Simply Psychology Logo


A Guide to Panic Attacks and Panic Disorder

By Olivia Guy-Evans, published March 01, 2022

by Saul Mcleod, PhD


What is Panic Disorder?

Panic disorder is a type of anxiety disorder which is characterized by intense, recurrent, and unexpected panic attacks.

Feeling anxious or fearful are normal human emotional reactions to frightening situations. Anxious feelings can be helpful, making someone more alert and responsive to their environment.

Fear can also be useful as it can signal imminent danger and allows the body to respond in order to increase chances of survival. Fear is thought of as an automatic alarm response which switches on the moment there is danger.

Although the biochemical reaction for fear may be the same, some people will experience the intensity of fearful situations differently than others.

The family of fearful experiences can be distinguished in terms of three factors:

Intensity: How severe is the harm that is threatened?
Timing: Is the harm immediate or impending?
Coping: What, if any, actions can be taken to reduce or eliminate the threat?

When the body responds to danger with physical symptoms, this is known as the fight or flight response. Sometimes however, it is possible to have an intense fear response when there is no apparent danger, almost like a false alarm that can happen when the person least expects it.

This response can be so intense that it results in a panic attack. A panic attack is a brief but extreme episode of overwhelming fear and intense physical and emotional reactions that one may have in response to a real danger but happens in situations that most people would not be afraid about.

Panic disorder describes a condition where panic attacks seem to happen unexpectedly rather than in predictable situations. These panic attacks can peak within 10 minutes and can be very frightening, and people experiencing an attack may feel a strong desire to escape the situation they are in.

Although panic attacks themselves aren’t life threatening, they can be very distressing and may significantly affect quality of life.

Most people are thought to experience a panic attack at least once in their lives, with the problem going away, usually once the stressful situation is over.

Panic disorder is thought to affect approximately 2.7% of the adult United States population each year, according to The National Institute of Mental Health.

The symptoms of panic disorder often begin to appear in young adults, between the ages of 20-24 years old and the prevalence seems to be higher for females than for males.

Types of Panic Attack

For panic disorder, there are two main types of panic attacks: unexpected and expected.

Unexpected Panic Attacks

Those with panic disorder most commonly experience these unexpected panic attacks. These can occur suddenly, without warning, or any known trigger.

These can even happen when the person is relaxed and not experiencing anxiety.

Expected Panic Attacks

Expected panic attacks are more likely to be predicted. They can often occur when exposed to a situation which the person finds fearful.

For instance, someone may have a panic attack when performing on stage or when giving a speech

What Do They Feel Like?

There are many physical and emotional symptoms associated with panic attacks. The physical symptoms of panic attacks correspond to the feelings experienced during the fight or flight response, but more intense.

The emotional symptoms of panic attacks are usually extreme fear and anxiety.

The experience is different for everyone, and the symptoms can often vary. Typically, the symptoms are not proportionate to the level of danger that exists in the environment.

Many people living with panic disorder describe feeling as though they are having a heart attack or on the verge of dying. The feeling may be so intense that they may seek emergency medical assistance, especially if they are not aware that they have panic disorder.

One of the worst reported feelings associated with panic attacks is the intense fear of experiencing another panic attack. Sometimes, even the fear of having another panic attack can trigger another for some people. 

panic attack symptoms

Panic Attack Symptoms

Below is a list of some of the symptoms that can be experienced:

  • Skipping, racing, or pounding heartbeat

  • Sweating 

  • Trembling or shaking

  • Shortness of breath or difficulty breathing

  • Chest pain, pressure, or discomfort

  • Nausea, stomach cramping, or other stomach problems 

  • Dizziness, feeling faint, or light-headedness

  • Chocking sensations

  • Tingling or numbness in parts of the body

  • Hot flushes or chills

  • Feeling detached from things going on in the environment

  • Feeling detached from the body

  • Thoughts of losing control or going crazy

  • Sense of impending doom or danger

  • Fear of dying

How Long Do They Last?

A panic attack can typically last between 5 to 20 minutes, reaching a peak of symptoms within about 10 minutes. In extreme cases, the symptoms may last for more than one hour.

Since the panic attacks cannot always be predicted, they can significantly affect everyday life.

Panic can lead to serious disruptions in daily functioning and make it difficult to cope with normal everyday situations that may trigger feelings of intense panic and anxiety.

Some people with panic disorder may even avoid leaving the house for extended periods of time, for fear of having a panic attack in public. 

Diagnosis

Many people may seek medical support after having a panic attack since they believe they are having a heart attack. It is reportedly difficult to differentiate between the symptoms without the help of a medical professional. 

