The Play-by-Play of a Panic Attack

A first-person look at what happens in the brain and body when panic sets in

Image: Andrzej Wojcicki/Getty Images

I’I’ve had panic attacks since I was 11 years old. I vividly remember the first one. I was in New York City for the first time, eating dinner with my grandparents at a Greek restaurant near Times Square. I was struggling to eat, overwhelmed by sensory stimulation. My grandfather was gruffly insisting I eat more, frustrated that I was not enjoying such an expensive meal. I was sweating, fidgeting, shaking, and nauseous. I felt unwillingly thrown into the ring with this beast of a meal—delicious, but excruciating.

Then the lava cake came. Every bite was richer and more difficult to swallow. I’d never felt more disgusting. A wave of electricity came over my body. I lost all visual clarity and was left with only a sense of colors and blinding lights. I desperately needed to escape.

I rushed to the restroom, hyperventilating and violently shaking. The floor was bright-white tile. The stalls were gray. It was tidy and smelled of cleaning products. I entered the accessible stall, undressed, and sat there terrified. Is this a seizure? Am I going to throw up? Explode? Die? After a minute or so, a woman entered the stall beside mine. I can imagine my episode was loud; she asked if I needed help.

I was hesitant to ask for my grandma, fearing retaliation. Plus, I was naked, sweating, convulsing, and hyperventilating. I wanted my mom, who was miles away in western Pennsylvania. But being only 11 years old, I had no choice but to accept this stranger’s help. Within minutes, I was naked, sweating, convulsing, and hyperventilating in the stall with my grandma.

She was concerned, of course, seeing me like this. Neither of us knew what was happening. We called my mom, who told me it was a panic attack. Mom had been getting them since she was seven and said there was nothing I could do to stop it. Just breathe, she told me.

What is a panic attack?

Hundreds of panic attacks later, the shock of terror never gets easier. I have spent the past 11 years learning how to reduce their frequency. But first you have to know your enemy before you can defeat it.

According to the Anxiety and Depression Association of America (ADAA), a panic attack is defined as “the abrupt onset of intense fear or discomfort that reaches a peak within minutes and includes at least four of the following symptoms”:

  • Palpitations, pounding heart, or accelerated heart rate
  • Sweating
  • Trembling or shaking
  • Sensations of shortness of breath or smothering
  • Feelings of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, unsteady, light-headed, or faint
  • Chills or heat sensations
  • Paresthesia (numbness or tingling sensations)
  • Derealization (feelings of unreality) or depersonalization (being detached from oneself)
  • Fear of losing control or “going crazy”
  • Fear of dying

Each of these symptoms on their own can be alarming, so you can imagine my terror when I felt them all at once as a kid in an unfamiliar environment, without my parents. People who experience them for the first time or have extremely intense panic attacks often seek emergency medical help. I went to the medical center during my freshman year of college when I collapsed during a particularly rough attack.

Panic attacks usually peak within 10 minutes and subside within half and hour. They can also recur in succession for hours. They can result from external stimulation or occur for seemingly no reason at all. Panic doesn’t happen in everyone, but it can happen to anyone.

The science behind panic attacks

In the simplest terms, a panic attack is an episode of a prolonged fight-or-flight response. Whether or not there is something tangible to fight or flee from, the brain behaves as though there is a sustained cause for alarm.

More specifically, distress causes the sympathetic nervous system to pump energy throughout the body, preparing to take action. Once the stressor disappears or is resolved, the parasympathetic nervous system calms everything down. But in the case of panic attacks, the parasympathetic nervous system may not activate, which can extend and amplify the effects triggered by the sympathetic nervous system (fight or flight). Thus, a panic attack ensues and lasts for several minutes.

To elaborate further, the amygdala, hypothalamus, periaqueductal gray, and ventromedial prefrontal cortex are parts of the brain involved in a panic attack. The amygdala handles emotional processing and fear. The hypothalamus and periaqueductal gray handle the defensive responses, including the choice of whether to fight or flee. These parts of the brain release hormones such as adrenaline when stimulated.

The ventromedial prefrontal cortex, however, may be the key in the development of panic disorder. The cortex is part of that crucial parasympathetic nervous system. It calms the other sections of the brain by releasing hormones that elicit positive emotions, such as serotonin. Those who experience panic attacks likely have a malfunction in communication between the cortex and the rest of the brain. How do researchers know this is the issue? Because of the success of SSRIs.

Imagine panic attacks as a roller coaster. The higher the car climbs, the longer the ride down. The more fear and anxiety that builds up without relief, the more intense the panic attack.

