Panic attacks seem to come out of the blue, and you suddenly experience fear and dread that can only be described as existential. Your heart may be beating faster and you feel like you cannot breathe anymore. Everything seems to close in on you. It feels as if this is the end or something very bad is going to happen to you. You may feel it is all over. You are experiencing a panic attack. Some people may fall to the floor (though they usually do so quite softly) or blackout from fear (though it is not a real blackout).
Panic attacks often begin during puberty or early adulthood, but that is not necessarily so. In Europe, about 3% of the population has a panic attack in a given year while in the United States they affect about 11%. They are more common in females than males. Children and older people are less commonly affected. 
Reoccurring Panic Attacks
Many people only have one or two panic attacks in their lifetime. However, if they occur more often, we call this a panic disorder. They are often grouped together with anxiety conditions. Even if it looks clearly like a panic attack, it is nevertheless important to make sure that there are no underlying physical conditions that can at least be partly responsible for the symptoms. Several treatments are available for panic attacks, and the earlier one begins the quicker they often subside. It is also important for the brain to unlearn to be afraid of being afraid, which helps prevent panic attacks in the future.
People with panic attacks often report a fear of dying or heart attack, flashing vision, faintness or nausea, numbness throughout the body, heavy breathing and hyperventilation, or loss of bodily control. Some people also suffer from tunnel vision, mostly due to blood flow leaving the head to more critical parts of the body in defense. These feelings may provoke a strong urge to escape or flee the place where the attack began (a consequence of the “fight-or-flight response”, in which the hormone causing this response is released in significant amounts). This response floods the body with hormones, particularly epinephrine (adrenaline), which aid it in defending against harm. 
According to DSM-5, a panic attack is characterized by four or more of the following symptoms (the presence of fewer than four symptoms may be considered a limited-symptom panic attack):
- Palpitations, pounding heart, or accelerated heart rate
- Trembling or shaking
- Sensations of shortness of breath or smothering
- A feeling of choking
- Chest pain or discomfort
- Nausea or abdominal distress
- Feeling dizzy, unsteady, lightheaded, or faint
- Feelings of unreality (derealization) or being detached from oneself (depersonalization)
- Fear of losing control or going crazy
- Fear of dying
- Numbness or tingling sensations (paresthesias)
- Chills or hot flushes
Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something really bad is going to happen.  The maximum degree of symptoms occurs within minutes. There may be a fear of losing control or chest pain.  Panic attacks themselves are not dangerous.  They are distinguished from other forms of anxiety by their intensity and their sudden, episodic nature.  They are often experienced in conjunction with anxiety disorders and other psychological conditions, although panic attacks are not generally indicative of a mental disorder.
Fear of Fear
A common mechanism in panic attacks is the fear of being afraid. The more worried I am that I will have a panic attack, the more likely I am to have one. And the more I focus on my fear, the more afraid I will be. This is the vicious cycle of panic attacks. Most people notice a feeling before their panic attack begins, which they often describe as a feeling of imminent doom. The world around me seems to change, and I feel differently. Unfortunately, this often raises any existing tensions or anxiety even more. One goal in therapy is to gain the ability to not counter fear with fear.
Controlling the Emotions
While it is helpful to work with the emotions to better connect with oneself and others, to get one’s needs, values, and aspirations met, putting a lid on one’s emotions can lead to the phenomenon of a pressure cooker. At some point, the pressure on the inside gets just too high, and everything explodes. Trying to control one’s emotions by suppressing rather than working with them can raise anxiety levels, which in turn can also increase the chances of a panic attack. In your work with a therapist, one goal can be to gain a greater sense of emotional freedom and a better sense of control by identifying and adjusting any strategies of working with one’s emotions that are unhelpful.
Panic Attacks with other Mental Health Conditions
Panic attacks can occur as part of a number of mental health conditions, including panic disorder, social anxiety disorder, post-traumatic stress disorder, drug use, depression, and a number of medical problems.  They can either be triggered or occur unexpectedly. Often people are not aware of a specific trigger or the underlying issues, feelings and emotions that may contribute to a panic attack. Uncovering these deeper issues is an important part of therapy. An awareness of them usually makes the panic attacks subside.
Common risk factors include smoking and psychological stress. Similar symptoms to panic attacks can be caused hyperthyroidism, hyperparathyroidism, heart disease, lung disease, and drug use.  Apart from age and sex, theWinchester Hospital has summarised risk factors as follows:
- It runs in your family—Having a close family member such as a parent, brother, or sister. Overprotection or lack of coping skills in your family may also play a role.
