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Panic Attacks in Adults

Summary: Panic attacks are sudden periods of intense anxiety and fear that can be severe and overwhelming. The good news is that there are many effective strategies and treatments for overcoming panic attacks.
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Introduction

Dave had his first panic attack about 3-months ago. He remembers the exact day and time it happened; he was at work, trying to meet an important deadline when out of the blue, he felt this sudden attack of intense panic. It passed after about 10-minutes, but he had to go home early that day. Since then, he continues to get attacks and they appear to be getting worse. The last one happened when he was out shopping. Since then, he only leaves his home to go to work, and otherwise tries to stay home, out of fear that another attack will happen....

What are Panic Attacks?

Panic attacks are sudden periods of intense anxiety and fear. Attacks come quickly and peak within 10-15 minutes. Sometimes they are triggered by stressful or frightening situations. However, sometimes panic attacks happen for no obvious reason, which may make it particularly distressing.

 

Panic attack symptoms can include:

 

1. Physical sensations

  • Chest-related symptoms
  • Pounding or racing heartbeat
  • Chest pain or discomfort
  • Shortness of breath
  • Feeling of choking and "can't get enough air'
  • Tingling or pins and needles sensations in the fingers or toes (from hyperventilation or breathing too fast)
  • Digestive tract related symptoms
  • Feelings of nausea
  • Other symptoms
  • Sweating, trembling, shaking
  • Hot flashes or chills

2. Fears

  • Feeling weak, dizzy, faint or lightheaded
  • Feelings of terror, powerlessness or doom
  • Feeling a sense that things aren't quite real, or feeling detached from oneself
  • Fear of losing control or going crazy, e.g. "I'm worried I'm losing my mind"
  • Fear of dying or "I'm having a heart attack",

The fears in a panic attack can be particularly bad. Until it is diagnosed, people usually do not know what is happening or why. There just appears to be these sudden physical symptoms which most people interpret to mean they are losing control, going crazy, or going to die. Having these types of fears further worsens the situation.

What Causes Panic Attacks?

There are different factors which may contribute to your risk of having panic attacks:

  • Genetic predisposition: if there are other relatives who have had panic attacks, you will be at a higher risk. (For this reason, it can be helpful to speak to relatives who are coping well with their panic attacks and ask them how they manage to deal with it).
  • Stress: panic attacks are often triggered by stressful times. (For this reason, it can be helpful to make sure you find ways to deal with the stress in your life, and consider seeing a counsellor/therapist.)

What is Happening During a Panic Attack?

During a panic attack, its like a false alarm going off in your body. It starts with a sudden release of adrenaline in your body. This adrenaline rush, reaching different parts of your body causes the symptoms you feel in a panic attack: 

  • Adrenaline makes you breathe more quickly, in an attempt to get more oxygen. In panic attacks, this explains the breathing symptoms.
  • Adrenaline makes your heart beat faster, in an attempt to pump more blood to your muscles. This explains the symptoms such as feeling your heart pounding.

When this "adrenaline alarm" goes off in the right situations, it's actually a good thing. This alarm system is what helped us to survive stressful, dangerous situations in the wild. Back then, we faced physical dangers such as being attacked by dangerous animals. Thus, having this ‘fight or flight' response helped us be able to either "fight" the dangerous animal, or take "flight" and run away from the danger.

 

Unfortunately, this primitive alarm system is not the best adapted to modern society. Although in the old days, this alarm made it possible for us to either run or fight, in modern society, it is usually not appropriate (or possible) to either run or fight.

 

In modern society, we face different types of dangers -- stresses at school, work or conflicts with other people. Although these modern stresses may not be immediately life-threatening, these modern stresses still pose a challenge to our bodies because they tend to be chronic and longer lasting.

 

Ultimately, all of this stress can contribute to panic attacks.

 

This is why it is so important to figure out if there are any stresses in your life, because dealing with them can help keep your body's alarm from being triggered.

Are Panic Attacks Dangerous?

A panic attack is primarily the symptoms caused by a sudden rush of adrenaline; panic attacks are not dangerous, though they can certainly feel absolutely terrifying. But because these symptoms of panic attacks may be similar to those seen in other medical conditions, it is nonetheless still important to see a doctor if you have panic symptoms.

What is Panic Disorder and Agoraphobia?

