Panic attack: why it feels like you're dying

It can start anywhere: on the Tube, in a queue at the shops, at the wheel, in bed at night. Suddenly the heart starts pounding, it’s hard to get enough air, the hands tingle and the room seems to tilt. One thought crowds out everything else: “I’m dying”, “it’s a heart attack”, “I’m losing my mind”. Some people call an ambulance, only to be told in A&E that their heart is fine. The relief comes mixed with embarrassment and a new worry: what if it happens again?

This is a panic attack: a sudden surge of intense fear that peaks within minutes, usually within ten. Most attacks are over within 5 to 20 minutes. A large study of more than 140,000 adults in 25 countries found that about 13% have at least one panic attack in their lives. Only about one in eight of them goes on to develop panic disorder.

What happens in the body

A panic attack is the body’s alarm system going off when there’s no real danger. The brain releases adrenaline and the body gets ready for fight or flight. Every sensation has a simple explanation:

• The heart pounds to pump more blood to the muscles.
• Breathing quickens. Breathing out too much carbon dioxide makes a person dizzy, makes the hands and lips tingle and, oddly, leaves them feeling short of air.
• Muscles tense, so the body shakes and the chest feels tight.
• Digestion slows down, which brings nausea and a dry mouth.
• Sometimes the world starts to feel unreal or far away.

All of this is frightening but not dangerous. The NHS is clear that a panic attack won’t cause any physical harm. The body can’t keep up that kind of jolt for long, and things gradually settle on their own.

Why it feels like dying

In the 1980s the British psychologist David Clark, at the University of Oxford, described why the body’s normal fear response tips over into panic. A person notices a sensation, say a faster heartbeat, and reads it as a catastrophe: “my heart is failing”. The fear releases more adrenaline, the heart beats faster still, and that seems to prove the danger is real. Within seconds the circle closes.

After the first attack, a second fear appears: fear of the next one. A person starts monitoring their body and noticing every flutter, and that attention alone makes the sensations stronger. If attacks keep coming out of the blue and, for a month or more, the person worries about the next one or changes their life to avoid it, doctors may diagnose panic disorder. Some attacks come at night and wake a person up, and then even going to bed can feel frightening.

The rescue kit that keeps panic going

To feel safer, people gradually put together a rescue kit: always carrying water or tablets, sitting near the exit, checking their pulse, only going out with someone else, avoiding coffee, exercise and crowded places, leaving a shop the moment their heart speeds up. Each of these brings relief. But the brain draws the wrong conclusion: “I survived because I sat down, left, held on”, rather than “nothing dangerous was happening”.

In 1999 Paul Salkovskis and colleagues at the University of Oxford put this to the test with people who had panic disorder and avoided places where they feared an attack. They spent 15 minutes in a situation they dreaded: some were asked to drop their usual safety measures, others kept them. When the test was repeated within two days, those who had dropped them believed far less in a catastrophe and felt less anxious. In other words, the rescue kit calms things in the moment but feeds the fear of further attacks.

What to do during an attack

• Stay put, if possible. Leaving teaches the brain that escape saved the day. Staying shows that the attack passes on its own.
• Name what is happening: “This is a panic attack. It’s unpleasant, but it isn’t dangerous, and it will pass.”
• Don’t fight the sensations. Trying to force them away usually adds a second wave of fear. It helps to let the wave rise and fall, like waiting out a strong gust of wind.
• Breathe more slowly, without trying to get it perfect. A calmer rhythm eases over-breathing, but nothing depends on doing it exactly right.
• Don’t breathe into a paper bag. It lowers the oxygen in the blood, and if the real cause is a heart or lung problem, it can be dangerous.
• Remember previous attacks: every one of them came to an end.

If you’re with someone during an attack, the most helpful thing is to stay calm and close by, speak slowly and breathe steadily alongside them. “Calm down” rarely helps: it sounds like being told to stop something that isn’t in the person’s control. And unless there are warning signs, there’s no need to hurry them out or off to A&E.

When it may not be panic

A first attack, especially with chest pain, is worth getting checked by a GP. Some heart rhythm problems, an overactive thyroid, lots of caffeine, drinking or alcohol withdrawal and some drugs can feel very similar.

Call 999 if chest pain or discomfort comes on suddenly and doesn’t go away (it can feel like squeezing, pressure, burning or indigestion), if pain spreads to the arm, neck, jaw, stomach or back, or if chest pain comes with sweating, feeling sick, light-headedness or breathlessness. These signs partly overlap with panic, so when they appear, it’s better to call than to guess.

How panic is treated

Panic disorder responds well to treatment. UK guidelines recommend starting with psychological help. In psychotherapy a person learns how the circle works, gradually gives up the rescue kit and, in a safe setting, deliberately brings on the sensations they fear, for example by breathing fast or running on the spot, to find out that they are harmless. Treatment can be short: in a small Oxford trial, a course with about six and a half hours of therapist time plus self-study materials worked as well as the full 12 to 15 sessions, and the gains held a year later.

Antidepressants can also help, especially if attacks have been going on for a long time. Fast-acting tranquillisers aren’t recommended for panic disorder, as they are linked to poorer results in the long term. In England, adults can refer themselves to NHS Talking Therapies without seeing a GP, or see a private psychotherapist.

A panic attack feels like the end of the world, but it’s a false alarm: the siren is wailing, but there’s no fire. And that alarm can be retrained.