Acute Panic Attack

What is a panic attack?

A panic attack is an abrupt episode characterized by a sudden, intense feeling of fear or discomfort.

Panic is the most acute form of anxiety.[1] One’s body goes into fight or flight mode – becoming ready to escape from physical danger – but there is usually no literal source of danger present. Instead, the concurrent mental and physical symptoms of a panic attack occur in response to a buildup of anxious thoughts.

A person having a panic attack may feel that they are dying or losing their sanity during the attack. Although this is an inherently distressing experience, panic attacks pose no serious actual health risks. The typical duration of a panic attack episode is between 5 and 20 minutes, after which both the mental and physical symptoms associated with the attack will abate. Practicing therapeutic techniques, in particular breathing exercises, can help an individual to feel better after a panic attack.[1]

Panic attacks can affect people of all ages, and may occur during any activity and in any location. Many people will experience a panic attack or two during the course of their lifetime, without developing an ongoing problem. Often, a panic attack will be associated with undergoing a particularly stressful life event such as bereavement, a job change or separating from a partner, but it is also common to be unable to identify a trigger.

If a person experiences recurrent panic attacks, this is called panic disorder, a condition which is usually treatable with psychotherapeutic methods and/or medication.

Symptoms

People who experience a panic attack are not usually aware that the episode is going to occur until it begins, particularly if the affected individual has not experienced a panic attack before.

Physiological changes in the body – such as an increasing heart rate – have been found to occur up to an hour in advance of a panic attack, but the first perceptible signs generally only become apparent as the attack begins. These include symptoms of mental distress such as the belief that one is dying, and concurrent physical symptoms such as increased heart rate (palpitations), sweating and trembling.

Onset

There are typically no perceptible signs of the onset of a panic attack. However, research has been conducted to test the hypothesis that panic attacks occur spontaneously. Findings suggest that imperceptible changes in the body can begin to occur before the actual panic attack begins.

Physiological changes which may take place up to an hour in advance of a panic attack include:[2]

  • Irregular breathing patterns
  • Increased heart rate

However, these physiological indicators are subtle, unlike the symptoms that are present during a panic attack itself. In general, they go unnoticed by the affected individual and those around them, and do not serve as an advance indicator of the panic attack they precede.

Symptoms during a panic attack

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), four or more of the following physical and psychological symptoms must be present:[3]

  • Palpitations, pounding heart, or accelerated heart rate
  • Sweating
  • Trembling or shaking
  • Sensations of shortness of breath or smothering
  • Feeling of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, unsteady, lightheaded, or faint
  • Chills or heat sensations
  • Paresthesias (numbness or tingling sensations)
  • Derealization (feelings of unreality) or depersonalization (being detached from oneself)
  • Fear of losing control or going crazy
  • Fear of dying

If four or more of the above symptoms are present, it is known as a full-symptom panic attack.

Limited-symptom panic attacks

It is possible to experience a panic attack in which less than four of the above symptoms are present. This is called a limited-symptom panic attack.

Limited-symptom panic attacks are often experienced by people undergoing effective treatment for panic disorder, as they learn to use therapeutic techniques to reduce the number and severity of the symptoms they experience during an attack.

Duration

The duration of a panic attack is usually between 5 and 20 minutes, with most panic attacks reaching their peak at around 10 minutes.

Nearly all panic attacks subside in under an hour, at which point the physical and psychological symptoms will be alleviating, or no longer be present. It is normal to feel exhausted and shaken by the experience of having a panic attack after the attack itself is over, and there are many techniques such as breathing exercises which can help one begin to feel better.

Recurrent panic attacks

It is possible for a person to become so distressed by a panic attack that, rather than calming down afterwards, they experience a recurrent panic attack, or more. One should not be concerned about one’s long-term health if one experiences one or more subsequent attacks after the initial episode, as there are no long-term health consequences.

Learning coping techniques such as breathing exercises to perform in the event of a panic attack can help one calm down efficiently, reducing the likelihood of recurrent panic attacks.

Nocturnal panic attack

It is possible to experience a panic attack in one’s sleep. This is called a nocturnal panic attack and involves waking up in a state of panic.[4] Nocturnal panic attacks are no different from panic attacks that occur when one is awake, in terms of their symptoms, duration and possible triggers.