The almighty SSRI

I mentioned earlier that I have been taking preventative measures to treat panic disorder. A major part of that has been finding the correct medication for my body.

Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs that aid in the production and delivery of serotonin. Celexa, Lexapro, Prozac, and Zoloft are some of the most common SSRIs and among the most commonly prescribed drugs in the United States, due to their effectiveness in reducing symptoms of depression, anxiety, panic, and fibromyalgia.

How SSRIs work is still a bit of a mystery. What researchers know is that serotonin is partially produced in the digestive system, so SSRIs are most effective when taken orally. We also know what the name suggests: These drugs regulate serotonin intake. They likely assist the parasympathetic nervous system in both the production and delivery of serotonin to the sympathetic nervous system. As research into these increasingly common disorders continues, the unknown aspects of how SSRIs work will likely become clear.

Getting an initial prescription for an SSRI is not difficult, but finding the precise type and dosage that works for you can be challenging. As my freshman engineering classes began to intensify, I found myself living in a constant state of anxiety. I was inconsistently meditating, exercising, and eating well and saw a counselor once a week. My health worsened as the semester progressed. When I came home for Thanksgiving in 2015, my doctor prescribed a low dose of Lexapro. As is customary, he asked me to check in after two weeks of journaling my symptoms. I made it only three days. I was cripplingly dizzy, absentminded, and nauseous. We halved the dosage and restarted the two-week trial. I became hyperfocused and hyperactive—vibrating with exhausted energy. I survived finals in this odd state and returned to my doctor with high hopes. My state was not optimal but certainly better than before. We switched to Zoloft and started the trial period all over again. By March 2016, I was set; I haven’t changed my medication much since.

SSRIs are not for everyone due to their finicky dosage and side effects. But I highly suggest that anyone who struggles with panic attacks consider discussing their options with a doctor.

Treating Panic

Only 2.7% of Americans have a diagnosed panic disorder, but everyone should know how to reduce the likelihood of panic attacks and what to do if you witness one.

Folks with panic disorder (myself included) often avoid situations that may trigger an attack. This is not a great method of prevention. Living a life in avoidance of potential triggers can spiral into additional anxiety disorders, including agoraphobia, the fear of being in public.

Caffeine, alcohol, and THC (found in marijuana) are major triggers that can be avoided with relatively low effort for nonaddicts. But if the perceived trigger is something like eating meals or attending social functions, the patient is likely to suffer, since these are crucial components to healthy living.

The most important factor in preventing panic attacks is living mindfully. Imagine panic attacks as a roller coaster. The higher the car climbs, the longer the ride down. The more fear and anxiety that builds up without relief, the more intense the panic attack.

What can help tremendously is discovering ways to relieve that fear and anxiety. Medication can ease one’s physical response to these factors, but meds do not get rid of the reasons behind fear and anxiety. Life stress, trauma, and overstimulation can be alleviated with the trial and practice of mindful actions, including meditation, therapy, and exercise.

If you’ve done everything you can to prevent an attack and yet find yourself naked, sweating, convulsing, and hyperventilating, just breathe (as my mom said over the phone as I sat in that New York City restroom).

It is hard in these moments to regain control over your body, but it’s vital to slow the breath down. You can expect that it will take several restarts to succeed. It’s okay. You will not suffocate. You will not die. You are not losing it. This is not your fault. This is just your brain overreacting. It will be over soon, on its own terms.

Try listening to a song you love. Watch a video that makes you laugh. Play a game. Hug your pet, someone you love, or even a pillow.

Count to 10 over and over again. Pray, if you’re religious.

Take a walk, even just around your home. Drink water.

Put a cool washcloth on the back of your neck. Turn on a recorded meditation.

Do not fight the panic; this will only prolong it. Do what you can to make yourself feel safe.

If you are witnessing a panic attack, you can help. You must be very clear; speak slowly and calmly. You must not let the panicking person know you are alarmed. Tell them to take deep breaths with you. Guide them through the suggestions in the section above. Ask yes-or-no questions: “Would you like some water?” “Can I put this cool washcloth on your neck?” Do not smother them—there is a high likelihood that they want to be left alone to sort it out for themselves. This is a battle only they can fight, but remind them that you are in their corner. Assure them that they are not a burden on you and that it will be over soon.

V (they/them) is a Staff Educator at the Carnegie Science Center in Pittsburgh. 3x NASA intern. B.A. Communication from The Ohio State University ‘19