Panic Attacks: Symptoms, Types, Causes and Treatment

Panic attacks are intense episodes of sudden fear and discomfort that can be deeply distressing and disruptive to daily life. Understanding panic attacks—their symptoms, the different ways they can manifest, underlying causes, and effective treatment approaches—empowers individuals and those around them to better address and manage these episodes. This comprehensive article synthesizes current scientific research to provide a clear and practical guide to panic attacks.

Symptoms of Panic Attacks

Panic attacks can feel overwhelming and often strike quickly, sometimes with no apparent trigger. The symptoms typically peak within minutes and may leave individuals feeling exhausted or shaken. Recognizing the hallmark features of panic attacks is the crucial first step toward seeking help and managing them effectively.

Symptom	Description	Typical Example	Sources
Physical	Bodily sensations	Palpitations, shortness of breath	1 2 4 11
Cognitive	Disturbing thoughts or fears	Fear of dying, losing control	2 4 5 11
Emotional	Intense fear or helplessness	Overwhelming terror	4 5
Behavioral	Avoidance or escape behaviors	Leaving situations, avoidance	5 6

Table 1: Key Symptoms

Physical Symptoms

Panic attacks are often marked by intense physical sensations. Common features include:

• Heart palpitations or racing heartbeat
• Shortness of breath or a feeling of being smothered
• Chest pain or discomfort
• Dizziness, lightheadedness, or faintness
• Nausea or abdominal distress
• Sweating, chills, or hot flashes
• Trembling or shaking
• Numbness or tingling (paresthesias)

These symptoms can be so severe that many people fear they are having a heart attack or another medical emergency 1 2 4 11. The physical intensity often leads individuals to seek emergency medical assistance, especially after their first attack.

Cognitive Symptoms

Beyond the physical, panic attacks are defined by a cascade of cognitive symptoms. Individuals may experience:

• Fear of dying, going insane, or losing control
• Feelings of unreality (derealization)
• Fear of impending doom

These catastrophic misinterpretations of bodily sensations are central to the panic experience and can perpetuate further anxiety 2 4 5 11.

Emotional and Behavioral Symptoms

Emotionally, panic attacks unleash a wave of fear and helplessness. People often feel an intense urge to escape their current situation. This leads to behavioral changes such as:

• Avoiding places or activities associated with past attacks
• Leaving situations abruptly
• Developing anticipatory anxiety about future attacks 5 6

Symptom Clusters

Research suggests that panic symptoms often cluster into groups or dimensions:

• Cardio-respiratory type: Palpitations, chest pain, shortness of breath
• Mixed somatic type: Sweating, nausea, dizziness, chills/hot flashes
• Cognitive type: Fear of going crazy, unreality, loss of control 2 4

Different clusters may predict the severity and frequency of attacks, as well as patterns of avoidance and worry.

Types of Panic Attacks

Not all panic attacks are the same. They can differ by symptom profile, underlying triggers, and how they unfold over time. Understanding these types helps tailor support and treatment.

Type	Defining Feature	Common Symptoms	Sources
Cardio-respiratory	Heart & breathing focus	Palpitations, chest pain	2 4 8
Cognitive	Thought-based distress	Fear of losing control	2 4 5 7 10
Derealization	Altered reality feeling	Detachment, unreality	8
Prototypical	High subjective & physiological arousal	Mixed intense symptoms	7 10
Anticipatory	Fear of future attacks	Anxiety before episodes	10
Nonfearful	Physical, little fear	Bodily symptoms, calm	7 10
Cued vs. Uncued	Triggered or spontaneous	Situation-linked or random	6

Table 2: Types of Panic Attacks

Symptom-Based Subtypes

Panic attacks can be classified based on the prominent symptoms:

• Cardio-respiratory attacks: Focus on heart and breathing symptoms, often with an intense fear of dying. These attacks are linked to greater severity and avoidance, especially in those with comorbid conditions like asthma 2 8.
• Mixed somatic attacks: Present with a blend of physical symptoms, including nausea, dizziness, and sweating 2 4.
• Cognitive attacks: Defined by disturbing thoughts such as fear of "going crazy" or losing control, sometimes with fewer physical symptoms 2 4 5 7 10.

