A panic attack is a false alarm
Maria was driving home from work on the highway when she felt her heart skip a beat. Within a minute it was pounding. Her chest felt tight, her hands tingled, and the road ahead started to look strange and far away. Sure she was having a heart attack, she pulled over and called 911. At the emergency room, her heart tests and blood work came back normal, and the doctor said it was most likely a panic attack.
A panic attack is a sudden rush of intense fear, along with strong feelings in your body. It comes on fast and peaks within minutes, often by about the 10-minute mark. It can bring a pounding heart, trouble breathing, dizziness, shaking, and a strong sense that something terrible is happening right now. All of it comes from your body's alarm system going off at full strength when there's no danger.
One panic attack is common, and it doesn't mean you have a disorder. Panic disorder is when attacks keep coming out of the blue and you start worrying about the next one, or changing your life to try to prevent it.
That's what happened to Maria. Knowing her heart was healthy helped for a few days, and then she started noticing every flutter in her chest and wondering if another attack was coming. A few weeks later, she had a second one in a supermarket checkout line and walked out, leaving her cart behind. After that, she stopped driving on the highway, which added 40 minutes each way to visits with her mom, and she turned down a job one town over.
If this sounds like you, you aren't weak, and you aren't going crazy. Panic is very treatable. The tools in this guide are the ones therapists who specialize in panic teach their patients, and they work for a lot of people.
What happens in your body
When your body's alarm goes off, it releases adrenaline and gets you ready to fight or run away. Doctors call this the fight-or-flight response. In a panic attack, it happens when there's no danger at all, so your body gets ready to sprint while you're standing in line or sitting in a parked car.
The feelings that come with it are frightening when they hit all at once for no reason you can see. Each one has a job, though:
What each feeling is doing
- Racing mindYour attention locks onto possible danger, including the feelings in your body, so it's hard to think about anything else.
- Feeling unreal or far awayWhen the alarm is high, especially when you're breathing fast, the world can seem dreamlike, or you may feel detached from yourself. Doctors call this derealization or depersonalization. It's harmless, and it passes.
- Fast breathingYour body pulls in extra air for your muscles. Breathing faster than you need can make your lips and fingers tingle, make you lightheaded, and make it feel like you can't get a full breath.
- Tight chestThe muscles around your ribs tense up. When they get tired, they can ache or even feel sharp.
- Pounding heartYour heart beats faster and harder to send blood to your muscles, the same way it does when you exercise.
- Upset stomachDigestion slows down, which can cause butterflies, nausea, or a sudden need to use the bathroom.
- Shaky handsMuscles full of adrenaline can tremble, especially in your hands, legs, and voice.
- SweatingYour body starts cooling itself down, as if you're about to run.
What a panic attack can't do to you
Most of the fear in a panic attack comes from what people think these feelings mean. Three fears cause the most suffering, and in a healthy person, all three are wrong.
A panic attack doesn't cause a heart attack. When your heart races during panic, it's a healthy heart working hard, the way it would on a steep hill, and panic doesn't damage it.
Panic almost never makes you faint. Fainting happens when your blood pressure drops, and panic raises your blood pressure.
People who faint at the sight of blood or needles have a different pattern: with that kind of fear, blood pressure can rise and then suddenly drop. A technique called applied tension keeps it up. Sit down and tense the muscles in your arms, legs, and body, hard, for 10 to 15 seconds, until your face feels warm. Then relax for 20 to 30 seconds without going fully limp, and repeat that five times. Do a set like this about five times a day for the week before a blood draw, and again in the chair. If you have high blood pressure or heart disease, ask your doctor first.
Panic doesn't make you go crazy or lose control. It doesn't turn into psychosis, which means losing touch with reality, and people having a panic attack don't suddenly act against their will. Feeling unreal is a normal part of a high alarm, and it passes.
Why panic keeps coming back
After a panic attack, your brain can start treating the feelings in your body as warning signs and watching for them. A skipped heartbeat or a moment of dizziness that you wouldn't have noticed before can now set off the alarm, and once it goes off, a panic attack can feed itself.
