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A panic attack is a brief period of intense fear or anxiety that peaks within 10 minutes. It typically subsides within 20 to 30 minutes and rarely lasts more than an hour. In contrast, periods of anxiety usually have a gradual onset and persist longer.

To classify an event as a full panic attack, there must be a sudden onset and at least 4 out of 13 symptoms. Most of these are physical, with three being cognitive:

Physical symptoms

A common feature of a panic attack is hyperventilation—rapid, shallow breathing that leads to quick oxygen intake but poor distribution through the lungs into the blood. This results in excessive carbon dioxide absorption, causing the aforementioned symptoms.

The respiratory response, triggered by high blood carbon dioxide levels, disrupts normal breathing mechanisms. This creates a feeling of breathlessness, further intensifying hyperventilation.

Given that 10 out of 13 panic attack symptoms are physical, it’s unsurprising that about 85% of individuals experiencing panic attacks repeatedly seek help at emergency rooms or doctors’ offices. They often believe they’re facing a medical emergency—typically cardiac, respiratory, or neurological in nature.

Cognitive symptoms

1. Depersonalization (feeling detached from one’s body) or derealization (perceiving the external world as strange or unreal)
2. Fear of death
3. Fear of losing control or “going crazy”

Panic Disorder

As previously mentioned, a panic attack can be part of an intense phobic reaction. However, a separate diagnosis of panic disorder can also be given, as defined by the DSM (APA, 2000).

To diagnose panic disorder, an individual must report recurrent, unexpected panic attacks. Additionally, for at least one month following an attack, they must experience one or more of these symptoms:

• Persistent worry about having additional attacks
• Concern about the implications or consequences of the attack, such as:
  • Loss of control
  • Fear of having a heart attack
  • Fear of “going crazy”
• Significant behavior changes related to the panic attacks

For a panic disorder diagnosis, there should be no presence of Agoraphobia*. Furthermore, the panic attacks should not result from the direct physiological effects of substances (e.g., drugs or medications) or a general medical condition (e.g., hyperthyroidism).

• It’s important to note that panic disorder can occur with Agoraphobia. Conversely, Agoraphobia can exist without panic disorder.

The Timing of the First Panic Attack

While panic attacks themselves often seem to occur unexpectedly, the first one frequently follows periods of distress or stressful life events, such as:

Although not all studies confirm this, some estimate that 80 to 90 percent of individuals report their first panic attack occurring after one or more negative life events.

Panic and the Brain

Current research recognizes that increased amygdala activity plays a central role in panic attacks. The amygdala, a cluster of nuclei located in front of the hippocampus within the brain’s limbic system, is crucial in processing fear.

Some studies suggest that the amygdala is the core of the “fear network,” connecting to lower brain regions and the prefrontal cortex.

However, panic attacks are just one aspect of panic disorder. People with this disorder also worry about future attacks and, like those with agoraphobia, often engage in phobic avoidance behaviors.

For those who experience one or more panic attacks and develop significant anxiety about having another in specific situations, the hippocampus is key. It’s believed to cause this conditional anxiety and likely plays a role in the learned avoidance associated with agoraphobia.

Lastly, higher cortical brain centers are responsible for the cognitive symptoms during panic attacks—such as fears of death or losing control—and exaggerated reactions to potentially threatening physical sensations.

Social Factors

High levels of social stress increase the risk of developing panic disorder. Individuals most at risk include:

• Widowed people
• Divorced or separated individuals
• Residents of urban centers

Other factors that heighten the risk of panic disorder are:

• Low educational attainment
• Early parental loss
• History of physical, verbal, or sexual abuse

Unsurprisingly, childhood anxiety—often linked to insecure parental attachment—also predicts panic disorder in adulthood (Biederman et al., 2005).

Psychological Interpretations

Some etiological models explore how thought patterns can trigger panic attacks without apparent external stimuli. Clark’s 1986 model, which has been particularly influential, identifies three key triggers:

• Fear-related thought patterns associated with specific stimuli or situations
• High levels of physical arousal linked to various emotional states
• Other events causing physical discomfort

Clark posits that each of these factors activates the core cognitive element of panic disorder: catastrophic misinterpretation of physical sensations.

