• The symptoms
• The Fight or Flight Response
• Some of the causes
• When it's a problem
• Fuelling anxiety and attacks
• What keeps panic attacks going?
• Self help and other treatments
• News on Panic-Attack Tests
• How to identify a panic attack
• Some useful organisations
• See also

The American Psychiatric Association's official Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) defines a panic attack as a discrete period of intense fear or discomfort, in which 4 (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes:

• Palpitations, pounding heart, or fast heart rate
• Sweating
• Trembling and shaking
• Sensations of shortness of breath or smothering
• Feelings of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, lightheaded, or faint
• Derealization (feelings of unreality) or depersonalization (being detached from oneself)
• Fear of losing control or going crazy
• Fear of dying
• Paresthesias (numbness or tingling sensations)
• Chills or hot flashes

Some of these symptoms will most likely be present in a panic attack. The attacks can be so disabling that the person is unable to express to others what is happening to them. A doctor might also note various signs of panic: The person may appear terrified or shaky or be hyperventilating (deep, rapid breathing causing dizziness).

Recent literature suggests that men and women may experience different symptoms during an attack. Women tend to experience a predominance of respiratory symptoms compared to men.


The fight or flight response can be seen as one of the most important parts of our make-up - a highly efficient survival response for dangerous times. Back then, threats were simple and straight forward but often very dangerous - a wild animal, or member of an enemy tribe for instance.

That is why the mind of a human being can trigger a panic attack fast and unconsciously. This is highly important. People who suffer panic attacks often report that "they come from nowhere" and this is an essential part of the fight or flight response.

The Panic Attack : Faster Than the Speed of Thought
If you are in a threatening situation and you have to think before getting the hormonal changes associated with the flight or fight response, it may well be too late. Alternatively, you might make the wrong choice, so the unconscious part of our mind takes care of it. And of course, in a survival situation, it is better to respond as if danger is present when it's not, rather than the other way round. Much safer to err on the side of caution!

[In case you're wondering what the 'unconscious mind' is : Processes such as digestion, blood pressure and body temperature are controlled and monitored by the brain. These functions generally occur outside of awareness. A panic attack is also controlled largely unconsciously, hence the feeling that they 'come from nowhere'.]

If it is unclear how this relates to a panic attack in a supermarket, or in the street, then bear with me - all will become clear. So, we've talked about the evolutionary reasons for panic, but what is actually happening to the body during a panic attack? Why does it feel so strange?

What happens during a panic attack?
Well, several things happen as your body alters its priorities from long term survival to emergency short term survival. In response to the release of hormones such as adrenaline, your blood pressure increases and breathing speeds up preparing you for muscular effort.

Your legs may shake as they are prepared for running; your hands may shake as the large muscles of your arms are prepared to fight. Your palms and feet may become sweaty to give you better grip.

Blood is shunted away from the stomach to the major muscle groups where it will be used during an emergency. This is why people who experience regular stress often have digestive problems: blood is constantly being pumped to areas other than the stomach.

Other changes that occur during a panic attack, or fight or flight response are that the pupils dilate to let in more light, so we can gain more information about the situation. You may also feel like vomiting or defecating, which too can be seen to have survival value. If you vomit or defecate then you will be lighter to run from an attacker and are less appetising as a potential meal.

Remember... all these responses have survival value in the sort of circumstances that they originally evolved for. So why is it that so many of us experience a panic attack in a comparably safe modern environment?


There are many physical and psychological factors, which may be interwoven. You may experience panic only in response to a particular situation, such as flying or visiting the dentist. Or you may feel perfectly fine during a stressful event, but may have an attack later. This is because adrenalin levels don’t drop straight away. Any major life changes and events can trigger panic attacks.

Childhood influences
Incidents in childhood, and the way you were brought up and taught to think about yourself, can make you vulnerable to panic attacks later on. If you experienced great fear at being separated from a parent, you may have gone on to develop school phobia. As an adult, you may then have panic attacks when threatened with the loss of a support system or of someone who is important to you. Adult survivors of abuse in childhood also frequently suffer panic attacks.

Personality traits
If you are always anxious, you are more likely to have panic attacks. Being over-critical and disapproving of yourself, and striving to conform to the expectations of others, is common in people who panic. You may have difficulties in expressing your own needs and asserting yourself.

