A Singular Point of View
Imagine the fire alarm in your building goes off, and there is no fire. You are in the queue at the till, or on the 17:42 home, or standing in the hallway with your keys still in your hand. Nobody has pressed anything. Your heart is hammering against your ribs, your hands have gone cold and tingling, and the floor tilts a few degrees to the left. A voice much louder than your usual one says you are dying, or about to collapse in front of everyone. Every instinct you own says leave. Now.
Perhaps that was you last Tuesday, at half past six, with the shopping half-packed. It lasted perhaps ten minutes and felt like an hour. Then the shaking stopped, and you were left with a different problem: what on earth was that, and will it happen again?
You may be reading this while you wait for an assessment. Or you came home from A&E with a normal heart trace and a leaflet, and a quiet sense that nobody quite believed how frightening it was. This post draws on two large pieces of research, one on how common panic attacks really are and one on which parts of treatment do the work. It ends with things you can do tonight.
It is far more common than anyone told you
In 2016, a team led by de Jonge published an analysis of the World Mental Health Surveys in the journal Depression and Anxiety. They had interviewed 142,949 adults across 25 countries. Of those adults, 13.2 per cent had had at least one panic attack in their lifetime. That is more than one in eight. Whatever you were doing when yours arrived, you were in the company of a very large crowd that never mentions it at parties.
Now the number that matters most, because it is the reverse of what the fear tells you. Only 1.7 per cent of the adults met the criteria for panic disorder, the diagnosis given when attacks keep coming and the worry about the next one starts to run your days. Among those who had ever had a panic attack, 12.8 per cent met those criteria. Put another way, roughly seven in eight did not.
Having had an attack is not a sentence. For many people it is one terrible evening that the body files under “never again”.
The same study carries a warning, and you deserve to see it. Of those who had panic attacks, 66.5 per cent had recurrent episodes, and recurrent attacks were associated with later mental disorders (an odds ratio of 2.0, 95 per cent confidence interval 1.8 to 2.2). Among those with lifetime panic disorder, 80.4 per cent also had another disorder. The median age at which panic disorder began was 32. The honest reading is that a single attack is common and often not the start of anything, but attacks that keep coming back deserve a conversation with a professional.
What is happening in those ten minutes
A panic attack is your threat system firing at full strength with nothing in the room to be threatened by. The NHS describes a racing heartbeat, sweating, nausea, chest pain, breathlessness and a dread that something awful is about to happen. It also says most attacks last between 5 and 20 minutes, and some can last up to an hour.
Notice what that means. It climbs, it crests, it falls. Your body cannot keep up emergency chemistry for ever.
The sensations are real. Adrenaline does speed your heart and quicken your breathing, and it does pull blood towards your big muscles, which is part of why your fingers go cold. Each of those has a sensible job in a real emergency. Your body is not broken. The alarm simply went off in a supermarket.
Then comes the trap. After a first attack, you start watching your own body the way you would watch a pan on the hob. A flutter in your chest. A dizzy moment after standing up too fast. A rush of warmth on a crowded bus. You read each one as the first note of another attack, which gives you a fresh jolt of fear, which produces more of the very sensations you were dreading. Clinicians call this the fear of fear, and it is what turns one bad evening into a pattern.
The avoiding that feels like help
The second half of the trap is avoidance. You stop taking that route home. You stand by the train door, then you stop taking the train. You carry water everywhere, or sit on the aisle, or never go out alone. Each of these feels sensible, and each works for an hour, which is exactly why it is so hard to let go. But every escape teaches your brain the same lesson: that was close, and we only survived because we left. The alarm sounds sooner next time, and the world you feel safe in gets a little smaller.
What the treatment research says
The talking therapy with the strongest evidence for panic disorder is cognitive behavioural therapy, or CBT: a structured, time-limited treatment that works on the link between what you think, what you feel in your body and what you do. In England you can refer yourself to NHS Talking Therapies without going through your GP first. But CBT is a bundle of techniques, and for a long time it was hard to say which ones were doing the work.
That is the question Pompoli and colleagues took on in a 2018 paper in Psychological Medicine. They pooled 72 studies with 4,064 participants and used a component network meta-analysis, a statistical method for pulling a treatment package apart to see which ingredients go with better results. What stood out was interoceptive exposure, a clumsy name for a simple idea. With a therapist beside you, you deliberately bring on the sensations you fear, such as a pounding heart from running on the spot or dizziness from spinning in a chair, and you find out in your own body that they are uncomfortable and not dangerous. Interoceptive exposure and a face-to-face format were both linked to better efficacy and acceptability, which means more people got better and more people stayed the course.