Panic Disorder (as opposed to panic attacks) is when people are having:

  • a) Repeated panic attacks, which cause so much distress that they are
  • b) Avoiding situations out of fear of having a panic attack. Agoraphobia: when people start avoiding numerous situations and become housebound (literally, fear of the marketplace or open spaces).

People with agoraphobia commonly try to avoid getting into situations where it might be difficult or embarrassing to escape quickly if they have a panic attack and need to get away. They may also avoid places where there would be no quick access to medical help.

How Common Are Panic Attacks?

It is believed that as many as 40% of people have had panic attacks happen out of the blue at some point in their life, but most of them do not go onto develop panic disorder (avoidance of situations) or agoraphobia.

How Common is Panic Disorder?

Approximately 1% of males and 2% of females have had Panic Disorder in the last year (Stats Can, 2002).

Treatment of Panic Attacks and Panic Disorder

The good news is that there are effective treatments for panic disorder, in addition to self-help strategies. 

  1. Cognitive behaviour therapy (CBT), a type of talking therapy that helps people coping by changing their thoughts and behaviours. This is typically given by a psychologist or psychiatrist. Family physicians who have had additional training in CBT may also give this as well.
  2. Medications, which can be prescribed by a physician such as a family physician, paediatrician or psychiatrist.

Cognitive Behaviour Therapy (CBT) in Detail

Cognitive behaviour therapy helps you develop coping thoughts (i.e. cognitions) and  behaviours to deal with panic disorder.

 

A typical CBT treatment plan would include:

  • Education about panic disorder (information, as provided elsewhere in this handout)
  • Identify triggers of panic attacks
  • Changing thoughts and fears about the symptoms of panic
  • Exposure to places where panic might occur
  • Exposure to the physical sensations of panic
  • Learning ways to reduce over-breathing and anxiety symptoms

a. Identifying triggers for panic attacks

Often (though not always), it is possible to find triggers for the panic attacks. Typical triggers include things such as:

  • Noticing physical sensations, even something as subtle as a slight change in heartbeat. Most people have periodic aches or pains. People with panic attacks however, often become overly preoccupied with even minor aches and pains, and rather than simply dismissing them, these aches and pains become a source of worry.
  • Thoughts, e.g. having panic thoughts alone such as "I'm feeling uncomfortable, oh no, I'm having another panic attack!" can contribute to panic attacks
  • Being sleep deprived --> if sleep deprived, then make sure you have a good sleep routine and that you get enough sleep.
  • Stress --> if you are under stresses at school, work or home, then find a way to cope and deal with your stresses.

Once you understand your triggers, you can do things to cope with and deal with those triggers.

b. Changing Thoughts and Fears about Panic Attack (Cognitive restructuring)

During a panic attack, many people get the fear that "I'm going crazy" or "I'm having a heart attack and I'm going to die." Such worry thoughts can understandably contribute to the panic attack and make things feel worse.

 

After the panic attack is over, most people realize "Its all over now - I'm not crazy!" and they "I'm alive and I feel fine - it wasn't a heart attack."

 

So understanding that "I am not crazy" and that "I am not going to die" can greatly help. Being able to use positive, coping thoughts early on can significantly help or even prevent a panic attack.

 

a)     What are the anxious or panic thoughts that you have?

 

Make a list of these thoughts...

 

1. ______________________________

2. ______________________________

3. ______________________________

 

Etc...

 

 

b)    Replace these anxious thoughts with more helpful thoughts.

 

1. ______________________________

2. ______________________________

3. ______________________________

 

Ask yourself: Is this a helpful thought to have?

 

Then: What would be a more helpful thought to have instead?

 

Example: 

 

Panic Thoughts

More Helpful Thought

I'm going to die

This has happened lots of times. It feels horrible, but I'm not dying!

I can't stand these attacks.

Its just an adrenaline rush. I know I can survive it, because I've survived plenty of them so far!

I'm all alone in having to deal with this.

I'm not alone - there are tons of other people who get panic attacks. After all, there are tons of books about panic attacks and I even know some other people who've gotten over this too. If they can get over this, then so can I.

I'm going crazy

I know I'm not going crazy. But yes, the adrenaline rush is pretty intense and it makes you feel pretty horrible.

c. Exposure to places where panic might occur

In panic disorder, people start avoiding places where they fear there may be a panic attack. This makes sense if these places are truly dangerous, but in panic disorder, such avoidance is not helpful.

 

To deal with this:

  • Make a list of all the places where you have troubles going out of fear of having a panic attack.
     