On the highway, Maria felt her heart skip a beat, and her mind jumped to a scary meaning: "I'm having a heart attack." That thought brought a jolt of fear, and the fear released more adrenaline. The adrenaline made her heart pound harder and made her dizzy, which seemed like proof that something was wrong. She got more scared, and the loop went around again.
The panic cycle
You can break this loop in two places. The first is the scary thought. When you know a pounding heart is adrenaline doing its job, it doesn't have to mean "heart attack." The second is what you do with the feelings. If you let them rise and fall without fighting them or running away, your brain gets to see that nothing terrible happens. The tools in this guide practice both.
Avoiding keeps panic going too. After her second attack, Maria stayed away from the highway and the big supermarket, and each time she felt relief. Her brain took that relief as proof that those places were dangerous and that staying away had kept her safe. So the fear grew and spread to new places, like crowded theaters, long lines, and anywhere far from home.
Things you do to feel safe
Some avoidance is harder to spot. You still go, and you do something extra to get through it. Therapists call these safety behaviors. With panic, common ones include:
- Carrying water, mints, or a pill "just in case"
- Sitting near the exit, or finding the exits as soon as you arrive
- Only going places when a certain person comes with you
- Checking your pulse, blood pressure, or breathing
- Holding on to a railing, a shopping cart, or your phone
- Driving only in the right lane, or with the windows down
- Distracting yourself with music, counting, or telling yourself "it's fine, it's fine"
- Planning an excuse to leave early
Maria kept a water bottle in the cup holder, drove with the windows down, stayed in the right lane, and called her sister on speakerphone whenever she drove. Safety behaviors like these feel like they help, and in the moment they do. But when Maria got through a drive with her sister on the phone, her brain gave the call the credit. It never found out she would have been fine without it, so the next drive felt just as dangerous.
Agoraphobia
For some people, avoiding keeps spreading until they fear many places where it would be hard to get out, or hard to get help, if panic hit: buses and trains, parking lots, stores and theaters, lines and crowds, or being out alone. This is called agoraphobia. It often grows out of panic attacks and can shrink someone's world to a few "safe" routes. It's treated with the same practice this guide describes, built around distance from home and being alone. If you've become housebound, start with a therapist. Many can do the first sessions by video and then coach you through the early steps.
How panic gets better
Maria's relief after the emergency room lasted only a few days, because the alarm in your body doesn't change much from being told you're safe. It changes when you feel the sensations you fear, stay where you are, and see for yourself that nothing terrible happens.
The treatment for panic uses that idea on purpose. It's called exposure, and it means facing what you've been avoiding, a little at a time. With panic, you face two things: the feelings in your body, and the places you've avoided because of them.
Maria's plan had four parts. First, she learned what her body was doing during an attack, which you've just read about. Next, she brought on panic feelings at home, on purpose, until they stopped scaring her. Then she went back to the places she'd been avoiding, one small step at a time. Along the way, she dropped her safety behaviors. These are the main parts of cognitive behavioral therapy (CBT) for panic, and the rest of this guide walks through them.
Practice is uncomfortable at first. A panic attack peaks within minutes and then passes on its own, even if you do nothing to stop it, and if you always leave, you never get to see that. A practice still counts if your fear stays high, because your brain learns from finding out that the thing you feared didn't happen.
Getting better takes time. A single step often gets easier within a handful of practices, and working through all the places you avoid usually takes several weeks to a few months.
What to do during a panic attack
When a panic attack starts, you'll probably want to get out or make it stop right away. It helps more to let the attack run its course while you stay where you are, because that's how your brain learns you can get through it.
When you notice an attack starting, say this to yourself:
"This is a panic attack. It's adrenaline. It peaks and it passes."
Then work through these steps:
- Stay where you are if it's safe. If you're driving and feel unsafe, pull over when you can and stay in the car. Leaving teaches your brain that escaping is what saved you.
- Slow your breathing, with a longer breath out. Breathe in through your nose for about 3 seconds, then out through pursed lips for about 6. Keep the breaths small and slow, since big gulps of air make tingling worse. You don't need a paper bag.
