It often starts with something small. A skipped heartbeat, a moment of dizziness, a tight feeling in the chest. Seconds later your heart is racing, your hands tingle and a thought takes over: I am having a heart attack, I am going to faint, I am losing my mind. Then, after some minutes, it fades and leaves you shaken and exhausted.
If you have had a panic attack, you know how real it feels. In this article I want to show you the circle that drives it, step by step, because once you can see the circle you can start to step out of it.
What a panic attack is
A panic attack is a sudden wave of intense fear that usually peaks within a few minutes. It comes with strong body sensations: pounding heart, breathlessness, chest tightness, sweating, trembling, nausea, dizziness, tingling, hot or cold flushes, and sometimes a strange feeling of unreality. Many people go to an emergency room the first time, which is completely understandable. Panic attacks are frightening, and they are not dangerous in themselves.
The vicious circle of panic
Panic is driven by a loop in which the body and the mind keep pushing each other. It usually has four steps.
1. A sensation
Something changes in the body. It might come from climbing stairs, coffee, a hot room, tiredness, a hangover, or simply from being stressed. Often it is a completely ordinary sensation that most people would not even notice.
2. An interpretation
The mind notices the sensation and reads it as a sign of danger. “My heart is beating strangely, something is wrong with it.” “I feel dizzy, I am going to faint.” “I cannot breathe properly, I will suffocate.” The interpretation happens in a fraction of a second and feels like a fact.
3. The fear response
If the body seems to be in danger, the alarm system does exactly what it is designed to do. It releases stress hormones and prepares you to fight or flee. Your heart beats faster, you breathe more quickly and your muscles tense.
4. Stronger sensations
These alarm reactions create new and stronger sensations: an even faster heartbeat, more dizziness, tingling from fast breathing. Breathing too quickly lowers the carbon dioxide in the blood, which itself causes dizziness, tingling and a feeling of air hunger (Meuret & Ritz, 2010). The mind takes these new sensations as proof that the danger is real, the interpretation becomes more catastrophic, the fear grows, and the circle turns faster.
The circle in short
Sensation → “something is wrong” → fear → stronger sensations → “it is getting worse” → more fear. The sensations are real. What drives the panic is the meaning the mind gives them.
The circle eventually slows down on its own, because the body cannot keep up such a strong alarm for long. That is why panic attacks pass, even if it feels like they never will.
Why some people are more sensitive to the circle
Not everyone who has a fast heartbeat panics. One important difference is what psychologists call anxiety sensitivity: the fear of anxiety-related sensations, based on the belief that they are harmful (Boswell et al., 2013). If you believe that a racing heart could mean a heart attack, you will watch your heart closely, notice every change, and react to it with fear. In a one-year study of people with panic disorder, those with higher anxiety sensitivity, especially fears about physical sensations, spent more time in active panic (Benítez et al., 2009).
The good news is that anxiety sensitivity can change. In a large study of cognitive behavioural therapy for panic, reductions in anxiety sensitivity and a growing sense of being able to cope both came before improvements in panic symptoms (Gallagher et al., 2013).
How the circle spreads into daily life
After a few attacks, many people start to avoid situations where panic happened before, or where help would be hard to reach: public transport, supermarkets, crowds, driving, being alone. Others develop safety behaviours, such as always carrying water or medication, sitting near the exit, or never going out without a trusted person. These strategies bring relief, and they also prevent the brain from learning that the sensations and the situations were safe all along.
What helps
Seeing the circle while it happens
The first step is to recognise the circle in the moment. You might say to yourself: “This is a sensation. My mind is calling it dangerous. That is the alarm. It will rise and fall.” Naming the steps does not stop the sensations, and it can slow down the interpretation that feeds them.
Testing the frightening interpretations
In therapy we look closely at the thoughts during an attack. What did you predict last time? What actually happened? Most people have had many attacks and survived every one of them, yet the fear keeps saying that the next one will be different. Writing down the prediction before a difficult situation and checking afterwards what happened can make this gap visible.
Interoceptive exposure
The most effective way to break the circle is to practise meeting the feared sensations on purpose, in a safe and planned way. This is called interoceptive exposure: for example spinning on a chair to bring on dizziness, running on the spot to raise the heart rate, or breathing through a thin straw. A large component analysis of 72 trials found that interoceptive exposure was one of the elements most clearly linked to better results in treatment for panic disorder (Pompoli et al., 2018). Over time the body learns that these sensations are uncomfortable and safe.
