Afraid of the next panic attack: how the fear of fear keeps panic going, and how to loosen its grip

The panic attack ended. Your heart slowed, the room steadied, and life carried on. But something stayed behind: a watchfulness. You notice every flutter in your chest. You check how you feel before you leave the house. You may have started to skip the bus, the supermarket queue, the gym, the motorway, the meeting, anything that reminds you of the place where it happened or where it would be hard to get out. You are not so much afraid of the bus as afraid of being afraid on it.

If this sounds familiar, there is nothing wrong with you. It is the most common way that panic takes hold of a life, and it is also the part that responds best to understanding and to patient, small steps. This page explains why the fear of the next attack tends to bring more attacks, what quietly keeps the fear going, how to let an attack pass, and how to take your life back a step at a time, safely.

How the fear of fear works

A panic attack is the body’s alarm system going off when there is no fire. Something ordinary happens: your heart speeds up on the stairs, you feel light-headed in a warm shop, your breathing changes when you are tired. Your mind reads the sensation as a warning of something terrible, such as a heart attack, fainting, suffocating or losing control. That thought frightens you, fear releases adrenaline, adrenaline makes your heart pound harder and your breathing faster, and now the sensation looks even more like the catastrophe you feared. In a minute or two the loop has run several times and you are in a full attack. Clark, 1986.

After one bad attack, the brain does what brains do: it learns. It files the sensations, and the place, as dangerous. From then on you scan your body for the first sign of trouble, and because you are watching so closely, you find things. A normal skipped heartbeat or a moment of dizziness, which you would once have ignored, now sets off the alarm. The NHS describes this plainly: avoiding situations for fear of another attack creates a cycle of living in fear of fear, which adds to the panic and can cause more attacks. NHS. Many people with panic disorder say the dread between attacks is worse than the attacks themselves. NIMH.

The way out follows from the way in. The less afraid you are of the sensations, the less adrenaline they release, and the more your brain has a chance to learn that nothing bad happens. That learning does not come from being told. It comes from living through the sensations, again and again, and finding that they pass. Everything on this page serves that one aim.

First, a word about safety

Panic attacks are frightening, but they are not dangerous in themselves, and they do not damage your heart or your mind. NHS. That said, the symptoms overlap with things that do need a doctor, including heart rhythm problems, an overactive thyroid, asthma, low blood sugar, some medicines and stimulants. healthdirect. If you have never had your symptoms checked, if the pattern has changed, or if you have a heart, lung or other medical condition, see your doctor before you start practising with the sensations. It is far easier to let an attack pass once you know, rather than hope, that your body is sound. The guide to physical symptoms of anxiety explains what the body is doing and when to get a symptom looked at.

Call emergency services if there is chest pain that feels tight, crushing or squeezing or spreads to an arm, the neck or the jaw; you are struggling badly to breathe; you faint or feel you might; one side of your body feels weak or your speech is slurred; it is the first time and you are frightened it is your heart; or you are in doubt. Ireland 112 or 999; UK 999 or 112; rest of the EU 112; US and Canada 911; Australia 000; New Zealand 111; elsewhere, your local emergency number.

Avoidance, and the quiet helpers that keep the fear alive

Avoidance is easy to spot once you look for it: the shop you no longer go to, the exercise you have stopped, the coffee you gave up, the trip you keep postponing. Each time you avoid, the relief is immediate, and that relief teaches the brain that you escaped something dangerous. The fear stays intact, and the list of avoided places tends to grow.

Harder to spot are the safety behaviours: the small things you do to feel safe inside a situation rather than leave it. They look sensible, which is why they survive.

• Sitting near the exit, or at the end of the row, and keeping an eye on the door.
• Only going out with a particular person, or with your phone in your hand in case you need to call them.
• Carrying water, mints, a paper bag or a tablet you never take, “just in case”.
• Checking your pulse, holding on to the trolley, leaning against a wall, sitting down the moment you feel light-headed.
• Breathing exercises used not to settle yourself but to stop the attack before it can happen.
• Searching your symptoms on your phone, or asking the people around you whether you look all right.

