A first panic attack can be frightening, particularly when physical sensations arrive suddenly and seem to have no obvious explanation. The heart may race, the chest may feel tight, breathing may change, and the hands may tingle or feel numb. These sensations can resemble symptoms associated with medical conditions, including cardiac and respiratory problems.
Understanding how the body’s threat response system works can make panic symptoms less mysterious. But an important distinction comes first: physical symptoms should not automatically be assumed to be caused by panic. New, severe, unusual, unexplained or changing physical symptoms should be medically assessed. Once appropriate medical causes have been considered, understanding the body’s alarm system can help explain why panic can feel so overwhelming.
The alarm system
Your body has a threat response system that can act before conscious thought has fully caught up. When the brain detects, or believes it detects, danger, it can activate the sympathetic nervous system. This is part of the body’s broader response to perceived threat. Stress hormones, including adrenaline, are released and the body begins preparing to respond.1
This response is designed to help the body respond to a perceived threat. Heart rate can increase, breathing can change, muscles can tense and attention can become more focused on what the brain considers important. During a panic attack, this alarm response can become intense even when there is no obvious external danger.2 The sensations that follow are real: the body is undergoing a genuine physiological response.
What can happen during a panic response
| Sensation | What the body is doing, and why |
|---|---|
| Racing heart | The heart may beat faster and more forcefully. Increased cardiac output is part of the body’s response to perceived threat and prepares the body for physical action. |
| Fast or altered breathing | Breathing may become faster, deeper or otherwise change. Changes in ventilation can alter carbon dioxide levels, which may contribute to sensations such as light-headedness or tingling.3 |
| Tingling hands or feet, light-headedness | Changes in breathing can alter carbon dioxide levels and blood chemistry. These changes may contribute to sensations such as tingling, dizziness and light-headedness.3 |
| Chest tightness | Muscle tension and changes in breathing can contribute to sensations of chest tightness or discomfort. However, chest pain or pressure can also have medical causes and should not automatically be attributed to panic. |
| Sweating | Sweat production can increase as part of the body’s response to perceived threat and preparation for physical activity. |
| Nausea or an urgent need for the toilet | Changes in autonomic nervous system activity can affect gastrointestinal functioning during periods of intense anxiety or perceived threat. |
| Feeling unreal or detached | Intense anxiety can affect attention and the way sensations and surroundings are experienced. Some people experience feelings of unreality or detachment during a panic attack.2 |
These are possible features of a panic response, not a diagnostic checklist. The same symptoms can occur for many different reasons, including physical conditions. Experiencing one or more of them does not, by itself, establish that a person is having a panic attack.
In a panic response, these sensations reflect activation of the body’s threat response system. The difficulty is that this alarm response can become activated even when there is no obvious immediate external danger.
Why it can feel so dangerous
The sensations of panic are real, intense and often arrive with little warning. When something unfamiliar happens in the body, the mind naturally searches for an explanation. One influential cognitive model of panic proposes that panic can be intensified when bodily sensations are catastrophically misinterpreted. For example, a person may interpret palpitations as evidence that they are about to have a heart attack.4
When sensations are interpreted as evidence of catastrophe, such as “I am having a heart attack”, “I cannot breathe”, “I am going to faint” or “I am losing control”, the interpretation itself can increase fear. That fear can activate the body’s threat response further. Increased arousal may produce stronger physical sensations, which can then appear to confirm the original interpretation.
A feedback loop can develop:
physical sensation → frightening interpretation → increased fear → stronger physical sensation → even more frightening interpretation
For some people, this feedback loop can sustain or intensify panic.4 Research has found greater catastrophic misinterpretation of bodily sensations among people with panic disorder compared with healthy controls and, in some analyses, people with other anxiety disorders.5 It is important, however, not to use this explanation to dismiss physical symptoms. A psychological explanation should not replace appropriate medical assessment when symptoms are new, severe, unusual or unexplained.
How long does a panic attack last?
Panic attacks develop abruptly and reach a peak within minutes.2 The intensity of the attack usually begins to decrease as the acute alarm response subsides, although some people may continue to experience anxiety or physical sensations after the most intense part of the episode has passed. The experience is not identical for everyone. A particular time course should not be used to decide that an unexplained physical symptom is “only panic”. If symptoms are new, severe, unusual or concerning, appropriate medical assessment remains important.
Why panic attacks can recur
A single panic attack can be a deeply frightening experience. What can contribute to the development and maintenance of recurrent panic is what happens afterwards. After experiencing an unexpected attack, it is understandable to become more alert to bodily sensations. You may begin monitoring your heartbeat, breathing, dizziness or other physical changes.
The more closely you monitor the body, the more likely you may be to notice ordinary fluctuations that would previously have gone unnoticed, such as a heartbeat that speeds up on the stairs, a brief sensation of light-headedness when standing, or a change in breathing. If these sensations are interpreted as signs that another panic attack is beginning, fear may increase. That fear can activate the body’s threat response, potentially producing more of the sensations you are already watching for.4 The cycle can therefore become self-reinforcing.
