“A panic attack is the scariest thing I’ve experienced. You feel like the earth will eat you whole, the walls will crush you, and you have difficulty breathing. On the outside, you look calm, but inside, there’s a volcano erupting. At that moment, you are prepared to do anything. If someone told you to shoot yourself, you probably would. It’s so scary,” Shaadi.com founder and CEO Anupam Mittal had said in a podcast earlier this year about his struggles with mental health.
Although the episode of a panic attack lasts briefly from a few minutes to hours, they can be overwhelming, says Dr Sangkshema Narayan, a clinical psychologist at BLK Max Super Speciality Hospital in Delhi. “They are generally brief and not life-threatening but they may require professional support to manage,” she adds.
While reports suggest that the prevalence of panic attacks among the Indian population is somewhere around 3-5%, due to the lack of awareness of its symptoms, the figure could actually be higher. It usually occurs as a part of disorders like panic disorders, generalised anxiety disorder, post-traumatic stress disorder (PTSD), and phobias, says Dr Aparna Ramakrishnan, consultant for psychiatry at the Kokilaben Dhirubhai Ambani Hospital in Mumbai.
Studies suggest that panic disorder occurs more frequently in women than in men with the former more likely to have severe and chronic forms of panic disorder with agoraphobia. They also say that women reported having more agoraphobic avoidance symptoms, especially when they were alone than men. With family history being one of the prominent reasons, there is a 40% increased risk of developing panic disorder if one of the first-degree relatives (biological siblings, children, or parents) has the condition.
They become panic disorders when they are recurrent and unexpected. As they appear suddenly and involve intense and overwhelming fear, they are different from anxiety attacks which are often triggered by stressors and can build up gradually. In anxiety attacks, one can have physical symptoms like a racing heart or stomach knots which are usually less intense and last longer than panic attacks. “Anxiety attack symptoms can be linked to mental health conditions like obsessive-compulsive disorder and trauma, while panic attacks mainly affect people with panic disorder,” says Dr Yogendra Singh, consultant for psychiatry at Fortis Hospital, Noida.
How to know
Panic attacks, often unpredictable, typically involve a combination of physical and psychological symptoms. Physical symptoms include rapid heartbeat or palpitations, dizziness, sweating, trembling or shaking, shortness of breath (dyspnea) or a feeling of being smothered, chest pain or discomfort, nausea or abdominal distress, feeling faint, chills or hot flashes, and numbness or tingling sensations. Psychological and cognitive symptoms include feelings of unreality or detachment from oneself (depersonalisation), fear of losing control, feeling of being trapped, intense feelings of impending doom and worst, fear of dying. “During a panic attack, your environment may feel strange or unreal, and you may experience a fear of death,” says Dr Narayan of BLK Max Super Speciality Hospital.
The exact cause of panic attacks is not known. However, several theories suggest the disorder develops based on a complex interaction of biological, genetic, environmental, and social factors and experiences.
They seem to come unexpectedly, but they can be associated with common triggers and contributing factors which include stressful situations like major life events, high-pressure environments; substance use like caffeine, alcohol, and recreational drugs; withdrawal from substances and mental health issues like generalised anxiety disorder, phobias, social anxiety, depression or bipolar disorder.
Doctors say overstimulation like being in a crowded, noisy, or overwhelming environment, and medical conditions such as thyroid problems, heart issues, and respiratory disorders can also be the reason. “Panic attacks can occur under various conditions and may differ from person to person. Some individuals experience them only once, while others may have them regularly or in clusters,” says Dr Narayan of BLK Max Super Speciality Hospital.
How to prevent
Various studies have shown that sustained or frequent panic attacks can affect both physical and mental well-being. Recurrent panic attacks can lead to an increase in blood pressure, cardiovascular issues exacerbating existing heart conditions, respiratory and digestive issues, a weakened immune system, and disturbed sleep patterns. This can result in ongoing physical symptoms like headaches, muscle tension, and gastrointestinal issues. Psychologically it can lead to chronic anxiety, potential development of panic disorder, persistent stress, depression, avoidance behaviour, and impaired cognitive function. A continuous state of heightened stress can negatively impact overall well-being affecting the quality of life and daily functioning in social life and at work.
“They can lead to chronic muscle tension and symptoms like headache, neck pain, backache and exacerbate asthma in patients. Chronic anxiety is associated with gut dysfunction, digestive issues, irritable bowel syndrome, and weakened immune system,” explains Dr Ramakrishnan of Kokilaben Hospital.
Preventing panic attacks often involves a combination of lifestyle changes, coping strategies, and sometimes mental professional help. Lifestyle changes include regular exercise, a healthy and balanced diet, and adequate sleep.
Relaxation techniques like deep breathing exercises, progressive muscle relaxation exercises, yoga, or mindfulness meditation have been shown to have preventive effects.
Dr Singh of Fortis says psychotherapy like cognitive-behavioural therapy which can help to identify and change negative thought patterns and behaviours, and exposure therapy which can help to desensitise the panic triggers, are found helpful in preventing panic attacks. Building a good social support system like connecting with friends, family, or support groups can provide comfort and reduce feelings of isolation. Learning more about panic attacks and anxiety can help to feel more in control and thus prevent panic attacks.
