Panic attacks at night: waking in panic, and getting your nights back

It is the middle of the night. You were asleep, and now you are sitting up with your heart hammering, gasping, soaked in sweat, sure that something is terribly wrong. There was no bad dream that you can remember. It came out of nowhere. If this has happened to you, you may have started to dread going to bed, and you may be tired in a way that is hard to explain to people who sleep through the night.

This page is about panic attacks that wake you from sleep: what they are, what helps in the moment, when a medical check matters, and how to get your nights back without turning bed into a battleground. It is written for the person who wakes in panic, and for anyone who shares a bed with them.

What waking in panic can feel like

A night-time panic attack is a panic attack that begins during sleep. You wake suddenly and fully, usually in the first few hours of the night, with the same wave of symptoms a daytime attack brings: a pounding heart, breathlessness or a feeling of not getting enough air, sweating, trembling, a tight chest, dizziness, a sense of unreality, and fear that you are dying or losing control. It is not a dream. People usually cannot point to anything they were dreaming about, which is part of what makes it so unsettling.

It is more common than people think. Among people who have panic attacks by day, roughly half to two thirds have woken in panic at least once. The attacks happen in the deeper, non-dreaming part of sleep, and research so far finds that people who have them do not sleep worse overall, or have worse panic, than people whose attacks come only by day. Craske and Tsao, 2005. Like any panic attack, it usually peaks within about ten minutes and passes in five to twenty, though the shaky, wide-awake feeling afterwards can last much longer. NHS; healthdirect.

One idea about why it happens is that the body misreads an ordinary change during sleep, such as a slower or shallower breath, as suffocation, and sets off a full alarm. Levitan and Nardi, 2009. Whatever the mechanism, the attack itself is not dangerous. The trouble is that it feels exactly as if it is.

Is it a panic attack, or something else?

Several things can wake you in fear or struggling to breathe, and they need different help. A doctor can tell them apart; this list is only so that you know what to describe.

• A nightmare. You wake from a bad dream and can remember it. Night panic has no dream behind it.
• A night terror. Mostly in children. The person shouts, thrashes or sits up with eyes open, but is not awake and rarely remembers it. If you remember the episode clearly, it was not a night terror. NHS.
• Sleep apnoea. Breathing that stops and starts, gasping, snorting or choking noises, loud snoring, waking many times, and heavy tiredness by day. Someone who shares your room may notice it before you do. It needs a GP, and it is treatable. NHS.
• Sleep paralysis. You wake but cannot move or speak for a short while, sometimes with a frightening sense of a presence. Unpleasant, and not a panic attack.
• A physical cause. Heart rhythm problems, asthma, reflux, low blood sugar, an overactive thyroid, some medicines, and alcohol wearing off during the night can all wake you with symptoms that overlap with panic.

Because of this overlap, a first episode, a change in the pattern, or any doubt deserves a conversation with your doctor. That is not alarmism. It is how you get to stop wondering.

Call emergency services if, on waking, 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; 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.

In the moment, at three in the morning

You will not remember much of a plan when you have just been jolted awake, so keep it small.

1. Sit up, feet on the floor, light on if it helps. Being upright and seeing the room helps the brain register that you are at home and nothing is attacking you.
2. Say what it is. “This is a panic attack. I have had this before. It peaks in a few minutes and then it fades.” If you have never had one, or it feels different, see the question above.
3. Let the breath settle rather than forcing it. A slow, unhurried out-breath, then let the in-breath come by itself. Counting to five on each, in and out, gives you something to hold. Do not take big deep breaths over and over; that makes the dizziness worse.
4. Give your hands and eyes something ordinary. Hold a glass of cold water and drink it slowly. Press your feet into the floor. Name five things you can see. Stroke the dog. Ordinary things, done slowly.
5. Do not fight it, and do not investigate it. Fighting a panic attack tends to prolong it; letting it run its course is what ends it. Checking your pulse every minute, or searching your symptoms on your phone, keeps the alarm ringing. NHS inform says it plainly: fighting an attack can make it worse; accept that it will pass.
6. If someone is beside you, tell them what helps. “Stay with me, keep it simple, no questions.” The guide on helping someone having a panic attack is written for them.
7. Once it has faded, give yourself a few minutes before lying down again. If you are wide awake twenty minutes later, get up and do something quiet and dull in low light until you feel sleepy, then go back to bed. Lying rigid, waiting for it to come back, teaches your body that bed is dangerous.