Psychological and Physiological Patterns

Researchers have identified three main patterns:

• Prototypical attacks: High levels of both subjective fear and physical arousal.
• Cognitive attacks: High subjective fear, but less physiological activation.
• Nonfearful attacks: Marked physiological symptoms, but little reported fear 7 10.

The frequency and distribution of these types differ between those with panic disorder and the general population 7.

Derealization and Other Subtypes

Some panic attacks feature strong feelings of unreality or detachment (derealization). These are linked with a broader range of psychiatric issues, such as phobias, but not necessarily with physical illnesses 8.

Anticipatory and Expected Attacks

• Anticipatory attacks: Anxiety and fear about having another attack, often leading to avoidance behaviors 10.
• Cued (expected) attacks: Occur in predictable situations (e.g., crowded places), leading to future avoidance of those contexts.
• Uncued (unexpected) attacks: Arise without warning or obvious trigger, making them particularly distressing 6.

Age and Onset Factors

Panic attack subtypes can also be distinguished by age at onset and whether fear or anticipatory anxiety was present when attacks first appeared. These factors are linked to different patterns of comorbidity and risk 9.

Causes of Panic Attacks

The roots of panic attacks are complex, involving a blend of biological, psychological, and environmental factors. Understanding these causes can demystify the experience and point the way toward effective coping strategies.

Factor	Influence on Panic Attacks	Example/Mechanism	Sources
Biological	Physical vulnerability	Genetics, respiratory sensitivity	2 12 14 15
Psychological	Cognitive misinterpretation	Catastrophic thinking, anxiety sensitivity	3 5 11 12
Conditioning	Learned responses	Association of cues with panic	12 15
Family/Social	Early experiences, modeling	Parental attention, sick-role behavior	1
Uncertainty	Intolerance of uncertainty	Heightened threat perception	3
Hyperventilation	Breathing changes	Blood alkalosis, panic sensations	13 14 15

Table 3: Causes of Panic Attacks

Biological Factors

Some people are more biologically susceptible to panic attacks. This includes:

• Genetic predispositions
• Sensitivity in respiratory or cardiovascular systems (e.g., people with asthma may have more cardio-respiratory symptoms) 2 14
• Physical illnesses in family members during childhood may reinforce beliefs that bodily symptoms are dangerous 1

Psychological Factors

Panic attacks are strongly influenced by how individuals interpret and respond to bodily sensations. Key elements:

• Catastrophic misinterpretation: Ordinary sensations (like a racing heart) are perceived as signs of impending doom or loss of control 11.
• Anxiety sensitivity: Fear of anxiety-related sensations themselves, which can amplify distress 3 5.
• Intolerance of uncertainty: A heightened tendency to feel threatened by ambiguous or uncertain situations, leading to increased fear and avoidance 3.

Conditioning and Learning

Repeated panic attacks can condition people to associate certain situations, thoughts, or bodily cues with panic, leading to anticipatory anxiety and avoidance 12 15. For example:

• Experiencing panic in a shopping mall may lead to future anxiety in similar settings.
• Internal cues (like slight dizziness) can become triggers for panic if they have been paired with previous attacks.

Family and Early Experiences

People who recall frequent parental concern about physical symptoms—or observed sick-role behaviors (acting as if ill) in family members—are more likely to interpret their own bodily sensations as dangerous, increasing their vulnerability to panic 1.

The Role of Breathing

Hyperventilation (over-breathing) is common during panic attacks and can produce many of the classic symptoms. However, research is mixed on whether hyperventilation is a cause or a consequence of panic. Some believe changes in breathing create symptoms that trigger panic, while others see hyperventilation as a reaction to panic symptoms 13 14 15.