Physical causes
There are a number of physical causes that could be causing or contributing to your panic attacks:

• Unstable blood sugar levels (hypoglycaemia) can be the result of poor eating habits, dieting and fasting.
• Over-breathing (hyperventilation) happens when you are under stress, though you may not be aware of it. Your breathing becomes more rapid, in order to meet the body's demand for more oxygen for the muscles. As a result, you breathe out more carbon-dioxide than normal, which can bring on panic symptoms.
• Digestive problems, particularly food allergies, may be to blame.
• Taking antidepressants, particularly the newer ones, may produce panic attacks, especially at first.
• Caffeine, cigarettes, alcohol, and certain street drugs (such as LSD, marijuana and cocaine) can bring on a panic reaction.
• Withdrawing from any drug that has a sedative effect, such as nicotine, alcohol and tranquillisers, can do the same.
• Some prescription medication, including some amphetamines, steroids, anti-asthma drugs, and even nasal decongestants have been reported to increase anxiety.
• Sometimes, problems with the way the brain works (known as organic brain dysfunction) will cause balance, coordination and visual difficulties that make people very vulnerable to stress, and may contribute to agoraphobia.
• Being in chronic pain can be another cause of panic attacks, as can simple jet lag.

A high level of adrenalin is not in itself a bad thing. It can give you the extra energy to deal with difficult demands and challenges. The damage is done when the levels of adrenalin don't fall, naturally, after a stressful event. Stress becomes prolonged and tension becomes a habit.

For many people, their first panic attack comes out of the blue and creates a state of arousal. You may find yourself becoming more nervous, impatient and irritable as you feel, understandably, apprehensive about having another attack.

If you experience panic attacks over a period of time, you may develop a fear of fear. Because you have become hyper-aware of the sensations associated with fear, sensitised to them, you tense up whenever anything at all reminds you of the original panic. This can include your own bodily sensations. So someone feeling hot, or with sweaty hands (perhaps because they are in a meeting in a warm room), may assume, automatically, that they are in for another panic attack. Anticipating this makes them tense up and produces the very panic response they feared.


Although people having panic attacks often feel as if they are the only ones in the World with the problem, the thoughts that accompany panic attacks are usually very similar.

Here are the most common ones we encounter.

Panic Thought 1: I might die from a heart attack
Although it may not feel like it at the time, the heart is designed to react in the way it does during a panic attack. It can feel unnatural because this type of heart activity is usually reserved for vigorous acitivity, when you don't notice it as much. However, unless you have a heart condition, it is not usually a threat to the heart. If you are worried about this, see your medical practitioner.

Panic Thought 2: I might die from suffocation
It may not feel pleasant, but you are less likely to suffocate during a panic attack than at any other time because you naturally take in more air. The shortness of breath you may feel is due to your body increasing its demand for oxygen, or because of hyperventilation.

Panic Thought 3: I'm having a stroke
When you don't understand what is happening to you, it's perfectly natural to try and explain in it terms you understand. However, strokes have nothing to do with panic attacks, so you can relax about that! However, if you are worrried about it, see your medical practitioner.

Panic Thought 4: I'm scared of fainting
Fainting is not an option when being chased by a wild animal, in fact it could be fatal, so it is highly unlikely that panic will cause fainting. And what if you did faint? How bad would it be? The end of the world? Worse than death itself? Probably not. Fear of fainting often comes about due to the sense of dizziness which accompanies hyperventilation, sometimes part of panic. We'll look at what you can do about that in a minute.

Panic Thought 5: I'm having a nervous breakdown, or going 'crazy'
If you were really going insane would you be aware or worried about going insane? You already know that the anxiety, panic, or 'fight or flight' response is a natural mechanism, so this one doesn't even figure.

Panic Thought 6: Losing control
When having an anxiety attack, it can feel like you have lost control. In fact, all that has happened is that control has shifted from your conscious to your unconscious mind, so things are still being regulated, just differently.

Panic Thought 7: Feeling so weak that you cannot move or might fall down
The feeling of weakness is caused by the shaking we mentioned earlier. In fact, you are stronger when panicking than at any other time as your large muscles are being supplied with plenty of oxygen.

