What is a panic attack and why do we have them?

Two in five Australians will have one at some point in their life. Why do panic attacks start? What happens in your brain? And are they dangerous?

It can feel like an out-of-body experience – your mind, heart and breath race all at once. It can feel like something catastrophic is going to happen; you’re going to faint, have a heart attack, go crazy or even die. A panic attack hits like an intense wave and, once it strikes, it seems to take on a life of its own.

Scary as they can be, panic attacks are actually common. Two in five Australians will have one at some point in their life, and they don’t only affect people with diagnosed anxiety disorders. While symptoms vary, at their core they’re an expression of severe anxiety. “So it’s almost no surprise it’s common because a condition of being alive is that you get anxious,” says Emeritus Professor Justin Kenardy of the University of Queensland’s school of psychology.

Why do panic attacks start? What happens in your brain? And are they dangerous?

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What happens when you have a panic attack?

As the body floods with the hormones adrenaline and cortisol, you might have a quickened heart rate, faster breathing, muscle tension, chest tightness, sweating and chills and feel hyper-vigilant. You can feel nauseous, vomit or have abdominal pain as your body puts digestion on hold. “It’s the body going into this sort of state where it’s ready for action,” says Professor Caroline Hunt, head of University of Sydney’s clinical psychology unit.

Many people hyperventilate during a panic attack, which can cascade into other issues. “Even though people are breathing really quickly, you can feel as if you’re not quite getting enough oxygen,” Hunt says. “[But] the thing that really is critical is you’re actually blowing off too much carbon dioxide.” The sudden drop in carbon dioxide changes the blood’s biochemistry. “You get some quite different and scary feelings,” she says, from dizziness, tingling lips, hands and feet and blurred vision to feeling spacey or disconnected from reality.

Nelani Botha had her first panic attack as a teenager while making a speech at her school in Sydney. She’d been feeling self-conscious because she’d been bullied over her South African accent. “I just completely lost control of myself,” she told The Age and Sydney Morning Herald’s youth mental health podcast Enough. “I started hyperventilating, my heart started racing, I started crying. It was quite intense. I would be shaking so much to the point where I couldn’t control it.”

A panic attack can’t be only mental, nor can it be exclusively physical, Kenardy says. The two seem to be wrapped together in a vicious cycle. If a researcher asks somebody with anxiety to hyperventilate, they’re highly unlikely to manufacture a panic attack. “It’s how you interpret the experience and how you think about your circumstances as well as the physical symptoms themselves,” he says.

“It often comes on suddenly and it’s so different to what people have experienced before, and so they think, ‘what on earth is going on?’.”

Someone having a panic attack might assume they’re physically ill, having a heart attack, for example, or anaphylaxis. “It often comes on suddenly and strongly, and it’s so different to what people have experienced before,” Hunt says, “and so they think, ‘what on earth is going on?’.”

“You’re having a complete mind and body reaction,” says Associate Professor Jess Nithianantharajah, of the Florey Institute of Neuroscience and Mental Health, “which is very scary, and you can’t effectively verbalise in these situations.”

Isaac Percy took himself to hospital after one panic attack. The 23-year-old from Sydney started to have panic attacks several times a week in 2018, although he didn’t realise it at first. He was unhappy in a relationship and was getting chest pains, body tightness and felt “shut down”. One day, he was driving when the symptoms started again. He detoured to an emergency department, convinced he was having a heart attack. “Everything was all clear,” he says. The doctors had a different diagnosis. “That’s when I figured out that it was a full-on panic attack.”

Attacks tend to last 10 minutes at most. “It’s very hard for the body to continue at very high levels of acute anxiety,” says Hunt. “People will get themselves to a place of psychological safety or their breathing rate will naturally come down, so the panic will actually settle.”

Afterwards, people typically feel washed out or exhausted. “After a panic attack you have to be kind to yourself and take it easy,” says Kenardy.

Nelani Botha: “I just completely lost control of myself.”Credit:Wayne Taylor, Jamie Brown

What’s behind panic attacks?

Panic attacks occur because something feels threatening, consciously or not. It could be an objective threat – such as the realisation you’re about to be attacked by a dog – or a psychological one where you’re overestimating a danger. You might be in a social setting where you worry that everyone is judging you negatively. “It might not be the case at all,” says Hunt, “but such an acute feeling of anxiety can lead to a panic attack.”