At an appointment, the healthcare professional may perform several tests to see if the symptoms were caused by a heart attack. They may run blood tests to rule out other conditions that can cause similar symptoms and use an electrocardiogram (ECG) to check heart function.

If it is determined that the person does not need emergency care, they should be referred back to their primary care provider who should perform a mental health examination and ask about the symptoms being experienced. 

All other medical disorders should be ruled out before the primary care provider makes a diagnosis of panic disorder. A mental health professional can also diagnose panic disorder using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 

The DSM-5 defines panic attacks as an abrupt surge of intense fear or discomfort that reaches a peak within minutes, and during which time, four or more of the panic attack symptoms occur.

At least one panic attack should be followed by a month or more of the person fearing that they will have more attacks and causing them to change their behavior, which often includes avoiding situations which may induce a panic attack. 

During the diagnosis process, the professional must rule out other potential causes for the panic attack, for instance:

  • The attacks must not be due to the direct physiological effects of a substance or general medical condition. 

  • The attacks are not better accounted for by another mental disorder including social phobia, another specific phobia, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), or separation anxiety disorder. 

Biology and Psychology of Panic

Panic attacks can be seen as a blend of biological, emotional, and psychological reactions, the emotional response being fear. 

Biological reactions: fight or flight

When there is real or imagined danger, the body goes through a series of changes known as the fight or flight response. Some of these biological changes include:

  • Increased heart rate

  • Increased rate and depth of breathing

  • Increased sweating

  • Muscle tension

Fight or Flight Response

When anxious or afraid in situations where there is no real danger, the body sets of an automatic biological alarm and the fight or flight response kicks in.

In this case, this would be a false alarm since there would be no danger to prepare the body for.

In those with panic disorder, the body will still respond as if there is an imminent threat to life and cause all the same biological reactions as the fight or flight response. 

Biological reactions: hyperventilation and anxious breathing

When breathing in, we obtain oxygen that can be used by the body, and we breathe out to expel carbon dioxide.

When someone is anxious, the optimal level of carbon dioxide is disrupted because the person is beginning to hyperventilate or breathe too much.

If the body cannot return the carbon dioxide levels to an optimal range, this can result in experiencing further symptoms such as dizziness, light-headedness, weakness, and muscle stiffness.

This can be very distressing for those with panic disorder as it may be perceived as being the sign of an oncoming attack.

Psychological reactions: thinking associated with panic

People who experience panic attacks are usually good at noticing physical symptoms. They may be constantly scanning their bodies for these symptoms, which can become an automatic habit for them.

Once they have become aware of any symptoms, these are often interpreted as signs of danger. This can result in them thinking that there is something wrong with them, that they are going crazy, losing control, or that they are going to die. 

Some of the types of unhelpful thinking patterns that often occur with panic disorder include:

  • Catastrophic thoughts about normal or anxious physical sensations.

  • Over-estimating the cost of having a panic attack, such as thinking the consequences of having a panic attack will be very serious or very negative.

  • Over-estimating the chance that they will have a panic attack. 

Psychological reactions: behaviors that keep panic going

When experiencing or expecting anxiety, people can act in certain ways to control the anxiety. A way in which this can be done is by keeping away from situations where they may expect to have a panic attack.

This is called avoidance and can include:

  • Avoiding situations where panic attacks have occurred in the past.

  • Avoiding situations from which it is difficult to escape or where it may be difficult to seek help, such as public transport or shopping centres. 

  • Avoiding situations or activities which may result in similar physical sensations such as physical activity or drinking coffee. 

A second behavioral response may be to behave differently or to use safety behaviors to cope with the anxious situation, such as:

  • Making sure there is an escape route nearby.

  • Carrying specific panic medications everywhere

  • Ensuring there is a wall nearby to lean on

  • Seeking reassurance from others

  • Reading 

  • Listening to music, such as using headphones on public transport

Although these behaviors may not seem harmful to begin with, if someone with panic disorder becomes dependant on these behaviors, they can become even more distressed if one day these safety behaviors are not possible. 

The Cycle of Anxiety – How is Panic Maintained?

The essence of anxiety is worrying about some potential threat and then trying to cope with future events that are believed to be negative.

Someone with panic disorder may do this by paying more attention to the possible signs of potential threats and looking internally to see whether they will be able to cope with that threat.

When they notice any indication of anxious symptoms, they may believe they cannot cope with the situation and therefore become more anxious.

How avoidance contributes to anxiety

When feeling anxious, it makes sense to want to do things to reduce the anxiety. Sometimes, people with anxiety will try and reduce their anxiety by avoiding the feared situation altogether.

anxiety avoidance graph

This avoidance can provide instant short-term relief for those with anxiety because they have not put themselves in a distressing situation.