- Let the feelings rise. Describe them to yourself like a weather report, with a number from 0 to 100: "Heart racing, hands tingling, chest tight. About an 85." You don't have to push them down.
- Drop whatever safety behaviors you can. Put the water down, let go of the railing, and stop checking your pulse.
- When it eases, go back to what you were doing, even slowly. Finish the errand.
- Afterward, write down what you were afraid would happen and what happened.
A few weeks into her practice, Maria had an attack in a checkout line. This time she stayed, and afterward she wrote: "I thought I'd get so dizzy I'd have to leave my cart and run out. I didn't. It peaked at 90 and was down to 40 in 12 minutes." Notes like this show you, in your own handwriting, that your attacks pass.
Use slow breathing to help you stay put. If it turns into something you believe you must do to survive an attack, it has become a safety behavior, and it's time to practice getting through panic without it.
Get used to the feelings
With panic, the thing you fear most is the feelings in your body. So part of getting better is bringing those feelings on yourself, on purpose and in a safe place. It sounds scary, and at first it can be. Each time your heart pounds or your head spins on purpose and nothing bad happens, your brain learns a little more that those feelings are safe.
Therapists call this interoceptive exposure, which means exposure to feelings from inside your body. It's a main part of the CBT treatment for panic developed by Michelle Craske and David Barlow.
Before you try any of these exercises, read the cautions:
- Check with your doctor first if you're pregnant, or if you have heart disease, lung disease or asthma, a seizure disorder (fast breathing can trigger seizures), neck or back problems, or a history of fainting or low blood pressure.
- If you have neck or back problems, skip head shaking, head between the knees, and spinning unless your doctor says they're okay.
- Do spinning and the head exercises sitting down, with nothing sharp nearby, and wait for the dizziness to settle before you stand up.
- Stop and get medical advice if you have chest pain, if you're short of breath and it doesn't settle within a couple of minutes of stopping, or if you faint.
Each exercise brings on a different set of feelings:
Exercises that bring on panic feelings
| Exercise | How to do it | What it usually brings on |
|---|---|---|
| Fast breathing | Breathe fast and deep through your mouth, about one full breath every 2 seconds, for 60 seconds. | Lightheaded, tingling, unreal, short of breath |
| Spinning | Spin in a swivel chair with your eyes open for 60 seconds. | Dizzy, off balance, queasy |
| Straw breathing | Pinch your nose and breathe only through a thin straw or coffee stirrer for 2 minutes. | Can't get enough air, tight chest, smothering |
| Running in place | Run in place with high knees, or go up and down a flight of stairs, for 60 seconds. | Pounding heart, out of breath, sweaty |
| Head shaking | Shake your head loosely from side to side, eyes open, for 30 seconds. | Dizzy, disoriented |
| Head between knees | Sit with your head between your knees for 30 seconds, then sit up quickly. | Head rush, lightheaded |
| Whole-body tension | Tense every muscle hard while breathing normally, for 60 seconds. | Trembling, weak, shaky afterward |
| Breath holding | Hold your breath for 30 seconds. | Can't get enough air, chest pressure, pounding heart |
To practice:
- Try each exercise once, with someone nearby the first time if you'd like. Right afterward, rate two things from 0 to 100: how strong the feelings were, and how much they felt like your panic.
- Pick the two or three that felt most like your panic, ideally ones you rated 40 or higher on that second number.
- Practice those every day. Do the exercise, then keep noticing the feelings for another 30 seconds without trying to make them go away. Do 3 to 5 rounds in a row.
- Keep going until they're boring, meaning the feelings are under about a 20. That usually takes one to two weeks.
- Then take it into everyday life: a strong coffee, a hot shower with the bathroom door shut, a warm and crowded room, taking the stairs fast, an exercise class, or a ride at a fair. Check with your doctor first if any of these could be risky for you.
Running in place and fast breathing felt the most like Maria's panic. The first time she ran in place, her heart pounded so hard that she rated it an 80 and wanted to check her pulse. Instead, she sat and noticed her heartbeat for 30 seconds while it slowed on its own. By the second week of daily practice, running in place was down to about a 15, and she started taking the stairs at work two at a time.