  • Gradually expose yourself to feared situations. Gradually confront feared situations, starting with the less anxiety-provoking situations, and gradually working yourself up to harder and harder situations.

    For example, in a person who is afraid of spiders, one of the ways to cure the phobia is to gradually expose that person, step-by-step to spiders. For example, starting with pictures of spiders, then progressing to toy spiders, then to real spiders in an aquarium and ultimately to a real spider.

    A person with panic attacks is most afraid of the actual panic attack, and thus fears the physical sensations during a panic attack, e.g. the rapid heart beating, the rapid breathing.

    Thus, a person with panic attacks is exposed to the actual physical sensations that are felt during a panic attack ("interoceptive exposure"). 

     
  • Use Relaxation Techniques. Relaxation techniques can also help people get through an attack such as:
     
    • Deep breathing: people with panic disorder tend to have faster breathing rates and learning to slow down their breathing can help. Breathing too fast can lead to hyperventilation, which can lead to symptoms such as tingling or numbness.
    • Visualization: imagining a calming soothing place in order to calm yourself down.

d. Exposure to the Feelings of Panic

In an attempt to avoid having panic attacks, people who have panic attacks tend to be very hypersensitive to even the littlest changes in their body that other people don't notice. When faced with even the littlest changes, they often get worry thoughts and sometimes it can contribute to ongoing panic.

 

By exposing yourself to those same physical feelings that you have in a panic attack and seeing that these feelings are not dangerous, it will help make these feelings less frightening in the future, if you have another panic attack (Lee et al., 2006). Some studies have even shown that interoceptive exposure on its own is able to reduce feelings of panic (without needing other strategies such as cognitive restructuring), and that head to head, it was even more effective than breathing retraining (i.e. deep breathing) (Craske, 1997).

 

Typical exercises to cause similar feelings as seen with panic attacks include (Anthony, 2006).

  • Hyperventilation,
  • Breathe as deeply and as quickly as you can for one minute.
  • Shaking your head
  • Shake your head from side to side for 30 seconds.
  • Step-ups
  • Run up and down on the spot as fast as you can for one minute.
  • Putting your head between the legs
  • Holding your breath
  • Hold your breath for 30 seconds.
  • Body tension,
  • Spinning,
  • Stand up and turn around in circles as quickly as you can for 30 seconds to make yourself dizzy.
  • Breathing through a straw
  • Breathe through a thin straw for one minute while holding your nose.
  • Chest breathing

These exercises are not fun. They are best done with the assistance of a trained CBT therapist, and are not meant to be used alone. Nonetheless, they are harmless yet effective in helping overcome one's fear of these feelings. 

Summary of Cognitive Behavioural Therapy (CBT)

CBT helps people by changing their thoughts and behaviours and in this way, it helps a person overcome those feelings of panic and terror, thus feeling more calmer.

 

Typical thoughts/feelings/behaviours seen in Panic Disorder:

 

Event

-->

Thoughts

-->

Feelings

-->

Behaviours

Having a drink at the coffee shop when a panic attack starts

 

"I'm going crazy, I'm having a heart attack and I'm going to die"

 

Panic and Terror

 

  • Running out of the coffee shop.
  • Avoiding all coffee shops in the future.

 

More helpful thoughts/feelings/behaviours that might be developed during CBT:

 

Event

-->

Thoughts

-->

Feelings

-->

Behaviours

Having a drink at the coffee shop when a panic attack starts

 

"Its just an adrenaline rush, I am not going to die, this feels horrible, but I'll get over it - I'm going to use my strategies..."

 

Not feeling panicky; feeling calmer

 

Staying in the coffee shop

Using deep breathing

Medications

In certain situations, medications may be helpful.

 

Typical medications include:

  • Specific serotonin reuptake inhibitors (SSRIs): these help reduce panic attacks by affecting the brain chemical serotonin. SSRIs can take 2-4 weeks before they start having an effect. Examples include Fluoxetine (Prozac); Citalopram (Celexa); Escitalopram (Cipralex); Venlafaxine XR (Effexor XR); Sertraline (Zoloft); Paroxetine (Paxil); Fluvoxamine (Luvox).
  • Tricyclic Antidepressants (TCAs), which also affect serotonin. Examples include: Imipramine (Tofranil); Nortriptyline (Pertofran); Desipramine (Nortabs); Amityptyline (Typtanol); Clomipramine (Anafranil)
  • Benzodiazepines are short-acting medications that can be taken to reduce anxiety. They act quickly and are often given initially until the SSRIs have had a chance to start working. Examples include Clonazepam; Diazepam; Alprazolam; Lorazepam. The advantages of benzodiazepines is that they are fast-acting. But the disadvantage is that many people may find it hard to stop taking benzodiazepines. For this reason, many health professionals will stay away from using benzodiazepines unless it is a last resort.