How to deal with it
Diagnosing a panic attack involves a combination of a thorough medical history, a physical examination, and psychological assessments. Medical history is required to rule out any other medical conditions or medications used that could be contributing to symptoms.
A physical examination is conducted to rule out other conditions that could cause similar symptoms, such as heart problems or thyroid issues. Psychological assessment is done as the diagnosis is often based on specific criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). For a panic attack, the DSM-5 criteria include experiencing a sudden onset of intense fear or discomfort, with symptoms like rapid heartbeat, sweating, trembling, shortness of breath, chest pain, nausea, dizziness, or feelings of unreality.
In the management, intervention is aimed at preventing further episodes of attacks, anticipatory anxiety, and agoraphobic avoidance, and achieving premorbid functioning by achieving full remission. Doctors may include pharmacotherapy as well as psychotherapy depending on one’s situation. Most of the panic attacks subside spontaneously within 20 minutes, they say, so explaining the very brief nature of illness and reassurance is helpful.
“Benzodiazepines are the drug of choice to abort a panic attack on an as-needed basis. In general, the first-line drug of choice is Selective Serotonin Reuptake Inhibitors (SSRI), though another antidepressant group (SNRI and tricyclic) may also be tried. In psychotherapy, most treatment guidelines recommend cognitive behaviour therapy (CBT). The other psychotherapy used are psychodynamic psychotherapy, interpersonal psychotherapy, and acceptance-based approach,” says Dr Singh of Fortis.
Dealing with panic attacks involves a combination of immediate coping strategies and long-term management techniques. Some of the approaches include relaxation exercises, which include deep breathing exercises and Jacobson’s progressive muscle relaxation exercises. The deep breathing exercise is diaphragmatic breathing which includes inhaling slowly through your nose for a count of four, holding for a count of four, and exhaling through your mouth for a count of four; working on the 5-4-3-2-1 grounding technique by focusing on an object and stimulating the five senses ( 5 things you can see, 4 things you can touch, 3 things you can hear, 2 things you can smell, and 1 thing you can taste). Thinking of it will pass, finding a peaceful spot, walking or doing some light exercises are some other practical ways to deal with an episode.
Meditation or yoga helps to reduce overall anxiety and stress levels. Creating a calm environment with a designated space along with soothing items like a favourite blanket, calming music, or essential oils also help. Staying active with regular physical exercise and following a daily activity schedule, avoiding anxiety-provoking substances like caffeine and alcohol are important. Equally important is to take regular breaks from work and routine, which include stepping outside for fresh air, going for a walk, or finding a quiet place to regroup. Doctors advise to identify and plan for known triggers at work and have a strategy in place for managing stressful situations. For this, they say, to seek support from friends and family members and to work with a mental health professional because they can help devise specific coping strategies for one’s stressors at work, home or other environments.
The triggers
- Phobias: People with phobias may experience panic attacks when they encounter triggers related to their phobia. For example, someone with trypanophobia (fear of needles) might have a panic attack if they need to get their blood drawn
- Activities: Activities that cause intense physical reactions, like exercise or drinking too much coffee, or smoking, can trigger panic attacks. Caffeine can increase alertness and heart rate, which can increase the likelihood of a panic attack
- Stress: Major life events, such as the death of a loved one, serious illness, divorce, or the birth of a child. Other stressful situations include intense confrontation, flying, boating, or public speaking
- Other factors: Family history of panic attacks or panic disorder, traumatic events, such as sexual assault or a serious accident, history of childhood physical or sexual abuse
- Mental health disorders: Anxiety, PTSD, and substance use or abuse disorders
— Dr Sangkshema Narayan, clinical psychologist, BLK Max Super Speciality, Delhi
How to help
- Keep calm: Don’t get overwhelmed by seeing the person’s symptoms. If you are calm, it will help the panicked individual know that everything is going to be fine and they can calm down
- Name it: “This is a panic attack. It will pass. I am with you.” Stay with the person and help them ride it out. Reassure them that you will not leave and the symptoms will gradually pass. Most panic attacks settle down in 20-30 minutes
- Calm them down: Invite them to sit down somewhere comfortable and quiet, give them space, and a glass of water
- Engage in light, slow conversation: Enquire about the trigger/stressor (if any) so that you can view the panicked individual’s situation objectively and give appropriate advice
- Help them breathe: Model deep breathing, box breathing, mindfulness, and grounding techniques to the individual and do these calming techniques with them. Use one technique at a time. Focus on breathing slowly. Distract them by external stimuli
- Offer coping statements: “You can handle this” or “This will pass.” Offer support and comfort to the individual
- Never say these: Do not say statements like “It’s not that bad,” ” You are overreacting,” “You just want attention,” “You have nothing to panic about,” “You need to think happy thoughts right now”
— Dr Aparna Ramakrishnan, consultant for psychiatry, Kokilaben Dhirubhai Ambani Hospital, Mumbai