Panic Thought 8: Believing that you are going to be embarrassed or humiliated
How many times have you actually been humiliated or embarrassed by a panic attack? If you ever have been, was it really that bad? During an attack, it is very common and quite natural to worry that your body can't take what is happening. The fact is that panic is a short-term response.

The worst part of a panic attack only lasts a few minutes although unpleasant anxiety feelings can persist for longer. It is similar to a fire or emergency drill for the body.

If you have panic attacks then at least you know that your anxiety or fight or flight response is in good working order.


As you will remember panic affects your body, your thoughts and your behaviour. All three work together to keep panic going.
PHYSICAL
Firstly, the physical symptoms can be part of the problem. For people whose breathing is affected by anxiety, something called hyperventilation can occur. This just means someone is taking in too much air and not breathing it out. This is not dangerous but can lead to feelings of dizziness and is often taken as further evidence that there is something seriously wrong.

People who have panic attacks often worry that the physical symptoms mean something different than they do, examples of some of the most common mis-interpretations are:

What you feel	Reasons this is happening	Common fears
Eyes go funny Blurred vision / Tunnel vision / Feel unreal	Eyes trying to focus to fight danger	Brain haemorrhage Going mad
Breathing changes	Body trying to take in more oxygen to fight or run away	Choking or suffocating Running out of air
Chest pains	Muscles held tight ready to fight	Heart attack
Heart pounding	Increase flow of blood through body	Heart attack
Pounding in head / Headache	Increased pressure of blood flowing through body for extra energy	Tumour Haemorrhage
Numbness or tingling in  fingers or toes	Blood diverted to muscles	Stroke

       
THOUGHTS
Secondly, the physical symptoms and anxious thoughts form a vicious circle that keeps panic attacks coming back again and again. Also, focusing your mind on your body can lead to noticing small changes and seeing this as a threat. People often find it hard to believe that our thoughts can produce such strong feelings as fear. But if we believe something 100% then we will feel exactly the same way as if it were true.

Another way thoughts can affect panic is when someone starts to worry that they are going to panic in situations where they have panicked before. This, unfortunately, makes it more likely to happen again.

BEHAVIOUR
Thirdly, how a person behaves before, during and following a panic attack has a big part to play in whether panic attacks keep happening. The avoidance, escape and safety behaviour described earlier all add in to the vicious circle. This vicious circle is illustrated below


Your panic attacks are likely to make you feel out of control and dependent; the victim of your bodily reactions and outside circumstances. The first step along the road to recovery is recognising that you have the power to control your symptoms.

Take control
Start by really looking, in detail, at your panic attacks. When did they happen? Where were you? What were you thinking? See if you can identify particular thoughts that trigger a panic reaction.

A number of experts have emphasised the need to accept the panic attacks when they occur and that it may in fact be most helpful if you try and ride out the attacks to learn that no harm will come to you. This may sound strange, but fighting them only increases your level of fear and allows your panic to take on tremendous proportions. Accept that a panic attack is unpleasant and embarrassing, but that it isn't life-threatening or the end of the world. By going with the panic, you are reducing its power to terrify you.

Creative visualisation and affirmations
Creative visualisation and affirmations are techniques that may be helpful. You can use them to re-train your imagination and to get yourself moving in a more positive direction.

Many people who suffer panic attacks have a vivid imagination, which they use to conjure up disaster, illness and death. You can train your imagination to focus on situations that give you a sense of wellbeing. You can imagine you are in a place that symbolises peace and relaxation for you, such as drifting on a lake. You can practise this anywhere but, until you have got used to doing this, try sitting in a chair with your limbs as floppy as possible, and think of calming images.

You can use visualisation to focus on situations that you fear. Imagine the situation and speak positively to yourself: 'I am doing well', 'This is easy'. These simple, positive, present-tense affirmations are messages that you can say silently or out loud. These techniques do not provide a quick fix. If you have been used to thinking negatively, over a long period of time, you will need to practise every day. You may then gradually notice positive changes in the way you think of yourself and others.

Assertiveness
You may be having panic attacks because there are aspects of your life that are undermining your confidence. It may be useful to look at your family life, your job, and so on, and identify changes you would like to make. If you feel trapped in a situation, and find it very difficult to express your true feelings (to say 'no' or to set proper limits in relationships, for example), you may find assertiveness training helpful.