Whilst avoidance may make anxiety better in the short-term, it can make anxiety worse in the long-term, as the confidence about coping in the situation will be reduced.

If the anxiety-provoking situation is always avoided, then this can make it even more challenging to face in the future.

How safety behaviors contribute to anxiety

As well as avoidance, people with anxiety may use safety behaviors to help them cope with their anxiety. Examples of safety behaviors include a reliance on carrying medication everywhere, the security of a phone, having an exit plan, or bringing a friend along for every situation stressful. 

These safety behaviours can also play a part in the cycle of anxiety. When someone depends on these behaviours, they do not learn that their emotions are not dangerous.

They may not learn that the distressing emotions such as panic tend to simmer down over time on their own. Instead of dealing with the emotions, the safety behaviors suppress them.

If the person’s fears do not come true, the person may mistakenly thank the safety behaviors for this. The behaviors can be heavily relied upon that if they were not available in a situation, the anxiety can increase even more.

Safety behaviors do not give the person the opportunity to learn to cope with their anxiety, or to directly test their fears. 

Reversing the vicious cycle of anxiety

As previously discussed, vicious cycles have shown to play a role in maintaining anxiety. However, this can be turned around to create a positive cycle that can help to overcome anxiety.

An important step to overcoming anxiety is to gradually confront the feared situations. This should lead to an improved sense of confidence, which will help those with panic disorder to reduce their anxiety and get back to the situations that are important to them. 

Some may think that jumping in at the deep end and facing the biggest fear first is best. However, many people prefer to take it one manageable step at a time, known as ‘graded exposure’.

This is where the person will start with situations that are easier to handle before working their way up to the more challenging tasks. This may cause a short-term slight increase in anxiety, but it allows confidence to be built up slowly and challenge the fears about each situation.

Through doing this in a structured and repeated way, the person with panic disorder can have a good chance of reducing their anxiety about many situations.

Graded exposure should also help to reduce the use of safety behaviors, avoidance, and a decrease in scanning for physical symptoms. 

Treatment

Exposure therapy

Exposure therapy is a psychological treatment which was developed to help people confront their fears. This works on the concept of breaking the cycle of anxiety by gradually exposing someone to the feared object, activities, or situations. 

Whilst being gradually exposed to the fearful situation, the therapist can teach the person with panic disorder some relaxation exercises to make the situation feel more manageable, and to associate the feared situation with relaxation.

With repeated practice, the person should feel more confident to face challenging situations whilst using relaxation and coping strategies they have learnt to help them manage. 

Cognitive behavioral therapy (CBT)

CBT is a type of psychotherapy which can help people with panic disorder learn new ways of thinking and with reacting to anxiety-provoking situations. CBT focuses on both behavioral and thought processes in understanding and controlling anxiety. 

Together with the therapist, negative and unhelpful thinking patterns can be identified. This can include uncontrolled worrying thoughts about what may or may not happen if the individual has a panic attack.

Unhelpful behaviors can also be identified, such as avoiding certain situations or using safety behaviors.

As part of this process, the therapist helps their client to challenge their unhelpful patterns of thinking and behavior and replace these thoughts with more realistic and helpful ways of thinking. 

Panic-focused psychodynamic psychotherapy (PFPP)

Based on certain psychoanalytic concepts, PFPP aims to uncover the underlying conflicts and experiences which may have influenced the person’s development of panic and anxiety.

The psychoanalytic concepts assume that people are shaped by early relationship experiences and that unconscious motives and psychological conflicts are at the core of certain current symptoms and behavior.

The belief is that the unconscious mind is a hiding place for painful emotions with defence mechanisms keeping these emotions hidden.

However, if these emotions can be brought to the conscious mind, through PFPP, it is thought they can be dealt with more adaptively, and the symptoms of panic disorder can be eliminated or reduced. 

Medication

The primary reason why someone with panic disorder may be taking medication is to help in reducing the symptoms of a panic attack.

Medication may only be prescribed for a short period of time to control the symptoms whilst utilizing other strategies such as those learnt in therapy. 

Medication for panic disorder usually falls under two categories: antidepressants and anti-anxiety drugs:

  • Selective serotonin reuptake inhibitors (SSRIs) are a commonly prescribed antidepressants for anxiety disorders as they act on the neurotransmitter serotonin, a chemical associated with mood and feelings of happiness. Examples of SSRI medications are Zoloft (Sertraline) and Prozac (Fluoxetine). 

