobia involves fear or avoidance of situations where escape might feel difficult or help might seem unavailable. It is not simply a fear of open spaces. Fear of physical sensations can maintain the cycle After an attack, you may monitor your heartbeat, breathing or balance closely. Ordinary changes caused by exercise, heat, caffeine or standing up may then feel threatening. You may repeatedly check your pulse, search symptoms online or seek reassurance. Reassurance may reduce fear briefly but may not address the underlying cycle. You may avoid exercise because a faster heartbeat reminds you of panic. You may avoid public transport, shops or unfamiliar places in case an attack occurs. This can gradually restrict daily life. Avoidance is understandable but can prevent you from learning that the sensations and situations may be manageable. Cognitive behavioural therapy often addresses these interpretations, safety behaviours and avoidance patterns in a planned way. Physical conditions can resemble panic Palpitations, chest discomfort, dizziness, breathlessness and sweating are not specific to panic. Heart rhythm problems, asthma, low blood sugar, thyroid disease and several other conditions can cause overlapping symptoms. Infection, anaemia, hormonal changes and some neurological conditions may also contribute to similar experiences. Fainting or loss of awareness is not a typical feature to dismiss as uncomplicated panic. A first episode, a clearly different episode or symptoms beginning during physical activity may need physical assessment. Your age, past health problems, medicines, pregnancy status and associated symptoms also influence what assessment is appropriate. A previous diagnosis of panic disorder does not prevent you from developing a physical illness. New warning signs should still be taken seriously. Medicines and substances can contribute Large amounts of caffeine, nicotine, stimulant drugs and some prescribed medicines can trigger anxiety like symptoms. Cannabis and other recreational drugs can also provoke panic in some people. Alcohol may temporarily reduce anxiety but can worsen it later. Withdrawal from alcohol or sedative medicines can cause severe anxiety, shaking, sweating, confusion, hallucinations or seizures. Do not stop prescribed medication suddenly without clinical advice. Tell the clinician about prescribed medicines, pharmacy products, supplements, alcohol and recreational drugs so that they can interpret the pattern safely. How a clinician assesses panic attacks The clinician asks what happened before, during and after the episode. They explore how quickly symptoms developed, how long they lasted and whether the attack was expected or unexpected. They ask about chest pain, palpitations, breathing, dizziness, fainting and neurological symptoms. They also ask whether attacks occur during exercise, sleep, substance use or changes in medication. The clinician explores how often attacks happen and whether you now fear or avoid particular situations. They ask about general anxiety, low mood, trauma, obsessive thoughts, alcohol, drugs and your current support. A direct question about self harm or suicide may form part of the assessment. Panic can coexist with depression, substance misuse or a mental health crisis. A mental state examination assesses your behaviour, speech, mood, thoughts, awareness and engagement. It does not diagnose the cause of chest pain or other physical symptoms. Tests depend on the presentation There is no blood test, scan or questionnaire that confirms a panic attack. Diagnosis depends on the history, the overall pattern and appropriate consideration of alternative causes. A clinician may check your pulse, blood pressure, breathing rate and oxygen level. An ECG may be appropriate when palpitations, chest discomfort, fainting or another cardiac concern is present. Blood tests may be considered when symptoms suggest anaemia, thyroid disease, abnormal blood glucose or another physical contributor. Not everyone with a familiar panic pattern needs extensive investigation. An ECG records the heart's electrical activity during the recording. A normal ECG does not prove that anxiety caused the symptoms and does not exclude every intermittent rhythm problem. Repeated investigations without a new clinical indication may provide only brief reassurance. The clinician should explain what each test can and cannot establish. What can help during a familiar panic attack When you recognise a familiar panic pattern and there are no new warning signs, remind yourself that the surge will pass. Try to remain somewhere safe rather than rushing into another hazard. Slow your breathing gently. Avoid repeated very large breaths, which may worsen light headedness. You might breathe in comfortably and allow a slightly longer, unforced breath out. Grounding can help redirect attention. You might notice your feet against the floor, describe objects around you or focus on one neutral sound. These techniques do not prove that an episode is panic. Do not use calming exercises to delay emergency help for severe, new or concerning physical symptoms. Treatment for recurring panic attacks Arrange an assessment if attacks recur, create persistent fear or change how you live. You can seek help after one attack if you are concerned or uncertain about the cause. Adults in England can usually refer themselves to NHS Talking Therapies. A GP can also assess physical and mental health contributors and discuss treatment options. Structured self help may be offered for mild to moderate panic disorder. Cognitive behavioural therapy is an established treatment for more persistent or disabling panic disorder. Therapy may explore feared interpretations of body sensations, avoidance and behaviours used to feel safe. Exposure exercises are planned and should not involve ignoring genuine medical danger. Antidepressant medication may be considered when panic disorder is persistent, psychological treatment has not helped, or you prefer medication after discussing the options. A medicine described as an antidepressant can treat panic disorder even when you are not depressed. Antidepressants can initially increase anxiety in some people and may take time to work. Stopping suddenly can cause withdrawal symptoms. Treatment should include information about adverse effects, follow up and safe reduction when appropriate. NICE advises that benzodiazepines should not be prescribed for panic disorder because they are associated with poorer long term outcomes. Treatment decisions should remain individual and based on clinical assessment. Panic attacks may overlap with "Anxiety", "Palpitations", "Feeling Short of Breath", "Chest Pain: What Could It Be?", "Dizziness and Vertigo" and "Fainting (Syncope)", but these symptoms should not automatically be attributed to panic.

Clinicians recognise panic from the complete pattern, not from one dramatic symptom. They consider how rapidly the episode developed, whether attacks recur unexpectedly, what the person now fears or avoids, and whether physical illness, medicines or substances could better explain the presentation.