What is a panic attack?

A panic attack is a discrete episode of intense fear or discomfort peaking within minutes, accompanied by a range of somatic and cognitive symptoms. Typical symptoms include palpitations, chest pain, breathlessness, dizziness, sweating, trembling, derealisation or fear of losing control or dying.

Common symptoms (DSM‑style list)

• Palpitations, accelerated heart rate
• Sweating
• Trembling or shaking
• Shortness of breath or sensations of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Dizziness, light‑headedness, faintness
• Derealisation or depersonalisation
• Fear of losing control, going crazy, or dying

Identification & differential diagnosis

1. Take a brief history: onset, duration, frequency, triggers, prior medical evaluation, and substance use (caffeine, stimulants, alcohol).
2. Red flags for medical causes: chest pain with new ischemic features, syncope, focal neurological deficits, severe hypoxia—arrange urgent medical assessment.
3. Consider medical mimics: cardiac arrhythmias, myocardial ischaemia, pulmonary embolism, asthma exacerbation, thyrotoxicosis, phaeochromocytoma, vestibular disorders and seizures.
4. If first presentation is typical and no red flags, provide immediate psychoeducation and brief coping strategies; still consider baseline investigations (ECG, glucose, TSH) when indicated.

Immediate management during an attack

• Reassure: explain the attack is scary but not dangerous and will pass.
• Breathing: guided slow breathing—inhale 4 seconds, exhale 6–8 seconds; avoid rapid compensatory breathing.
• Grounding: 5‑4‑3‑2‑1 sensory exercise (name 5 things you see, 4 you can touch, 3 you hear, 2 you smell, 1 you taste/feel) to reduce dissociation.
• Physical grounding: hold an ice pack, splash cold water on face, or press feet firmly on the ground.
• Medication: short‑acting benzodiazepines can be effective but use cautiously; seek medical review for repeated severe attacks or first‑time events.

Evidence‑based treatments

• Cognitive Behavioural Therapy (CBT): gold‑standard—includes psychoeducation, cognitive restructuring, interoceptive exposure to feared bodily sensations, and in vivo exposure for avoidance/agoraphobia.
• Interoceptive exposure: deliberately inducing physical sensations (spinning, straw breathing, running on spot) to reduce fear of sensations through habituation and disconfirmation of catastrophic beliefs.
• Medications: SSRIs and SNRIs are first‑line pharmacotherapy for panic disorder; TCAs effective but less tolerated. Short‑term benzodiazepines help acute distress but risk dependence and may hinder exposure learning.
• Combined treatment: CBT plus antidepressant may be used for severe or treatment‑resistant cases.

Self‑management & relapse prevention

• Maintain regular sleep, reduce caffeine and stimulant use, and limit alcohol.
• Practice breathing and grounding exercises daily to improve automatic coping during attacks.
• Keep a panic diary: note triggers, context, symptoms, SUDS and coping used—review with therapist to identify patterns and progress.
• Engage in graded exposure to avoided situations and interoceptive exercises as homework to generalise gains.

Practical tips for clinicians

• Always assess first presentation for medical red flags—collaborate with emergency/primary care for baseline tests when needed.
• Teach simple, replicable coping strategies patients can use immediately (paced breathing, grounding, physical grounding).
• Use structured panic diaries and plan interoceptive exposure homework to accelerate recovery.
• Avoid long‑term benzodiazepine prescribing where possible—prioritise CBT and SSRIs for sustained benefit.

Key takeaways

• Panic attacks are intense, time‑limited episodes that can be frightening but are not usually life‑threatening—unless medical red flags are present.
• Immediate management includes reassurance, paced breathing and grounding; evidence‑based long‑term treatment is CBT with interoceptive exposure and pharmacotherapy when indicated.
• Identify and exclude medical mimics, support self‑management skills and coordinate care for optimal outcomes.