Some people, such as Percy, experience “spontaneous” panic attacks that occur when they wake up or while driving. “They’ll say it just comes out of the blue, but that’s often more for people who had a history of having them and so the triggers might be very, very subtle … deep in the back of your mind,” Hunt says. The key is to identify what the trigger is (more on why later).

“The build-up and overdrive of these brain circuits is what elevates into a panic attack.”

“Panic attacks are really the symptom of the brain circuitry that controls our fight or flight response. And that circuitry goes into overdrive,” says Nithianantharajah. Magnetic resonance imaging (MRI) scans of brain activity have shown that panic attacks occur due to an imbalance between two important regions of the brain. The amygdala, which acts as a watchman to detect potential dangers and sends signals to have the fight or flight response, becomes hyperactive.

Meanwhile, the rational decision-making part of the brain, the prefrontal cortex, becomes underactive and so doesn’t step in to better regulate how the body reacts. “Someone who has anxiety finds it harder to reach a sense of calm because in stressful situations, the stress hormones keep coming and the brain becomes overwhelmed by that,” she says. “The build-up and overdrive of these brain circuits is what elevates into a panic attack.”

Isaac Percy was getting chest pains, body tightness and felt “shut down”.Credit:Simon Schluter, Jamie Brown

Are panic attacks dangerous?

Even though they feel threatening in a heightened state, panic attacks themselves aren’t dangerous: you’re not running out of oxygen to breathe and your heart won’t leap out of your chest. “Even though they feel bad, they pass,” says Kenardy. Still, they’re deeply unpleasant and debilitating.

The risk lies in people trying to organise their lives around not having another one. If someone has worried about their safety during an episode, they might begin to socially withdraw. “They’ll avoid anything that might trigger those feelings,” Hunt says. “You hear people saying they have fear of public transport or fear of open spaces or fear of crowds. But it’s often more about, ‘This would be a really bad place for me to have a panic attack’.”

Once the panic attack becomes the threat this can lead to panic disorder (recurrent, severe panic attacks) or agoraphobia (a fear of situations that cause panic). About 5 per cent of Australians will suffer from panic disorder at some point in their lives.

Are certain people more likely to have panic attacks?

We all possess the bodily functions and brain circuitry that can push us into a panic attack but not everyone who is anxious has attacks. The brain learns to perceive certain cues as more or less threatening, and the circuitry in the brain that stores representations of these cues will reinforce whether they’re seen as positive or negative. “We are all different when it comes to the triggers or the cues that set a panic attack off,” Nithianantharajah says.

Certain factors can make us more vulnerable.

Anxiety can run in families. Some of us are more genetically predisposed to it and therefore to panic attacks, too.

It can also have to do with what happens as you’re growing up. Stress or trauma in adolescence can affect how a maturing brain lays down the connections that regulate behaviour. There is much evidence that childhood trauma is linked to the poor development of several brain regions, affecting behaviour and regulation of emotions, among other things.

Your life experiences can also influence how you interpret sensations in your body. If you have a light pain in your stomach you might ignore it and see what happens, but if you have a family history of bowel cancer, it might lead to panic.

There are also theories that people whose temperament is more sensitive are more likely to have a panic attack, Hunt says, although she believes that anybody is capable of having one. “It’s luck of the draw, in a sense. If you haven’t had one, maybe you haven’t been in a situation where you’ve been so scared or threatened.”

“People who panic are often the high-achievers … the ones who are really pushing themselves hard and expecting much from themselves.”

Kenardy is keen to clear up a common misconception. “People who panic might be seen as not as effective, not as capable – and that couldn’t be further from the truth. People who panic are often the high-achievers … the ones who are really pushing themselves hard and expecting much from themselves,” he says, adding they perhaps overlook the psychological impact that the stress is having.

If you’re frequently under high stress – it could be due to work or the pandemic – you may be more easily tipped into a panic attack, too. “Everyone’s capacity to manage stress differs and also changes constantly,” Kenardy says. “This can be associated with your body’s – including your brain’s – inherited and learned capacity, and the changing demands you face.”

And you can be susceptible at some times more than others. Panic attacks usually occur in times of transition, says Kenardy – after a break-up, leaving home for the first time, unemployment, bullying – or during illness or other life stresses. These life events – even good change – can be destabilising because processing them is inherently stressful and places more demand on your capacity to cope. “Life transitions are particularly challenging because … you haven’t experienced them before and so you don’t necessarily have the experiences and skills to adapt to them,” he says.

