Panic attacks and panic disorder: why they happen and how CBT can help

A panic attack is a sudden surge of intense fear, usually peaking within a few minutes. For many people, the first one comes out of nowhere: a racing heart, difficulty breathing, dizziness, and an overwhelming sense that something is terribly wrong. Many people are convinced they are having a heart attack, losing control or about to collapse. It is one of the most frightening experiences a person can have, and it is also one of the most treatable.

What a panic attack feels like

Panic attacks involve a cluster of physical and mental symptoms, which can include:

• A pounding or racing heart
• Shortness of breath, or a feeling of not getting enough air
• Chest tightness or discomfort
• Dizziness, light-headedness or feeling faint
• Sweating, trembling, hot flushes or chills
• Tingling or numbness, often in the hands or face
• Nausea or stomach discomfort
• Feeling detached or unreal, as if things around you aren't quite real
• A fear of dying, losing control, fainting or "going mad"

If you have had symptoms like these, it is sensible to see your GP to rule out a physical cause. Once that has been done, it helps to know that panic attacks, however frightening, are not dangerous.

Panic attacks and panic disorder

Panic attacks are common. Many people have one or two at some point in their lives, often during a stressful period, and never have another. Panic disorder is different. It involves repeated, often unexpected panic attacks, together with a persistent fear of having more and changes in behaviour because of that fear.

For many people, the fear of the next attack becomes as much of a problem as the attacks themselves. They may start avoiding places where an attack would be difficult to escape from or embarrassing, such as public transport, supermarkets, meetings or travelling far from home. When that avoidance becomes widespread, it is known as agoraphobia.

Why panic attacks happen

The CBT understanding of panic is one of the best-established models in psychology. It centres on a vicious cycle:

• You notice a bodily sensation, such as your heart beating faster, a slight dizziness or a tight chest.
• You interpret it as a sign of danger: Something is wrong with my heart. I'm going to faint. I'm losing control.
• That interpretation triggers fear, and fear produces more physical sensations.
• The stronger sensations seem to confirm the danger, and the cycle spirals within seconds.

The original sensation may have come from something quite ordinary, such as caffeine, climbing stairs, stress or simply standing up quickly. It is the interpretation that turns it into panic.

What keeps panic going

After a first panic attack, people naturally try to protect themselves. They become watchful for any change in their body. They develop small strategies for getting through: sitting down, holding on to something, carrying water or medication, keeping close to an exit, having someone with them. And they start to avoid situations that might trigger an attack.

These responses make complete sense. But they also mean the feared outcome never gets tested. If you always sit down when you feel dizzy, you never discover that you wouldn't have fainted anyway. Each attack that passes seems to have been survived only because of the precautions, and so the fear stays intact.

How CBT can help

CBT for panic disorder is one of the most effective treatments in the whole field of psychological therapy, and it is recommended in the UK's NICE guidelines. Treatment starts with building a clear understanding of your own panic cycle: the sensations, the interpretations, and everything you do to protect yourself. From there, the work involves testing the predictions panic makes, in a planned and graded way, and gradually reducing the precautions and avoidance that keep it going.

This is hard to do alone, for an understandable reason: approaching the sensations you fear most goes against every instinct. People who try often do it while quietly holding on to a safety behaviour, which undoes much of the benefit. Working with someone who understands the mechanism makes it possible to do this at the right pace and in a way that actually changes the fear.

When to seek help

It may be worth getting help if panic attacks are recurring, if you are worrying about the next one, or if you have started avoiding places or activities because of them. Panic tends to respond well to treatment, often more quickly than people expect, and avoidance is usually much easier to reverse before it has become established.

In my practice

People often come to me after months or years of managing panic quietly: planning journeys around it, turning down opportunities, or carrying a constant low-level fear of the next attack. Many have been told it is "just anxiety", which is accurate but doesn't explain what to do about it. Understanding the panic cycle is often the turning point. You can read more about how I work with anxiety on my anxiety therapy page, and about a related form of anxiety in Social anxiety: why it persists and how CBT can help.

Guy Klein

BABCP-accredited CBT therapist and EMDR Europe accredited practitioner, in clinical practice since 2015. Guy works with adults online and in Queen's Park, North West London, with a particular focus on OCD, anxiety and trauma. More about Guy