The problem with each of these is the same. When the attack does not end in disaster, you credit the water bottle or the wall or the person beside you, not the fact that the disaster was never coming. You never find out that you would have been fine anyway. In a study of people with panic and agoraphobia, those who dropped their safety behaviours during a short period in a feared situation showed a bigger fall in their catastrophic beliefs and their anxiety than those who kept them. Salkovskis and colleagues, 1999. Giving up a safety behaviour feels like taking a risk. In fact it is how you collect the evidence.

You do not have to drop them all at once. Pick one, and see what happens without it.

Letting a panic attack pass

This is the hardest skill on the page, and the most useful. Every instinct says fight, control, escape. The attack feeds on exactly that. Fighting a panic attack can often make it worse; accepting that it will pass is what helps. NHS inform. Letting it pass does not mean liking it. It means not adding a second layer of fear on top of the first.

1. Name it. “This is a panic attack. It is unpleasant and it is not dangerous. It will peak and then fade.” Most attacks peak within about ten minutes and are over in five to twenty. healthdirect; NHS.
2. Stay where you are, if you safely can. Leaving brings relief now and a stronger fear next time. If you must step aside, step aside; but try not to go home.
3. Let the breath settle rather than controlling it. A slow, unhurried out-breath, then let the in-breath come by itself. No big deep breaths over and over; that feeds the dizziness. Never breathe into a plastic bag. Mind.
4. Drop the fight and let the wave come. Imagine the fear as a wave that rises, crests and falls, and let it. Some people find it helps to think “Go on, then. Do your worst.” The attack has no answer to that.
5. Give your attention somewhere ordinary. The weight of your feet on the floor. Five things you can see. The texture of your coat. Not your pulse, and not your phone.
6. Stay a few minutes longer than you want to. Once the worst has passed, do not leave straight away. Let your body register that the situation is still here and you are still fine.
7. Afterwards, be kind and be ordinary. A drink of water, a sit-down if you need it, and then on with what you were doing if you can. Treating the attack as an event rather than an emergency is itself part of the learning.

The free panic attack plan puts this on one page. If your attacks come at night, panic attacks at night is written for that. If you want the person beside you to know what helps, give them how to help someone having a panic attack.

You will not do this perfectly, and you do not need to. An attack that you partly fought and partly allowed is still evidence. Over weeks, as your body learns that the alarm leads nowhere, the attacks tend to come less often and to matter less when they do. Nobody can promise you a date when they stop.

Small steps back

Avoidance shrinks a life quietly, and it is reversed the same way: one step at a time, repeated. CBT for panic usually starts with modest goals, such as the local shop, before harder ones. NHS agoraphobia. You can begin on your own.

1. Write down what you avoid. Places, activities and sensations. Be honest and be specific: “the big supermarket on a Saturday”, not “shops”.
2. Put them in order, easiest first. Give each a rough score out of ten for how anxious it would make you. Your ladder will have gaps; that is fine.
3. Choose a rung that is small enough to do this week and big enough to matter. Three out of ten is a good place to start. Zero teaches you nothing.
4. Go, and stay until the anxiety has clearly eased, or until you have learnt what you came to learn. Expect anxiety. It is the point, not a sign of failure. If it rises into panic, use the steps above and stay if you safely can.
5. Repeat it soon, and often. Once is an experience. Four or five times in two weeks is learning. The second visit is usually easier than the first, and that is worth noticing.
6. Then drop one safety behaviour in the same situation. Leave the water bottle at home. Sit in the middle of the row. Go without your companion for ten minutes, then twenty.
7. Move up a rung. And keep the lower rungs in use, so they stay ordinary.

A few cautions, because the aim is to feel safe, not to prove something.

• Choose places where you would be all right even if you felt dizzy or shaky. Practise on a walk, in a shop or on a bus before a motorway, a height, deep water or anything where a moment of faintness could hurt you. Save those for when the easier rungs are routine, or for work with a therapist.
• If panic affects your driving, talk to your doctor. Some countries ask drivers with panic disorder to tell the licensing authority. Mind. A doctor can also help you plan driving practice that is safe for you and for others.
• Go gently with alcohol, caffeine and energy drinks. They can bring on the very sensations you are learning not to fear, and alcohol can make the next day’s anxiety worse. NHS.
• Setbacks are part of it. A bad day, a bout of flu or a stressful week can bring the fear back for a while. It does not undo what your brain has learnt. Go back a rung and carry on.
• Therapists use a stronger version of this, called interoceptive exposure, in which you bring on the sensations deliberately, for example by climbing stairs fast or spinning in a chair, and let them pass. It is one of the best-supported parts of treatment. Boettcher, Brake and Barlow, 2016; Pompoli and colleagues, 2018. It is best learnt with a therapist, after your doctor has confirmed it is safe for you, especially if you are pregnant or have a heart, lung or seizure condition.