The free panic attack plan puts the daytime version of this on one page. Many people keep a copy on the bedside table.

The next day, and the next night

After a night attack most people are drained, jumpy and short of sleep. You can go gently, but it helps to go through the day rather than around it. Cancelling everything and staying in bed makes the night loom larger. A short walk in daylight, regular meals and ordinary company do more for the following night than resting all day.

The bigger problem is usually not the attack but the dread of the next one. Lying in bed on guard, listening to your heartbeat, is itself a kind of alarm; it makes the body tense and sleep lighter, which makes another attack more likely. The way out is not to try harder to sleep but to make bed a less watchful place.

If the dread of the next attack has spread into your days, afraid of the next panic attack explains the fear of fear and how to loosen its grip.

Getting your nights back, without making bed a battleground

• Keep the same getting-up time, even after a bad night. A regular wake time steadies sleep more than an early bedtime does.
• Go to bed when you are sleepy, not when you are trying to sleep. If you are not asleep within what feels like twenty minutes, get up, do something quiet in dim light, and come back when sleepy. It feels wrong, and it works.
• Give yourself a wind-down. Half an hour of low light and something undemanding before bed. Leave the phone outside the bedroom if you can; it is where the symptom-searching happens.
• Watch caffeine, alcohol and nicotine. Caffeine late in the day lightens sleep. Alcohol helps you fall asleep and then wakes you as it wears off, often with a racing heart. Smoking does both. NHS; NHS insomnia.
• Do not go to bed to practise being safe. Checking that the door is locked once is fine. Checking your pulse, your breathing or your phone for reassurance is the daytime panic loop moved into the dark.
• Do not avoid sleep. Staying up until exhaustion to skip the dangerous hours makes the sleep that follows deeper and the attacks, if anything, more likely. If fear of sleep itself has taken hold, the guide on sleep anxiety and the fear of sleep is for you.

The free two-page sheet When sleep is difficult gathers the sleep side of this in one place.

If it keeps happening

Repeated night attacks are a reason to get help, not a sign that you are beyond it. Cognitive behavioural therapy for panic, which teaches you to read body sensations differently and to stop bracing against them, works for night-time attacks as well as daytime ones; in one study the night attacks faded faster than the daytime ones, and the gains held a year later. Marchand and colleagues, 2013; Craske and Tsao, 2005. Current guidance recommends CBT first, and an antidepressant of the SSRI type if medication is used; sleeping tablets of the benzodiazepine kind are not recommended for panic disorder, because they do not treat it and tend to make things worse over time. NICE. Any decision about medication, including something you already take for sleep, needs to be discussed with a qualified prescriber.

The panic attacks page explains the treatment options, and anxiety treatment sets out what therapy involves. If physical symptoms are the part that frightens you most, physical symptoms of anxiety explains why the body does what it does.

Talking to someone

It can be very helpful to talk to someone. Night panic is lonely, partly because it happens when everyone else is asleep, and partly because it is hard to describe by daylight. 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

• Craske and Tsao (2005): assessment and treatment of nocturnal panic attacks
• Marchand and colleagues (2013): CBT for panic disorder with nocturnal panic attacks
• Levitan and Nardi (2009): nocturnal panic attacks, clinical features and respiratory connections
• NICE CG113: generalised anxiety disorder and panic disorder in adults
• NHS: panic disorder
• NHS: night terrors and nightmares
• NHS: sleep apnoea
• NHS: insomnia
• NHS inform (Scotland): panic disorder
• NIMH: panic disorder, what you need to know
• healthdirect (Australia): panic attacks and panic disorder