Today’s fast-moving, high-tech environment can add to a sense of being overwhelmed. “I think we have far more sensory experiences at a faster rate than maybe we ever did,” says Nithianantharajah. “Our brain is geared to perceive what’s happening in the world and respond appropriately … But when you give it too much it can become overstimulated.” Given you can’t necessarily remove yourself from these eternal influences forever, “it’s actually about being aware of how the complexities of the environment are going to shape you”.

What can you do if you are having a panic attack?

Slow breathing can help. “That has the effect of potentially adjusting the symptoms of the respiratory impacts of panic, but it also sends signals to our parasympathetic nervous system to engage, which calms you and … brings your focus more to your breathing and away from the panic,” says Kenardy.

If you’re with someone who is experiencing panic, your job is to help decelerate their breathing and talk to them calmly.

Then, how the person interprets the episode matters. “The more that you reduce the amount of negative self-talk associated with how bad a panic attack is the more it will diminish its effect,” says Kenardy. Recognise that panic attacks are a form of anxiety and not dangerous, and that you do have a degree of agency over them. “Whether that’s through controlling your breathing and talking a bit of sense to yourself or looking around and taking stock of the things that might be happening to you that might be underlying the anxiety,” he says. “You want to use them as a signpost – not to run screaming but to take a breath and to take stock.”

As he explains, while we’ve inherited the fight-flight mechanism to respond to stress, many of us have limited ability to recognise what’s actually causing us stress. After a panic attack, getting to the bottom of what’s stirring your anxiety is critical.

“Once I started having those conversations with my friends, and doing things that were more myself, that’s when I felt the anxiety attacks go away.”

That’s what Isaac Percy did. The panic attack that led him to hospital was the catalyst for him to make some life changes. He opened up to his family and friends, contacted youth mental health service headspace, broke up with his girlfriend and went on anti-anxiety medication. “Once I started having those conversations with my friends, and doing things that were more myself, that’s when I felt the anxiety attacks go away,” Percy says.

Once people understand their triggers, they should come up with strategies for managing them, says Nithianantharajah. In other words, to “maintain brain control”. “Because it’s what you’re thinking that regulates how your body responds,” she says.

This, in turn, can have marked effects on your neuroplasticity: neural networks in the brain change structure and reorganise connections in response to experiences. “It’s hard work, shifting our behaviour, but once you do, it starts to shift the circuits in the brain,” she says. “The connections are still there, but the strength of those connections is rewired in a way that doesn’t lead to the overdrive behaviour.”

Getting perspective on the nature of panic attacks is important too. After all, a panic attack stems from a natural, vital response. The human mind deserves some credit for – for the most part – adapting to better suit our modern lives, says Nithianantharajah. It’s just that the connections in some people’s brains can make them more susceptible to panic attacks. “A lot of people get blamed for these things as though it’s a choice,” she says, “and I want to remove that stigma.” As with physical health conditions, mental health conditions involve changes in the brain. “It’s an organ.”

When should someone seek professional help?

Once panic attacks recur or start interfering with your life, it’s crucial to get psychological help. “If you’re finding that you’re avoiding things or if you’re going to events and enduring them with high levels of distress or discomfort, that’s a problem,” Hunt says.

Breathing training alone won’t fix the issue because it’s not teaching a person that nothing bad will happen from a panic attack. Cognitive behavioural therapy (CBT) can help reframe the way you react to a trigger. About 80 per cent of people with panic disorder will be fully recovered after undergoing CBT. Exposure therapy, confronting a feared situation in a controlled way, can also be helpful, in particular for agoraphobia.

“It’s about appreciating where you sit on that spectrum and getting the treatment that’s appropriate for you.”

“It’s about people understanding that, should they get these feelings, they’re actually not going to lead to a catastrophic outcome, so they’re no longer organising their whole lives around trying to avoid them,” Hunt says. “It’s as people become less scared of them that they’re less likely to happen.”

Therapy also helps induce the brain rewiring that’s needed to turn down the severity of a reaction to a trigger, Nithianantharajah says.

Meditation, exercise, a healthy diet and quality sleep can all help, as can anti-anxiety medication in more severe cases. “It’s about appreciating where you sit on that spectrum and getting the treatment that’s appropriate for you,” she says.

She likes to encourage people to think of panic attacks as you would heart attacks. “If you’re more prone [to a heart attack], you have to make changes to your life to make sure you don’t have another one. Anxiety and panic attacks are a bit like that.”

So if you have a panic attack, don’t let it slide. It’s your body and mind telling you something. There’s a vulnerability there, and the best thing you can do is to implement lifelong changes to manage it.

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