If avoidance has grown large

For some people the circle has drawn in so far that leaving home, being alone, or going anywhere without a trusted person feels impossible. This is what agoraphobia means: not a fear of open spaces, but a fear of being somewhere escape or help would be hard if panic struck. It is common alongside panic disorder, and it is treatable. Mind; NHS agoraphobia. It is not a sign that you are beyond help or that you have failed at the steps above. It is a sign that doing them alone is too much to ask, and that is what therapists are for. Treatment can start at home or online if that is where you are. NICE.

What treatment involves, and what the research says

Cognitive behavioural therapy for panic is a short, practical treatment, usually around seven to fourteen hours in total over a few months. NICE. You and the therapist map your own panic loop: the sensations, the frightening thoughts, the safety behaviours and the avoidance. You test the frightening thoughts against what actually happens. You bring on the sensations on purpose and learn to let them pass, and you climb your ladder back into the places you have been avoiding, with someone to plan each step with.

The evidence for this is strong. A review of 136 trials found CBT the best-supported psychological treatment for panic disorder; short-term psychodynamic therapy is also a reasonable choice. Papola and colleagues, 2022. Within CBT, deliberately practising with the sensations and working face to face with a therapist were linked with better results; relaxation training alone was not. Pompoli and colleagues, 2018. Guided self-help, with a book or programme and a few short contacts with a practitioner, also works for milder panic; working through a programme entirely on your own showed no clear benefit in the trials. Papola and colleagues, 2023; NICE. That is one reason why reading a page like this is a good start and not the whole answer.

If medication is part of your treatment, current guidance recommends an antidepressant of the SSRI type licensed for panic disorder. Anxiety can rise briefly in the first week or two, and stopping suddenly can bring unpleasant withdrawal effects, so any change is made gradually. Benzodiazepines, the fast-acting tranquillisers, are not recommended for panic disorder: they are linked with a worse outcome over time, and they tend to become a safety behaviour in tablet form. NICE. Any decision about starting, changing or stopping medication needs to be discussed with a qualified prescriber.

The panic attacks page describes the treatment options, and anxiety treatment explains what therapy involves in practice. If you would like to work on this with me, I offer therapy for anxiety and panic in Dublin 2 and by video call across Ireland, where that is suitable.

Talking to someone

It can be very helpful to talk to someone. The fear of fear thrives in private; saying it out loud to a person you trust, or to a professional, makes it smaller and gives you a companion for the steps. A few ways to begin, to use or change as you like.

There are more words to borrow in the free communication and appointment prompts. If someone is treating you badly or you do not feel safe with them, they are not the person to tell. Choose someone else, or a helpline.

If you need help now

If you are in immediate danger, or cannot keep yourself safe, contact your local emergency services straight away. Ireland 112 or 999; UK 999 or 112; rest of the EU 112; US and Canada 911; Australia 000; New Zealand 111; elsewhere, your local emergency number.

Someone to listen, day or night: Samaritans 116 123 (Ireland, UK); text HELLO to 50808 (Ireland); call or text 988 (US, Canada); Lifeline 13 11 14 (Australia); call or text 1737 (New Zealand); elsewhere, findahelpline.com lists free helplines.

Sources

• Clark (1986): a cognitive approach to panic
• Salkovskis and colleagues (1999): safety-seeking behaviours in panic disorder with agoraphobia
• Boettcher, Brake and Barlow (2016): origins and outlook of interoceptive exposure
• Pompoli and colleagues (2018): dismantling CBT for panic disorder
• Papola and colleagues (2022): psychotherapies for panic disorder, network meta-analysis
• Papola and colleagues (2023): CBT delivery formats for panic disorder
• NICE CG113: generalised anxiety disorder and panic disorder in adults
• NHS: panic disorder
• NHS: agoraphobia, treatment
• NIMH: panic disorder, when fear overwhelms
• Mind: panic attacks
• NHS inform (Scotland): panic disorder
• healthdirect (Australia): panic attacks and panic disorder