Returning to avoided places
Exposure to avoided situations works in a similar way. You build a ladder of steps, from easier to harder, and drop safety behaviours one by one. The aim is to learn that you can handle the situation without the protection you have been relying on.
Breathing, used wisely
Slow breathing, around six breaths per minute, may help: a meta-analysis of randomised trials found small to moderate benefits of breathing practices for stress, anxiety and low mood (Fincham et al., 2023), and some people find it helpful to slow down during an attack. It is best used as a way to stay in the situation, not as a rescue you must perform to stay safe. In research on panic treatment, breathing retraining made treatment easier to accept while adding little to its effect (Pompoli et al., 2018).
Being mindful of caffeine
People with panic disorder are particularly sensitive to caffeine. In controlled studies, high doses triggered panic attacks in about half of them (Klevebrant & Frick, 2022). Cutting down can lower the number of “starting sensations”.
Treatment that research supports
Cognitive behavioural therapy brings all these elements together and is the best-studied psychological treatment for panic disorder (Pompoli et al., 2016). It is practical and structured, and the pace is agreed together. Many people need only a limited number of sessions to feel a real difference.
When to look for support
If panic attacks keep coming back, if you live in fear of the next one, or if you have started to avoid places or activities, it is a good moment to talk to someone. It also makes sense to have new symptoms checked by a doctor once, because some physical conditions can cause similar sensations. I describe these in Anxiety: what it is for, and when the cause may be physical.
If you have chest pain, trouble breathing, fainting or symptoms you have never had before, please seek medical help straight away. If you are in crisis or having thoughts of ending your life, call your local emergency number (for example 112 in Europe or 911 in North America and Mexico), or find a free, confidential helpline in your country at findahelpline.com.
More about therapy with me.
References
- Benítez, C. I., Shea, M. T., Raffa, S., Rende, R., Dyck, I. R., Ramsawh, H. J., Edelen, M. O., & Keller, M. B. (2009). Anxiety sensitivity as a predictor of the clinical course of panic disorder: A 1-year follow-up study. Depression and Anxiety, 26(4), 335–342. https://doi.org/10.1002/da.20423
- Boswell, J. F., Farchione, T. J., Sauer-Zavala, S., Murray, H. W., Fortune, M. R., & Barlow, D. H. (2013). Anxiety sensitivity and interoceptive exposure: A transdiagnostic construct and change strategy. Behavior Therapy, 44(3), 417–431. https://doi.org/10.1016/j.beth.2013.03.006
- Fincham, G. W., Strauss, C., Montero-Marin, J., & Cavanagh, K. (2023). Effect of breathwork on stress and mental health: A meta-analysis of randomised-controlled trials. Scientific Reports, 13(1), 432. https://doi.org/10.1038/s41598-022-27247-y
- Gallagher, M. W., Payne, L. A., White, K. S., Shear, K. M., Woods, S. W., Gorman, J. M., & Barlow, D. H. (2013). Mechanisms of change in cognitive behavioral therapy for panic disorder: The unique effects of self-efficacy and anxiety sensitivity. Behaviour Research and Therapy, 51(11), 767–777. https://doi.org/10.1016/j.brat.2013.09.001
- Klevebrant, L., & Frick, A. (2022). Effects of caffeine on anxiety and panic attacks in patients with panic disorder: A systematic review and meta-analysis. General Hospital Psychiatry, 74, 22–31. https://doi.org/10.1016/j.genhosppsych.2021.11.005
- Meuret, A. E., & Ritz, T. (2010). Hyperventilation in panic disorder and asthma: Empirical evidence and clinical strategies. International Journal of Psychophysiology, 78(1), 68–79. https://doi.org/10.1016/j.ijpsycho.2010.05.006
- Pompoli, A., Furukawa, T. A., Efthimiou, O., Imai, H., Tajika, A., & Salanti, G. (2018). Dismantling cognitive-behaviour therapy for panic disorder: A systematic review and component network meta-analysis. Psychological Medicine, 48(12), 1945–1953. https://doi.org/10.1017/s0033291717003919
- Pompoli, A., Furukawa, T. A., Imai, H., Tajika, A., Efthimiou, O., & Salanti, G. (2016). Psychological therapies for panic disorder with or without agoraphobia in adults: A network meta-analysis. The Cochrane Database of Systematic Reviews, 4, CD011004. https://doi.org/10.1002/14651858.cd011004.pub2
This article is exploratory and meant for information and reflection. It cannot capture the full complexity of any individual situation, and your own experience may be different. It does not replace a diagnosis or treatment.