  • Serotonin and norepinephrine reuptake inhibitors (SNRIs) are another type of antidepressant which, as well as acting on serotonin, also work on the neurotransmitter norepinephrine, a chemical associated with helping the body respond to stress. The SNRI Effexor XR (Venlafaxine) is approved for the treatment of panic disorder. 

  • Benzodiazepines, a type of anti-anxiety medication, acts as a depressant on the central nervous system (CNS). This type of medication can work quicker and stronger than antidepressants but are generally used only on a short-term basis as they can cause dependence. Xanax (Alprazolam) and Klonopin (Clonazepam) and types of benzodiazepines which are approved for the treatment of panic disorder.

Finding the right medication that works best for the person with panic disorder can take time. It is useful to keep in mind that it can also take several weeks since first starting a medication to notice an improvement in symptoms.

All medications also come with the risk of side effects, so these should be discussed with a doctor before beginning to take any.

How to cope with a panic attack

There are several methods that someone can use to help them cope with their panic attacks. 

Relaxation

Relaxation exercises have been found to be beneficial for those with panic disorder. This can include partaking in yoga, meditation, mindfulness, and deep breathing exercises.

During or immediately after a panic attack, it may be useful to complete relaxation exercises to help manage or recover from the intense feelings quicker. 

A technique known as progressive muscle relaxation is a method wherein individuals will purposely tense a muscle, before releasing it after a few seconds, so that this muscle group feels relaxed.

Someone with panic disorder could start by tensing and relaxing their feet, working their way up their body through their legs, arms, and face, until their whole body feels more relaxed and focused. 

Likewise, visualization is another relaxation technique which can be used during a panic attack.

This is where individuals imagine they are in an environment that they find relaxing, with the aim of calming down their anxious and panicked symptoms. 

Exercise 

A study investigated the effects of exercise, specifically aerobic exercise, on anxiety symptoms in people with panic disorder.

They found that regular aerobic exercise can promote a reduction in anxiety levels (Lattari et al., 2018). 

Sleep

People with panic disorder often report having trouble sleeping. This deprivation can result in greater panic symptoms, so it is important to get plenty of sleep.

Also, it is important to try to stick to a regular sleeping schedule such as starting to settle down for bed at the same time every day to get into a consistent routine. 

Keeping a journal

It may be useful to keep a journal to track when panic attacks occur, whether there were any known triggers, and to record symptoms (physical and emotional).

As well as this, documenting any coping strategies that were used that helped to cope with the symptoms can be useful to determine what works for the individual. 

Do you need mental health help?

USA

Contact the National Suicide Prevention Lifeline for support and assistance from a trained counselor. If you or a loved one are in immediate danger: https://suicidepreventionlifeline.org/

1-800-273-8255

UK

Contact the Samaritans for support and assistance from a trained counselor: https://www.samaritans.org/; email [email protected].

Availiale 24 hours day, 365 days a year (this number is FREE to call):

116-123

Rethink Mental Illness: rethink.org

0300 5000 927

Fact Checking
Simply Psychology content is rigorously reviewed by a team of qualified and experienced fact checkers. Fact checkers review articles for factual accuracy, relevance, and timeliness. We rely on the most current and reputable sources, which are cited in the text and listed at the bottom of each article. Content is fact checked after it has been edited and before publication.

About the Author

Olivia Guy-Evans obtained her undergraduate degree in Educational Psychology at Edge Hill University in 2015. She then received her master’s degree in Psychology of Education from the University of Bristol in 2019. Olivia has been working as a support worker for adults with learning disabilities in Bristol for the last four years.

How to reference this article:

Guy-Evans, O. (2022, March 01). A Guide to Panic Attacks and Panic Disorder. Simply Psychology. www.simplypsychology.org/panic-disorder.html

Sources

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition. American Psychiatric Association; 2013.

Cleveland Clinic. Anxiety disorders: Diagnosis and tests.

Lattari, E., Budde, H., Paes, F., Neto, G. A. M., Appolinario, J. C., Nardi, A. E., Murillo-Rodriguez, E. & Machado, S. (2018). Effects of aerobic exercise on anxiety symptoms and cortical activity in patients with panic disorder: a pilot study. Clinical practice and epidemiology in mental health: CP & EMH, 14, 11.

Locke, A. B., Kirst, N., & Shultz, C. G. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. American family physician, 91(9), 617-624.

National Institutes of Mental Health. Panic disorder: When fear overwhelms.

Nathan, P., Correia, H., & Lim, L. (2004). Panic Stations! Coping with Panic Attacks. Perth: Centre for Clinical Interventions.

Home | About Us | Privacy Policy | Advertise | Contact Us

Simply Psychology's content is for informational and educational purposes only. Our website is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

© Simply Scholar Ltd - All rights reserved