Learn a relaxation technique
If you habitually clench your jaw, and your shoulders are up around your ears, this will generate further tension. Relaxation techniques focus on easing muscle tension and slowing down your breathing. It helps your mind to relax.

Breathing
Hyperventilation (over-breathing) commonly leads to panic attacks. Many people get into the habit of breathing shallowly, from the upper chest, rather than more slowly from the abdomen. Put one hand on your upper chest and the other on your stomach. Notice which hand moves as you breathe. The hand on your chest should hardly move, if you are breathing correctly from the diaphragm, but the hand on your stomach should rise and fall. Practise this breathing, slowly and calmly, every day.

Diet
Unstable blood sugar levels can contribute to symptoms of panic. Eat regularly and avoid sugary foods and drinks, white flour and junk food. Instead, choose complex carbohydrates, such as potatoes, rice and pasta. Caffeine, alcohol and smoking all contribute to panic attacks and are best avoided.

First aid
If you are having a panic attack, try cupping your hands over your nose and mouth, or holding a paper bag (not plastic!) and breathing into it, for about 10 minutes. This should raise the level of carbon-dioxide in the bloodstream and relieve symptoms.

Other first-aid tips include running on the spot during a panic attack. If you feel unreal, carry an object, such as the photograph of a loved one, to anchor you in reality, or finger a heavily textured object, such as a strip of sandpaper. You could also distract yourself, by trying to focus on what is going on around you.

Drug therapy
The NICE (National Institute for Health and Clinical Excellence) guidelines on the treatment of anxiety state that benzodiazepine tranquillisers, such as diazepam (Valium), are associated with a less good outcome in the long-term and should not be used to treat panic disorder. If drug treatment is used, SSRI antidepressants, such as Prozac, should be used first, and if these are not effective, the tricyclic antidepressants imipramine or clomipramine (Anafranil) may be tried instead. SSRI antidepressants are difficult to come off for many people, so when you are ready to stop taking them, you should always withdraw slowly. When starting antidepressants, the side effects may include anxious, jittery feelings. The longer you are on them, the more likely you are to experience withdrawal symptoms, which can cause panic attacks.

Psychotherapy
Emotional conflicts and past difficulties may lead to anxiety, which is released through panic attacks. Without realising it, you may be experiencing these bodily sensations and physical reactions as a way of avoiding painful emotions. Psychotherapy can help you to understand your present reactions in the light of past difficulties, and to overcome them.

Cognitive behaviour therapy (CBT)
Our thoughts have a very powerful impact on our behaviour. You may be unaware of seemingly automatic thoughts and misinterpretations that provoke attacks. This is because thoughts happen so quickly and may take the form of images and sensations, rather than words. The way we interpret things can cause extreme distress. But it is possible to bring about a state of wellbeing by changing habitual thought patterns. If we think that our racing heart is a sign of a possible heart attack we'll be very frightened, but if we think that it is due to excitement or too much coffee, we'll feel very differently about it.

CBT aims to identify and change the negative thought patterns and misinterpretations that are feeding your panic attacks. If you are interested in this kind of therapy, ask your GP to refer you to a clinical psychologist. It’s also possible to apply self-help techniques.

Behaviour therapy
Many people develop a pattern of avoiding situations that have previously provoked a panic attack. They may become withdrawn and phobic. A clinical psychologist can address the problem using behavioural therapy. The therapy concentrates on encouraging you to imagine anxiety-provoking situations, at the same time as practising relaxation. You will be encouraged to confront your fears, in fantasy, and then move on to facing your fears in reality. In learning to relax and face up to feared situations, you will unlearn your feelings of panic.

Complementary and alternative therapies
Complementary and alternative therapies have proved to be helpful when people are experiencing stress-related symptoms, anxiety and depression. They can be a useful tool in promoting relaxation and inducing a state of wellbeing. Complementary health practitioners stress the connections between mind and body, and aren’t concerned with merely treating symptoms. There is an enormous number of different therapies: acupuncture, aromatherapy, autogenic training and homeopathy, to name but a few.