- Stressful events such as:
- Loss of a job
- Marriage or first child
- Prior victim of crime or abuse
- Anxiousness—Taking something normal and worrying more than needed. The body reacts to this worry, making the risk of panic attacks higher.
- Mental health illness—Mainly with other anxiety disorders or depression.
- Problems with alcohol use disorder or substance use disorder. These can cause a fast heartbeat or lightheadedness, which can lead to feelings of panic.
- Smoking—Risk is higher if smoking was done during the teen years or as a young adult.
The Autonomous Nervous System
A panic attack is a response of the sympathetic nervous system (SNS). The most common symptoms include trembling, dyspnea (shortness of breath), heart palpitations, chest pain (or chest tightness), hot flashes, cold flashes, burning sensations (particularly in the facial or neck area), sweating, nausea, dizziness (or slight vertigo), light-headedness, hyperventilation, paresthesias (tingling sensations), sensations of choking or smothering, difficulty moving, and derealization. These physical symptoms are interpreted with alarm in people prone to panic attacks. This results in increased anxiety and forms a positive feedback loop. 
Often, the onset of shortness of breath and chest pain are the predominant symptoms. Shallow and rapid breathing can change the pH level in one’s blood, which leads to even more symptoms of a panic attack. Breaking this vicious cycle is difficult once the panic attack has started.
Treatment of Panic Attacks
Psychotherapy should always be a part of treatment. It is considered a first-choice option. It is helpful to divide the therapies into three major approaches:
- tools – these therapies provide concrete tools, such as thinking differently about the fear or habituation through exposure to fearful stimuli (e.g. CBT)
- insight – these therapies focus on an understanding of why you have the fears in the first place, which often reduces them (e.g. psychodynamic psychotherapy)
- interaction – these therapies focus on the role of interpersonal interactions in the experience of fear, for example (interpersonal psychotherapy)
Cognitive Behavioral Therapy (CBT) may be the most widely tested therapeutic approach in the literature for anxiety and panic attacks, but that may also be due to the fact that is easier to operationalize and manualize. For current research on panic attacks, you may want to consult Google Scholar and the National Library of Medicine in the US.
Medication can be added to prevent the occurrence of panic attacks for a while. This lowers the anxiety of having another panic attack, which in itself lowers the likelihood of having a panic attack. First-line treatment is often an antidepressant from the group of serotonin reuptake inhibitors (SSRIs) for the longer term, sometimes in the short term in combination with a faster-acting benzodiazepine, like Alprazolam (Xanax(R)) or Lorazepam (Temesta(R)), as emergency stand-by medication. The disadvantage of the benzodiazepines is that their effect is not instantaneous, they work only for up to a couple of hours, they can lead to cognitive impairment, and, if they are taken regularly, they can be addictive. However, many patients find it psychologically helpful to carry a stand-by tablet with them. This already often lowers the fear of having a panic attack by breaking the vicious cycle of fearing the fear and the sense of having no control over the panic attacks.
For more articles about panic attacks on jonathanhaverkampf.com you may be interested in the following:
- Therapy for Panic Attacks
- Benzodiazepines and Psychotherapy in the Treatment of Anxiety and Panic Attacks
- Escitalopram in the Treatment of Anxiety and Panic Attacks (1)
- Communication-Focused Therapy® (CFT) for Anxiety and Panic Attacks (3)
- Panic Attacks
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 American Psychiatric Association (2013), Diagnostic and Statistical Manual of Mental Disorders (5th ed.), Arlington: American Psychiatric Publishing, pp. 214–217, 938, ISBN 0890425558
 Craske, MG; Stein, MB (24 June 2016). “Anxiety.”. Lancet (London, England). PMID 27349358.
 Bourne, E. (2005). The Anxiety and Phobia Workbook, 4th Edition: New Harbinger Press.
 Klerman, Gerald L.; Hirschfeld, Robert M. A.; Weissman, Myrna M. (1993). Panic Anxiety and Its Treatments: Report of the World Psychiatric Association Presidential Educational Program Task Force. American Psychiatric Association. p. 44. ISBN 978-0-88048-684-2.
© Dr Christian Jonathan Haverkampf. All rights reserved.
Psychotherapy & Counselling; Dublin, Ireland
This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition.
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