The gap was large. The most efficacious combination of components, set against the least, had an odds ratio of 7.69 for remission (95 per cent credible interval 1.75 to 33.33). That interval is wide, and the next section explains why it matters.
The finding that cuts against popular advice is this. Muscle relaxation and virtual-reality exposure were linked to lower efficacy. Breathing retraining and in vivo exposure, which means facing the real situation rather than imagining it, had small effects on efficacy but made treatment easier for people to accept.
Slow breathing and relaxation are usually the first things you are told to try. They may well take the edge off in the moment, and nothing here says you should stop. What the research points to is that they are unlikely to be the part that cures the problem. The part that seems to do that is learning, again and again and with support, that the feared sensation can rise and fall while you stay where you are.
What these studies cannot tell you
I want to slow down here, because hope without honesty is no use to you. These limits are here to protect you, so you do not walk into your GP’s surgery expecting a headline to carry more weight than it can.
The Pompoli analysis reports high uncertainty, remission defined differently from one trial to the next, and limited long-term data. It shows which ingredients went with better results across many trials. It cannot tell you what will work for you. Nor does either study replace an examination. Chest pain, a racing heart and breathlessness can also come from the heart or lungs, so have them checked, especially the first time or if the pattern changes. If chest pain is crushing, spreads to your arm or jaw, or does not ease, call 999. Do not assume it is panic.
A normal test result does not mean you imagined it. It means one frightening explanation has been ruled out, and the figures above give you somewhere to start the next conversation.
What to do when it starts, and when it has not
None of what follows replaces treatment if your attacks keep returning. It is all within reach tonight, and none of it comes from the two studies above.
Name it. Say, out loud or in your head, “This is a panic attack. It peaks and it passes.” An unknown threat becomes a known event with an ending, usually within 5 to 20 minutes. Stay if you can. Leaving tells your brain the place was dangerous. If you must move, move towards somewhere calmer, not out of your life.
Keep the breath slow, not forced. Breathe in through your nose and out for longer than you breathe in. If that makes you more aware of your breathing and more anxious, drop it and rest your eyes on something outside you, like the colour of the shelves in front of you. Rate the wave. Score the fear from 0 to 10 every minute or so. You will usually see it crest and drop, which is the best evidence you will get that your body can do this.
When it is quiet, write down what happened: where you were, what you felt first, what you did and how long it lasted. A page like that is exactly what a GP or therapist needs. Then take one small step back towards the place you have been avoiding. Not the whole journey. One stop, one aisle, five minutes.
Try cutting back on caffeine for a fortnight and see what changes, since it can produce sensations much like an attack. And ask for help. If you are in England, self-refer to NHS Talking Therapies, or book a GP appointment and say plainly, “I have had panic attacks and I would like to be referred for CBT.” Medication is also an option. An SSRI (a selective serotonin reuptake inhibitor, a type of antidepressant) usually takes 2 to 4 weeks to start working, so ask your GP what to expect.
It peaks and it passes
Put the two studies side by side and they say something quietly remarkable. Panic attacks are common: more than one in eight adults across 25 countries have had one. Most who have one do not go on to develop panic disorder. Every attack has a shape, a surge that peaks and falls. And the part of treatment most linked to getting better is the very thing the fear tells you never to do. You let the sensation come, and you find out you are still here when it goes.
So what would change if you believed that the next time your pulse jumps in the queue at the till?
The alarm was never your fault. It learned too well, and an alarm that learned can learn something new. Next time you will have a sentence ready, and it is the truest one you own: this peaks, and it passes, and I have been here before and I am still standing. Say it until your body believes it. Then take one step towards the place you have been avoiding.
Source: de Jonge P. et al., “Cross-national epidemiology of panic disorder and panic attacks in the World Mental Health Surveys”, Depression and Anxiety, 2016. Pompoli A. et al., “Dismantling cognitive-behaviour therapy for panic disorder: a systematic review and component network meta-analysis”, Psychological Medicine, 2018. NHS, “Panic disorder” (nhs.uk). This article is for general information and is not a substitute for advice from your GP or a qualified clinician.
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