Available blood tests for panic disorder and other mental-health conditions are potentially around the corner, according to results from a new study initiated by the University of Iowa.

The findings, based on analysis of genetic information in immature white blood cells, just appeared in the online version of the American Journal of Medical Genetics.

"The ability to test for panic disorder is a quantum leap in psychiatry," said the study's lead author, Robert Philibert, M.D., Ph.D., professor of psychiatry at the University of Iowa's Roy J. and Lucille A. Carver College of Medicine.

"Panic disorder will no longer be a purely descriptive diagnosis, but, as with cystic fibrosis, Down syndrome and other conditions, a diagnosis based on genetic information," he said.

In addition, noted Philibert, "the finding could help us better understand the pathways that initiate, promote and maintain panic disorder."

The team compared gene expression in lymphoblasts (immature white blood cells) culled from 16 participants with panic disorder and 17 participants without it.

The study found that many genes were more expressed in people with panic disorder than in people without the condition.

Similarly, the study found that many genes were less expressed in people with panic disorder. There were also sex-related differences to be considered, according to the report.

Different Patterns

Overall, people with panic disorder had noticeably different patterns of gene expression than people without the disorder.

Although panic disorder is a disease of brain cells, the study used lymphoblasts as "stand-ins" for the genetic testing because brain cells are not accessible or easily tested.

About 3 percent of people in the United States have panic disorder, which involves having at least one panic attack every four weeks.

Panic attacks can involve up to 10 symptoms, including palpitations, shortness of breath, sweating, and a feeling of a loss of control or even dying -- symptoms very similar to those who are suffering from actual heart attacks.

A blood test for commercial use is currently being developed by the university, which raises larger questions about how information revealed by such tests will then be used.

Philibert said that the issue of patient medical records -- and how those records can potentially be used by employers, insurers, government agencies and other institutions -- remains a concern.


Research shows that a feeling of choking along with dizziness and weak knees or legs are all symptoms of a panic attack.

The Professional Association of German Psychiatrists (PAGP) states that a fast heart rate, pain, discomfort and a feeling of trepidation are further indicators of panic attacks.

Those feelings are frequently associated with a fear of 'going crazy' or experiencing a nervous breakdown.

The chairwoman of PAGP, Christa Roth-Sackenheim, explains that "most people who are affected suddenly experience weakness and dizziness without explanation or a physical trigger," DPA reported.

Roth-Sackenheim states "symptoms appear from out of the blue and become very intense after a few minutes, before they subside within a short time."

Roth-Sackenheim says that panic attacks are a "very tortuous experience" and maintains that people who do experience them can develop chronic fears.

"A range of effective therapies can help sufferers," but without the proper treatment, a panic attack is rarely completely cured, says the PAGP chairwoman.

The cause of panic attacks is yet unknown but researchers believe a failure in the body's fear -stress -mechanism is to blame.

Panic attacks that begin during childhood often increase the chance of suffering from depression, addiction and other mental abnormalities later on in life.

According to a study published in the Psychiatric Times, panic attacks affect more individuals on a yearly basis than strokes, epilepsy or even AIDS. The study concluded that people who experience panic attacks are 20 percent more likely to commit suicide.


British Association for Behavioural Cognitive Psychotherapies (BABCP)
Tel: 01254 875 277
web: www.babcp.com
Promote CBT and provides a list of private accredited therapists

British Association for Counselling and Psychotherapy (BACP)
BACP House, 35–37 Albert Street, Rugby CV21 2SG
Tel: 0870 443 5252
web: www.bacp.co.uk
See website or send A5 SAE for details of local practitioners

The Institute for Complementary Medicine (ICM)
Tel: 020 7237 5165
web: www.icmedicine.co.uk
Has a register of professional, competent practitioners

National Phobics Society
Tel: 0870 122 2325
web: www.phobics-society.org.uk
For those suffering from anxiety disorders

No Panic
helpline: 0808 808 0545
web: www.nopanic.org.uk
Helps people experiencing panic and anxiety disorders

See also
Anxiety
Cognitive Behavioural Therapy
Neuro-linguistic programming
Diabetes and depression
A new high for the UK
Handling stress in the US
Mental Health day the news
Stress on the brain
Why we worry
SAD