Go back to the places you've been avoiding
The other kind of practice is going back to the places you've been avoiding, in small steps, using a list called a fear ladder.
To make one, write down the situations you avoid, and be specific. "The grocery store" is too vague to practice. "Walk through the whole store at 6 pm on a weekday, alone, for 20 minutes" is a step you could do this week. Next to each one, write a number from 0 to 100 for how anxious you'd feel doing it without your safety behaviors. Then put the list in order, from easiest to hardest.
If there's a big jump between two steps, add one in between by changing one thing, like the time of day, how far you go from home, whether someone comes with you, how long you stay, or how crowded it is. This is Maria's ladder, with the hardest step at the top:
Maria's fear ladder
Drive 30 minutes on the highway at rush hour, alone
Sit in the middle of a row at a full movie theater
Drive one exit on the highway, in the right lane, at midday
Walk 30 minutes away from home without calling anyone
Stand in a full checkout line at a busy supermarket
Drive 15 minutes on local roads alone
Spend 10 minutes in a small grocery store at a quiet time, with my phone in my bag Maria starts here
Drive around the block alone
Start with a step you rated around 30 to 50, one that feels uncomfortable and still doable. Maria started with the small grocery store.
Before she went, she wrote down her fear and how sure she felt: "I'll get so dizzy that I'll have to run out. 70% sure." At the store, she kept her phone in her bag. Near the back, she got dizzy, and her anxiety climbed to about a 60. She stayed, and within a few minutes it started to come down. Afterward she wrote, "Dizzy for a few minutes. Didn't leave. Bought what I came for." Now her fear felt about 25% likely.
Practice most days, or at least three or four times a week. Stay long enough to find out whether what you fear happens, which for a store or a drive is often 20 to 45 minutes, though a first step can be shorter. When a step feels noticeably easier, with your anxiety about half of what it was the first time, or your fear clearly isn't coming true, move up to the next one. Our general anxiety guide explains how to practice a step in more detail.
If you only feel okay when a certain person is with you, fade them out in steps, each one its own rung: first they come along, then they wait in the car, then they stay home where you can reach them, and finally they don't know when you're going.
Progress won't be a straight line, and a step can feel harder when you're tired, stressed, or sick. If an easy step suddenly feels hard, go back down one rung for two or three practices, then climb again. If you have a panic attack after weeks of calm, do a planned practice within a day or two, so avoiding doesn't get a head start.
Let go of safety behaviors
Safety behaviors keep your brain from finding out that you're safe on your own, so letting go of them is a big part of getting better. They're often an easier place to start than your hardest steps.
List the ones you use, and rate each from 0 to 100 for how anxious you'd feel without it. Drop the easiest one first, all at once or in stages, then add the next one about once a week. The hardest ones can become steps on your fear ladder.
Maria started with the car windows, which she rated a 30, and kept them up on every drive for a week. The next week, the water bottle went in the trunk, and she changed lanes once on each drive. The calls to her sister were harder to give up. First she hung up partway through each drive, and a week later she stopped calling and sent a text when she arrived.
Expect your anxiety to go up when you first drop a safety behavior. That's your brain getting the chance to learn you're okay without it, and the anxiety comes down if you stick with it. It's fine to keep one for a while as a stepping stone, as long as you set a date to drop it.
Medical needs are different. Keep your asthma inhaler, EpiPen, glucose tablets, or any medicine your doctor told you to carry, and talk to your prescriber before you change how you take a medication.
Other anxiety guides
These guides cover anxiety in general and other kinds of anxiety:
A workbook for panic
For a step-by-step program to work through at home, try Mastery of Your Anxiety and Panic: Workbook by Michelle Craske and David Barlow. It's the workbook for their CBT program for panic disorder. It covers breathing, bringing on the feelings on purpose, and going back to avoided places step by step, and this guide follows its approach.
The book link is an Amazon affiliate link. As an Amazon Associate, Psychofarm earns from qualifying purchases, at no extra cost to you. See our disclosures.
The treatment methods in this guide are based on cognitive behavioral therapy research, especially Michelle Craske and David Barlow's treatment for panic disorder.