Panic attacks: what is happening in your body, and how they are treated

01

What is happening in your body

Your heart may race, and you may sweat, tremble or feel breathless, dizzy, sick or tingly. Many people feel a rush of dread, as if they are about to lose control or even die.

These sensations come from your body’s built-in alarm, often called the fight-or-flight response. When your brain senses danger, it releases stress chemicals such as adrenaline. Your heart and breathing speed up and blood is pushed towards your muscles, ready to run or fight. A panic attack is this alarm going off when there is no danger in front of you.

Over-breathing lowers the carbon dioxide in your blood, which can bring on light-headedness and tingling. Then a second loop starts: you notice the racing heart, think “something is wrong with me”, and that thought frightens you more, which pushes the alarm harder. The sensations do settle with time, often within minutes, though some attacks last longer.

02

“Is this a heart attack?”

Because the symptoms feel so physical, many people first reach an emergency department convinced their heart is failing. The Indian Psychiatric Society’s guidelines note that people with panic often turn up in emergency settings and, after a thorough check, are found to be medically well.

Going to get checked is the right call, especially the first time. Chest pain has many possible causes, and some, like a heart attack, need treatment straight away. Treat it as an emergency if the pain is sudden and does not go away, spreads to your arm, neck, jaw, stomach or back, or comes with sweating, nausea, light-headedness or breathlessness. Conditions such as an overactive thyroid can also mimic panic.

Once a doctor has ruled out a physical cause, you can treat the panic with more confidence. Get any new or different symptoms checked too.

03

When panic becomes panic disorder

A single panic attack, or an occasional one, is not considered a mental disorder. Panic disorder means attacks keep coming back unexpectedly, not only in one particular situation, and start to shape your life.

The two main diagnostic systems, DSM-5 and the WHO’s ICD-11, describe repeated unexpected attacks followed by ongoing worry about another one, or changes in behaviour to avoid them. In DSM-5, this worry or change lasts at least a month. A doctor also checks that the symptoms are not better explained by a medical illness, a medicine or another substance.

Avoidance is where the cycle tightens. You might stop taking the metro, avoid crowded markets, give up exercise, or refuse to go out without a family member. Escaping brings quick relief, but it also teaches your brain that the place, or the sensation, really was dangerous. The fear grows and your world can quietly shrink.

04

How panic disorder is treated

The two main treatments are a talking therapy called cognitive behavioural therapy (CBT) and medicine. Indian clinical guidelines describe CBT and antidepressants as roughly equally effective for panic disorder, and some people do best with a combination.

In CBT, you learn how the panic cycle works and how to question frightening thoughts about body sensations. A key part is gradual exposure, guided by your therapist. This includes interoceptive exposure, where you deliberately bring on mild versions of the feared sensations, such as a faster heartbeat or a little dizziness, in a safe setting until they lose their power to scare you. You also step back, bit by bit, into places you have been avoiding. NICE in the UK suggests about 7 to 14 hours of CBT in total, usually as weekly sessions.

When medicine is used, antidepressants called SSRIs are generally the first choice. They take several weeks to start working, and side effects are usually not severe, particularly when started at a low dose. Doctors usually advise continuing them for some months after you feel better to lower the chance of relapse, so plan any stopping with your psychiatrist.

Benzodiazepines are sedatives that calm panic quickly, but some people build up tolerance and some become dependent on them. That is why, when a psychiatrist uses them at all, it is usually only for a short time, for example while an antidepressant starts to work. UK guidance from NICE advises against them for treating panic disorder. Never take them without a prescription, and do not stop them suddenly, as that can cause withdrawal symptoms.

05

What helps during an attack

These steps will not cure panic disorder, but they can make an attack easier to ride out.

• Breathe slowly. Breathe in gently through your nose for a count of three, letting your belly rise, then breathe out slowly through your mouth. Repeat a few times.
• Ground yourself. Notice five things you can see, four you can feel, three you can hear, two you can smell and one you can taste.
• Name what is happening. Once your heart has been checked, remind yourself: “This is my alarm going off. It is unpleasant, but it will pass.”
• Stay put if you can. Riding out the wave, rather than rushing away, builds confidence that you can cope.

06

When to see a psychiatrist

It is worth booking an appointment if attacks keep returning, if you spend a lot of time dreading the next one, or if you have started avoiding travel, work, exercise or social plans. Seek help too if you are using alcohol or pills to cope, or feel low or hopeless.

A psychiatrist can confirm what is going on, make sure nothing else is being missed, and plan treatment that suits you. For example, someone might start with CBT and add medicine only if needed. Getting help early can stop the cycle of fear from tightening.