Treatment of Panic Attacks

Panic attacks can be effectively managed and treated. A range of evidence-based approaches—psychological, behavioral, and sometimes medical—can help individuals regain control and confidence.

Treatment	Approach/Technique	Effectiveness/Outcome	Sources
Cognitive Behavioral Therapy (CBT)	Restructuring thoughts, exposure	High remission, lasting benefit	16 18 19
Applied Relaxation (AR)	Relaxation training, coping skills	Comparable to CBT, long-term gains	18
Exposure Therapy	Gradual exposure to triggers	Reduces avoidance, improves outcomes	16 20
Breathing Retraining	Respiratory control techniques	Reduces attack frequency	17
Cognitive Therapy	Changing misinterpretations	Reduces panic frequency	19
Early Intervention	Prompt treatment after first episode	Reduces long-term consequences	20

Table 4: Treatment Approaches

Cognitive Behavioral Therapy (CBT)

CBT is the gold standard for treating panic attacks and panic disorder. It combines:

• Cognitive restructuring: Identifying and challenging catastrophic thoughts about bodily sensations.
• Exposure therapy: Gradually facing feared situations or sensations in a controlled way.
• Psychoeducation: Teaching about the nature of panic and how to respond 16 18.

Studies show that CBT leads to high rates of remission, lasting improvements, and reductions in both panic attacks and broader anxiety or depression symptoms 16 18.

Applied Relaxation (AR)

AR focuses on teaching relaxation techniques and coping strategies to manage anxiety. It has been shown to be as effective as CBT in patients without severe avoidance and produces durable reductions in panic and associated symptoms 18.

Exposure and Behavioral Treatments

Exposure to feared bodily sensations (interoceptive exposure) or situations (in vivo exposure) is a core component of effective treatments. Combining exposure with cognitive therapy is more effective than relaxation alone 16. Early exposure-based intervention, even after a first panic attack, can prevent the development of chronic avoidance and agoraphobia 20.

Breathing Retraining

Some programs teach controlled breathing techniques to counteract hyperventilation and reduce panic symptoms. These methods can lower attack frequency, especially when combined with education about the role of breathing in panic 17.

Cognitive Therapy Alone

Targeting catastrophic misinterpretations of bodily sensations—even without exposure or breathing retraining—can reduce panic attack frequency, supporting the central role of cognitive factors in panic 19.

Key Points on Treatment

• Both CBT and AR are highly effective, with benefits maintained or improved at follow-up 18.
• Relaxation alone may reduce generalized anxiety but is less effective for panic unless combined with cognitive or exposure techniques 16.
• Early intervention after an initial panic attack can prevent progression to panic disorder and agoraphobia 20.

Conclusion

Panic attacks are complex, intense, and highly distressing episodes with a variety of symptoms and underlying causes. Thankfully, they are also highly treatable. By understanding the diversity of panic attack experiences, their roots, and the most effective treatment strategies, individuals and clinicians can work together for meaningful recovery and improved quality of life.

Key Takeaways

• Symptoms: Panic attacks involve physical, cognitive, emotional, and behavioral symptoms, often clustering into recognizable patterns 1 2 4 5 11.
• Types: There are multiple subtypes of panic attacks, including cardio-respiratory, cognitive, derealization, and anticipatory types, as well as cued/uncued forms 2 4 6 7 8 10.
• Causes: A mix of biological vulnerability, psychological factors, learned associations, family influences, intolerance of uncertainty, and breathing patterns contribute to the onset and persistence of panic attacks 1 2 3 12 14 15.
• Treatment: Evidence-based treatments such as CBT, applied relaxation, exposure therapy, breathing retraining, and early intervention are highly effective in reducing panic attacks and restoring well-being 16 17 18 19 20.

Understanding panic attacks is the first step toward reclaiming control—and with support, effective strategies, and perseverance, recovery is within reach.