How Long Does Treatment Take?

The length of treatment depends on your specific situation, but most people will notice significant improvement within the first few visits with a mental health professional.

What to do if you are having a Panic Attack

  • Sit down in a place away from other people
    • If you have a jacket with a hood, you may find it helpful to put a hood over your head
    • If you have a hat, feel free to put that on
  • What is it that might be making you panic?
    • Knowing what might have triggered your attack can give you a greater sense of understanding and control.
  • Use positive coping thoughts
    • "I'm not going to die. This is harmless. It will soon pass, because it always does. I'll live. I'm going to get through this."
  • Use deep breathing.
    • Breathe very slowly: inhale while counting to three; exhale slowly, all the way.
    • Consider using the older paper bag technique. Note that paper bags are safe to use; plastic bags are not.
    • Take a paper bag and hold it over your nose and mouth.
    • Even if you aren't having a panic attack, consciously remembering to breathe deeply and slowly will still help with relaxation at other times.
    • Why is slow, deep breathing so important? Because during a panic attack, people tend to breathe too quickly, which causes hyperventilation, which by itself can cause panic symptoms such as dizziness, light-headedness, tingling in fingers and feet. To prove this for yourself, just try breathing as quickly as you can for one minute.
  • Expose yourself to the situation rather than just escape it.
    • The panic fears may be trying to tell you to run away from the situation but if you give in, it won't help things in the future. Tell yourself to stay for another 1-2 minutes before leaving. When that 1-2 minutes has passed, see if you can stay yet another 1-2 minutes. You may very well discover that you are able to stay longer than you thought! But if it is too much, then by all means, feel free to leave the situation.
  • Use distraction or visualization techniques.
    • Close your eyes, imagine yourself in a calming/soothing place. Try to use all your senses.
    • For example, in a beach visualization:
      • Feel the warm sun on your face; the warm sand beneath your feet; the warm wind blowing against your face
      • See the bright blue water and the brilliant sand
      • Smell the salty ocean smells

Remember that all of these panic strategies is a learned skill, like any other skills. And like other skills, it can take lots of practice before you get good at it. So don't be disappointed if you try a strategy and it doesn't work the first time. Most skills in life take time (if not a lifetime) to practise and master. 

Other Strategies

  • Peer Support, Mutual Aid and Support Groups. Support groups can be very helpful by giving an opportunity to meet, get support and advice from others coping with the same issue.
     
  • Ensure a healthy diet. Avoid drinking excess alcohol. Avoid excess caffeine (found in large amounts in coffee and energy drinks). If you are having panic, try cutting caffeine out of your diet altogether. If you are drinking a lot of caffeine (e.g. more than 2 cups of coffee daily), or if you have been drinking caffeine for a long time, note that you may need to cut back gradually.
     
  • Ensure regular exercise, which helps give an outlet for your adrenaline, and helps the body release calming hormones such as endorphins.
     
  • Have healthy connections. Human beings are social creatures, and one of our deepest needs is to have healthy connections and relationships with one another. Focus on building up and keeping healthy relationships in your life. 

For More Information

References

  • Antony, MM; Ledley, DR; Liss, A; Swinson, RP. Responses to symptom induction exercises in panic disorder. Behav Res Ther. 2006;44:85-98.
  • Craske, MG; Rowe, M; Lewin, M; Noriega-Dimitri, R. Interoceptive exposure versus brething retraining within cognitive-behavioural therapy for panic disorder with agoraphobia. Br J Clin Psychol. 1997;36:85-99
  • Lee K et al.: Interocceptive hypersensitivity and interoceptive exposure in patients with panic disorder: specificity and effectiveness. BMC Psychiatry. 2006; 6:32.
  • Statistics Canada. 2002 Canadian Community Health Survey: Mental Health and Well-Being. Retrieved Nov 10, 2008 from http://www.statcan.ca/Daily/English/030903/d030903a.htm

About this Document

Written by the eMentalHealth Team.

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance. 

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Date Posted: Nov 13, 2008
Date of Last Revision: Oct 9, 2016

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