The misinterpreted sensations are primarily those typical of normal anxiety responses. Additional factors include physical arousal from intense emotions like anger, and physiological changes such as increased heart rate from caffeine consumption.

The Tendency of Catastrophic Thinking in Panic Attacks

These thoughts trigger the fight-or-flight response (activating the amygdala in the brain), causing increased physical arousal. This heightened state is then reinterpreted catastrophically:

“My heart is racing—I must be having a heart attack!“

These anxiety-inducing thoughts further intensify arousal and physical symptoms, including:

• Rapid heartbeat
• Sweating
• Trembling
• Dizziness

This escalation leads to even higher anxiety levels, creating a vicious cycle that culminates in a panic attack.

Individuals often make these catastrophic interpretations unconsciously. These “automatic thoughts,” as Beck calls them, essentially trigger panic. While the origin of catastrophizing tendencies remains unclear, the cognitive model suggests that only those prone to such thinking develop panic disorder.

Furthermore, people who interpret harmless symptoms so catastrophically are considered to have high anxiety sensitivity.

How Panic Disorder Is Maintained

Once an individual develops the habit of catastrophically interpreting bodily sensations, two processes contribute to maintaining panic disorder:

• First, fear of specific sensations leads to hypervigilance. Individuals constantly monitor their bodies, noticing sensations most people would overlook. They interpret these as further signs of serious illness.
• Second, safety behaviors—such as avoiding feared situations or fleeing when symptoms appear—reinforce negative interpretations. This avoidance prevents individuals from learning that their symptoms are not as dangerous as they believe, blocking the extinction process.

This model suggests that changing one’s interpretation of physical symptoms can reduce or prevent panic. Moreover, understanding what to expect during a panic attack can help mitigate its symptoms.

Managing Panic Disorder

1) Consultation and Medical Advice

As mentioned earlier, most people experiencing panic attacks initially seek advice from their doctor.

As a preventive measure, it’s advisable to undergo regular medical check-ups—annually or biennially, depending on individual needs—to monitor your body’s physiology. It’s also crucial to understand the symptoms of a heart attack to avoid confusing them with those of a panic attack. For more information, refer to these links:

• Information on heart attacks
• Distinguishing panic attacks from heart attacks

Note: This article is for informational purposes only and doesn’t replace professional medical advice. If you have heart-related concerns, consult a cardiologist—for yourself or a loved one.

2) Relaxation Exercises and Proper Breathing

Since hyperventilation often accompanies panic attacks, learning correct breathing techniques is essential.

While most of us typically breathe from our chest, mastering diaphragmatic breathing is beneficial.

Various relaxation techniques teach diaphragmatic breathing. Consider exploring meditation or mindfulness classes, which also emphasize proper breathing.

Discover more about the benefits of proper breathing: link

3) Psychotherapy

Psychotherapy is crucial in managing panic attacks or panic disorder. While this article focuses on cognitive-behavioral therapy (CBT), which is particularly effective for panic-related issues, other therapeutic approaches can also be beneficial.

CBT

CBT typically involves two phases. In the first phase, individuals learn about the cognitive model of panic. The second phase comprises three key elements:

• Relaxation techniques to reduce physiological arousal during stressful moments
• Cognitive processes to alter panic-triggering thought patterns
• Behavioral processes to control panic symptoms

Through relaxation techniques, individuals learn to calm their body, slow down, and regulate their breathing—skills applicable before a potential panic attack.

Cognitive processes include self-guidance and cognitive challenging.

• Self-guidance training involves creating reassuring statements to use when sensing an impending panic attack. These pre-prepared reminders reinforce that symptoms won’t lead to feared outcomes and prompt the use of coping strategies like relaxation.
• Cognitive challenging helps individuals identify and question the thought patterns contributing to panic, challenging inappropriate assumptions.

Behavioral experiments aim to demonstrate through direct experience that the feared outcomes of panic attacks are unlikely to occur in reality.