Avoidance can strengthen the cycle
Avoidance is another common response to panic and fear. You might stop going to the place where an attack occurred. You might avoid driving, flying, exercise, shopping centres, public transport, caffeine or being alone.
Avoidance and other safety behaviours can bring immediate relief. They can also make it harder to discover that the feared outcome might not occur without the safety behaviour. In cognitive models of anxiety, this can contribute to the maintenance of fear because the person’s expectation of danger is not fully tested.6 Over time, this can cause a person’s world to become smaller. This does not mean that every situation should simply be faced regardless of circumstances. Effective treatment involves understanding what is maintaining the fear and approaching avoided situations in a safe, gradual and clinically appropriate way.
The core of it
A panic attack involves a powerful activation of the body’s threat response system. The sensations can be intensely frightening because they are physical, immediate and difficult to control. For some people, fear of the sensations themselves then becomes part of the problem. Understanding this cycle can be an important part of treatment. But frightening physical symptoms should never be dismissed simply because panic is a possible explanation. If symptoms are new, severe, unusual, unexplained or different from previous episodes, medical assessment is appropriate.
What helps
Panic disorder is treatable, and psychological treatment, medication and self-help have all been shown to be effective treatment options.7 NICE guidance recommends cognitive behavioural therapy for panic disorder and recognises medication as another treatment option in appropriate circumstances. Treatment decisions should be guided by assessment, individual circumstances and shared decision making.7 Treatment may involve:
Treatment is not about convincing yourself that every physical sensation is harmless. It is about developing a more accurate understanding of bodily sensations and the fear response, while recognising when physical symptoms require medical attention.
When physical symptoms should be checked
Please do not assume that new, severe, sudden, unusual or unexplained physical symptoms are caused by anxiety or panic. Symptoms such as chest pain or pressure, difficulty breathing, palpitations, fainting, significant dizziness or neurological changes can have medical causes as well as psychological ones. Someone cannot determine from a website article whether a physical symptom has a medical cause.
If you experience new, severe, sudden, unusual or concerning physical symptoms, seek appropriate medical assessment. If symptoms are severe or you believe you may be experiencing a medical emergency, seek urgent medical attention. This is particularly important if symptoms are occurring for the first time, are different from previous episodes, occur with physical exertion, are becoming more severe, or are accompanied by other concerning symptoms. Clinical guidance also recognises the importance of assessing people presenting with panic symptoms for acute physical problems where appropriate.7 Once relevant physical causes have been appropriately assessed, psychological treatment can proceed with greater confidence about what is contributing to the experience.
A final distinction
Understanding panic does not mean assuming that every frightening bodily sensation is panic. The purpose of understanding the physiology is not to tell you to ignore your body. It is to help you understand what can happen when panic is the explanation, so that appropriate treatment can address the cycle of fear, bodily sensations, interpretation and avoidance. If panic has begun to influence where you go, what you do or how closely you monitor your body, psychological treatment can help.
Our anxiety page explains how we work, and you are welcome to send an enquiry if you would like to discuss whether psychological treatment may be appropriate for you.
This article provides general educational information about panic and anxiety. It is not a diagnosis and is not a substitute for individual medical or psychological assessment, professional advice or treatment. Physical symptoms should not be assumed to be caused by panic without appropriate consideration of possible medical causes. If you are experiencing severe, sudden or concerning physical symptoms, seek appropriate medical attention. If you are in crisis, please see our emergency resources.
References
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed., text revision (DSM-5-TR). Washington, DC: American Psychiatric Association Publishing; 2022.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed., text revision (DSM-5-TR). Washington, DC: American Psychiatric Association Publishing; 2022.
- Meuret AE, Kroll J, Ritz T. Panic disorder and the role of carbon dioxide in the pathophysiology and treatment of panic disorder. Current Psychiatry Reports. 2010;12(4):306–313.
- Clark DM. A cognitive approach to panic. Behaviour Research and Therapy. 1986;24(4):461–470.
- Ohst B, Tuschen-Caffier B. Catastrophic misinterpretation of bodily sensations and external events in panic disorder, other anxiety disorders, and healthy subjects: a systematic review and meta-analysis. PLOS ONE. 2018;13(3):e0194493.
- Salkovskis PM. The importance of behaviour in the maintenance of anxiety and panic: a cognitive account. Behavioural Psychotherapy. 1991;19(1):6–19.
- National Institute for Health and Care Excellence. Generalised anxiety disorder and panic disorder in adults: management. NICE guideline CG113. Published 26 January 2011. Updated 15 June 2020.
- Lee K, Noda Y, Nakano Y, et al. Interoceptive hypersensitivity and interoceptive exposure in patients with panic disorder: specificity and effectiveness. BMC Psychiatry. 2006;6:32.
- Pompoli A, Furukawa TA, Imai H, et al. Dismantling cognitive behavioural therapy for panic disorder: a systematic review and component network meta-analysis. Psychological Medicine. 2018;48(12):1945–1953.