Nocturnal panic attacks are a common occurrence in people with panic disorder, but can also be one’s first or only experience of a panic attack.

Panic attack or heart attack?

The symptoms of a panic attack can be similar to those of a heart attack. It is common for people experiencing a panic attack to become convinced that they are having a heart attack during the episode. Although this may be related to the distressing thoughts that accompany a panic attack, emergency medical services should be called if a heart attack is suspected, as – unlike a panic attack – a heart attack requires prompt medical attention and can be life-threatening.

Key differences between a heart attack and a panic attack include:[5]

  • Tingling: In a heart attack, a person may experience a tingling sensation in their left arm, whereas in a panic attack the tingling sensation, if present, will affect the entire body.
  • Breathing: A panic attack often causes hyperventilation (breathing too quickly) but a heart attack does not. However, both panic and heart attacks can cause the sensation of shortness of breath.
  • Vomiting: It is common to vomit during a heart attack, but less common to do so during a panic attack.
  • Pain in a panic attack: The sensation will be sharp, will feel worse when one breathes deeply or puts pressure on the chest, and will usually be felt all over the heart. It will disappear within five to ten minutes.
  • Pain in a heart attack: The sensation will be like a crushing feeling all over the chest and may extend into the shoulders, left arm, neck and back. It will last longer than ten minutes and will not be made worse by breathing or pressing on the chest.

Despite being able to identify these differences, it is advisable to always seek medical attention if the affected person:[6]

  • Has a history of heart attacks
  • Meets the risk criteria for a heart attack (such as high blood pressure, being overweight, getting limited physical exercise)
  • Has never had a panic attack before

People who believe that they are experiencing a heart attack during a panic attack should seek medical attention the first time this occurs. They will be screened in order to determine whether they are at risk of a heart attack.

If one is not deemed to be at risk of a heart attack, psychotherapeutic techniques such as cognitive behavioral therapy (CBT) may be recommended in order to help the affected person overcome any long-term anxiety about having a heart attack. This will help prevent a fear of having a heart attack from manifesting in, or forming the basis of, future panic attacks.

Risks

Around 10% of people will experience a panic attack in their lifetime. Panic attacks are more common in women than men. Panic attacks are more common in people who are experiencing a stressful event in their life, or who have an anxiety disorder. Certain drugs (such as recreational drugs), physical illnesses (such as thyroid dysfunction) and mental illnesses (such as depression) may raise the risk of panic attacks.

Diagnosis

The diagnosis of panic attacks depends on the symptoms and the individual's medical history. Since the symptoms for panic attacks can mimic some more serious medical emergencies, a physical examination and several investigations might be needed to rule out other causes. If panic attacks happen often and interfere with one's life, a psychiatric evaluation for anxiety disorders might be performed.

Treatment

Deep, calm breathing is helpful to cope with the symptoms of an attack, and helps prevent hyperventilation. It is helpful to see a general practitioner, psychologist or psychiatrist for advice after having a panic attack, or if one develops a fear of having further panic attacks. Psychological therapy, counseling or support groups can provide valuable information about how to cope during a panic attack and techniques to avoid future panic attacks. People who have recurrent panic attacks, and who develop a panic disorder, might benefit from medications which treat anxiety.

Prevention

Regular exercise, avoiding caffeine and eating regular meals may help in preventing some panic attacks. Some people find that practicing slow, regular breathing regularly helps them to be able to use this technique during a panic attack.


  1. Panic disorder.” NHS Choices. 15 August 2017. Accessed: 23 December 2017.

  2. Do unexpected panic attacks occur spontaneously?” Biological Psychiatry. 15 November 2011. Accessed 23 December 2017.

  3. Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition (DSM-5).” American Psychiatric Association. June 2013. Accessed: 23 December 2017.

  4. Assessment and treatment of nocturnal panic attacks.” Sleep Medicine Reviews. June 2005. Accessed: 23 December 2017.

  5. “[Panic attacks](https://www.anxietyuk.org.uk/docs/panic.pdf].” NHS Greater Glasgow. 2004. Accessed: 23 December 2017.

  6. Am I having a panic attack or a heart attack?” Anxiety and Depression Association of America. Accessed: 23 December 2017.