Panic attacks and panic disorder

Ted's story

During a stressful time in his life Ted experienced his first panic attack. He had been rushing to get some work done so that he could leave on time to visit his mother in hospital. He got stuck in traffic on the way to hospital and was worried that he wouldn't make it on time. At the hospital he suddenly began to feel lightheaded and felt that he couldn't breathe properly. Ted felt a wave of fear come over him, and noticed himself getting hot and sweaty. He left the hospital and smoked a cigarette in the car park to calm himself down. The sensations had only lasted a few minutes but to Ted it felt like forever.
Ted experienced another few panic attacks over the next week. Each time they would come completely out of the blue and he would experience an overwhelming sensation of dread and fear. He could feel his heart race and his throat getting tight. He worried that he wouldn't be able to get enough air and would pass out, and only felt better when he got out in the open, away from people Ted tried to avoid going to places where he had panicked before. He avoided crowds and anywhere busy. He took to doing his shopping at night when it was less busy.

People with panic disorder have sudden and repeated attacks of fear. These attacks are accompanied by strong phy.sical reactions, such as a racing heartbeat, sweating, or shaking, and thoughts that something terrible is happening or will happen. Panic attacks can happen at any time, and people who have experienced a panic attack often dread the possibility of having another one - they often take steps to prevent another one from happening.

What are the symptoms of a panic attack?

Panic attacks are an abrupt surge of intense fear or discomfort that reaches a peak within minutes, and which involve feeling at least four of the following symptoms:

  1. Palpitations, pounding heart, or accelerated heart rate
  2. Sweating
  3. Trembling or shaking
  4. Sensations of shortness of breath or smothering
  5. Feeling of choking
  6. Chest pain or discomfort
  7. Nausea or abdominal distress
  8. Feeling dizzy, unsteady, lightheaded, or faint
  9. Chills or heat sensations
  10. Paresthesias (numbness or tingling sensations)
  11. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
  12. Fear of losing control or going crazy
  13. Fear of dying

Some people might just have a one-off panic attack and not experience any more. People who go on to develop panic disorder typically take steps to prevent the possibility of having another panic attack.

Why do we panic?

All animals have a fight or flight response. This is a system built into the body which is designed to keep it safe from danger. This threat system is always on the lookout for dangers in the world around you. If it detects a threat it sets off a cascade of reactions in the body which are designed to increase your chances of surviving the danger. All of this can happen quickly and automatically, before the conscious 'you' even has a chance to think about it. The threat system worksheet below shows all of the key body changes, and describes the good reasons why each of them is designed to happen.

Ok, so I have a system designed to sense threats. But why is mine going off when I'm not in danger?

Our brains are incredibly smart in some ways, but not in others. Brains can respond in the same way to things we think about as they can to things that really happen.

For example, think about something you have done that is a bit embarrassing, did you blush a little? Try thinking about your favourite food, did you notice your mouth watering a little bit?

In the same way, the threat system can be set off by real dangers in the world around us, but also by things that we think about.

Things we know about the threat system

  • It can be set off by real dangers in the world around us, or by thing we think about
  • It is automatic - it can go off before you even have a chance to think
  • It's really sensitive - it has a 'better safe than sorry' attitude

Understanding panic attacks

Everyone's panic attacks are different but psychologists have a good understanding of what happens in a panic attack. The diagram below shows the key stages.

Graphical description of each step of a panic attack

  1. Panic is triggered by something. This can be something in the world, or in our own minds
  2. The brain perceives this trigger to be a threat or danger
  3. You feel fear or anxiety, and the fight or flight reflex is set off
  4. The fight or flight reflex leads to changes in the body as it gets ready to fight or run away
  5. If these body changes come out of the blue they can be very confusing. In a panic attack these body or mental symptoms are misinterpreted - usually in that moment you think that they are dangerous
  6. This misinterpretation leads to more anxiety, and very quickly a vicious cycle is set up - this is why panic attacks can build up so quickly

Understanding why panic attacks keep happening

Panic attacks feel horrible - the fear is very intense. Our fight or flight system is designed like this to force us to take action. It is normal to want to avoid having more panic attacks, and there are a number of common-sense ways of trying to do this. Unfortunately these common-sense ways of coping, which psychologists call 'safety behaviours', often have the unintended consequence of making future panic attacks more likely.

Cognitive formulation of panic disorder

How can I overcome my panic attacks?

You can overcome panic attacks. It often takes work in different stages. You don't have to do these in order.

  1. Understand what your body is trying to do (protect you from threat), and how it is trying to do it (setting off a fight or flight reaction to get you ready to fight or run away)
  2. Identify what is going on in your mind just as you begin to have a panic attack, and learn to challenge any unhelpful thinking
  3. Interoceptive exposure (exposure to feared body sensations). You need to learn that the sensations of panic are not harmful, and the best way to do this is to bring them on deliberately in a controlled way.

1. Understand what your body is trying to do to protect you from threat

This first step is really important - the aim is to become a real expert on your panic attacks. Print copies of the Threat System and Taking Panic Out Of Your Body worksheets. First read the Threat System worksheet below, paying close attention to the symptoms that you experience. Then, on the Taking Panic Out Of Your Body worksheet make a note of the physical and mental symptoms you experience when you have a panic attack (you might find it helpful to refer back to the 'threat system' worksheet to do this.

2. Challenge any unhelpful thinking

This goes back to the core message of CBT - change the way you feel by changing the way you think. One way to look at panic is to say that the emotional side of our brain is thinking catastrophic thoughts. Our job is to use the rational side of our brain to balance things out. Try using the Unhelpful Thinking Styles and Thought Challenging Record worksheets below. There are more detailed instructions on how to use these on the Thought Records page.

3. Expose yourself to the body sensations you are afraid of

The critical part of overcoming panic disorder is to learn how dangerous the body sensations truly are. We can learn this in two ways. One way is to know things in theory, using the rational side of our minds - the first two steps above aim to give you this experience. The other way that human beings know things is emotionally - and the best way to do this is to take actions. The Interoceptive Exposure (literally 'exposure to body sensations') worksheets below are designed to take you through a series of exercises which can help you to overcome panic. There are more detailed instructions on how to do these exercises on the Coping With Body Sensations page.

Warning: If you have certain health conditions (including epilepsy, heart problems, asthma, pregnancy) then you should discuss these exercises with your doctor before attempting them

Self-help tools for panic

Self-help tools for panic was written by Dr Matthew Whalley (who created this site). It is a CBT workbook for overcoming panic attacks. It contains everything you need to know about the causes of panic attacks, and teaches you what to do to overcome panic. You can buy a paperback copy from Amazon, or digital copies from Psychology Tools.

Panic worksheets

Anxiety can set off the 'threat system'. This is an automatic reaction that human (and other animals) have to make then function at their best when they are threatened or in danger.


Everybody's panic attacks are unique, but they often happen in a similar way. This diagram explores the key steps in a panic attack, and what turns panic attacks into panic disorder.


Record details of your panic attacks


Maintain your motivation by recording your progress.


Record the effectiveness of your relaxed breathing practice.


A key step in overcoming panic is understanding the why changes happen in our bodies when we feel in danger.


One of the most important stages of treatment is to learn how dangerous different body sensations truly are. Interoceptive expoure (coping with body sensations) exercises are the best way to do this.


Identify your anxious predictions and learn to bring anxious thoughts under control.


Make a prioritised list of situations which you avoid in order to enable exposure practice.


References and further reading

For more information see the Panic disorder page on Psychology Tools