I hope you’ve never experienced a panic attack, but if you have… keep reading! You know the signs: your heart races, chest tightens, you feel like you can’t breathe, maybe your face and lips go numb, or you suddenly feel hot– then, a dizziness and sense that something catastrophic is happening to your body and you can’t control it. If you live with panic disorder, you might find yourself avoiding certain situations or places because you don’t know what you’d do if you had another panic attack there.
It always surprises me that even adults well into their 40s and 50s don’t know that this is a highly treatable condition. It’s best treated initially in tandem with medication, but later on, that probably won’t be needed anymore.
What Is Panic Disorder?
The DSM-V defines Panic Disorder by the following criteria:
A. Recurrent unexpected panic attacks – A panic attack is an abrupt surge of intense fear or discomfort that reaches a peak within minutes, with four or more of these 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
- Paresthesias (numbness or tingling sensations)
- Derealization (feelings of unreality) or depersonalization (being detached from oneself)
- Fear of losing control or “going crazy”
- Fear of dying
B. At least one attack followed by one month (or more) of one or both:
- Persistent concern or worry about additional panic attacks or their consequences
- Significant maladaptive change in behavior related to the attacks (e.g., avoiding exercise or unfamiliar situations)
C. The disturbance is not attributable to the physiological effects of a substance or another medical condition
D. The disturbance is not better explained by another mental disorder (such as social anxiety disorder, specific phobia, OCD, PTSD, or separation anxiety disorder)
The key distinguishing feature is that the panic attacks are unexpected (not cued by specific triggers) and cause significant distress or impairment.
The Role of Medication: Your Training Wheels
When in the midst of frequent panic attacks, learning coping skills to manage this own your own can feel impossible. It’s like jumping on a bike before riding with training wheels or skiing down a mountain before a day on the bunny hill. Medication can be thought of as those training wheels or time on the bunny hill– you probably won’t need it forever, but you will while you learn and practice your coping skills until you’re confident you can make it on your own.
Medications That Work for Acute Panic
Most panic attack medications kick in within 20 minutes. Most people who experience panic attacks can feel them coming on in advance. Taking medication as needed can help stop the panic attack from happening or at least lessen its severity.
Lorazepam (Ativan) is one of the most effective fast-acting medications for panic attacks. It kicks in within 20-30 minutes. You don’t have to take it everyday as it’s designed to be taken as needed, when you feel the panic attack coming on or when you know you’re about to enter a highly stressful or challenging situation.
Other benzodiazepines like alprazolam (Xanax) or clonazepam (Klonopin) work similarly, providing rapid relief during acute panic episodes. These medications are prescribed for short-term use—typically a few months—while you’re actively learning and practicing the techniques that will eventually replace them. I would recommend exploring this option for periods of time in life that are accompanied by significant distress.
Beta-blockers like propranolol (Inderal) offer another approach, especially if your panic attacks involve intense physical symptoms like racing heart, trembling, or sweating. Beta-blockers work by blocking adrenaline’s effects on your body. People who use them say they can feel their heart rate slowing down, avoiding the panic attack altogether.
Of course you will need to consult with a prescribing physician after a diagnosis of panic disorder has been made. You should always seek therapy in conjunction of medications, and never rely on the medications alone. Once you learn the skills you need to stop panic attacks in therapy, you will be able to taper off and perhaps completely end the use of these medications.
Coping Skills: Developing Your Personal Toolkit
There are a variety of coping skills a person can learn. The challenge always comes with remembering to use them when they are needed. That takes practice and is a good reason to have medication on board for a few months until using them becomes second nature.
The 5-4-3-2-1 Technique
When panic hits, your brain believes you’re in immediate danger. The 5-4-3-2-1 technique pulls you back into the present moment by engaging your senses. It works by rerouting blood flow from your limbic brain (responsible for your fear and fight or flight response) to your prefrontal cortex (the area of the brain responsible for sequencing, reasoning, and decision-making). It goes as follows. Name:
- 5 things you can see (the corner of that picture frame, the blue pen, your shoe laces)
- 4 things you can touch (the chair beneath you, your shirt’s texture, the cool desk surface)
- 3 things you can hear (the hum of the AC, distant traffic, your own breath)
- 2 things you can smell (coffee, soap, fresh air)
- 1 thing you can taste (mint gum, water, or just notice your mouth)
4-2-8 Breathing (Polyvagal Therapy)
I swear if I hear box breathing one more time… grrr. How about using a technique that will work and work quickly? Based off of Polyvagal Therapy, the 4-2-8 count technique will help shut down the over-activation of the vagus nerve. The goal is to focus on slow exhales. Develop this practice and you’ll be on your way to keeping calm, even in the most stressful of situations. Kids driving you crazy? Your boss raising her voice? Traffic? Develop a relationship with this coping skill if you want to look like a sensei while everyone else is freaking out.
Here’s how it works: Breathe in through your nose for 4 counts, hold for 2 counts, then exhale slowly through your mouth for 8 counts. Rinse, repeat. Focus on the extended exhale—it’s longer than your inhale, which signals your vagus nerve that you’re safe. This overrides your current over-activation and brings you to a state of calm very quickly.
The Ice Dive (Dialectical Behavioral Therapy technique)
When panic is intense, a DBT technique is to hold an ice cube in your hand or splash cold water on your face. This triggers the dive reflex—an evolutionary response that slows your heart rate and shifts your body out of panic mode. It’s also a great distraction.
Body Scans
Search Spotify, the Calm App, or Insight Timer App for a body scan meditation. These usually start at the top of your head and work their way down, bringing your awareness to the sensations in the different parts of your body. Once you get to know yourself, what your signals are that panic is coming on, you’ll be able to orchestrate and redirect the panic with more ease. You’ll know it’s time to use a tool from your toolbox.
Cognitive Reframing
During panic, your thoughts spiral: “I’m dying,” “I can’t breathe,” “I’m going crazy,” “I can’t handle this.” An example of cognitive reframing would be, “I’m going to live, I’m just feeling anxious in this moment. I have the tools to shift out of this,” or “there is plenty of oxygen available to me, things are just momentarily out of sync, but I will feel fine later,” and “many people experience panic attacks, this is a part of the universal experience of being a human. If they got through this, I can too,” and finally, “I am learning to manage my mind and body when this happens, in a little while, I won’t have to deal with this anymore. I’m going to keep going and keep practicing my skill set.”
The Path to Medication-Free Living
Most people who do the work in therapy will not have to rely on medication forever. Research suggests that cognitive-behavioral therapy (CBT), particularly when combined with short-term medication, leads to lasting recovery from panic disorder. Many people successfully taper off medication after 6-12 months once they can rely on themselves to use their learned coping skills at the proper time.
What Success Looks Like
Recovery doesn’t mean you’ll never feel anxious again. It means:
- Panic attacks become less frequent and less intense, if you have them at all
- You recognize your body’s panic mode signals
- You trust your ability to handle anxiety when it arises
- You stop avoiding situations because you’re afraid of how you might respond
- You understand that uncomfortable sensations are just sensations— not cardiac or respiratory dangers
Medication helps patients experience stability while learning to implement the new skills. Eventually the skills can take over. Think of an actor that has to memorize lines in order for the final performance to go smoothly… that is what you are doing with learning your coping skills. It’s about practicing enough that you’re confident in your skills, they’re second nature even, so that you can deliver the moment needed, even in public. You become your own emergency response team.
Reach Out
If you’re struggling with panic disorder, please reach out to a psychotherapist trained in working with intense anxiety. Your therapist can help you find a psychiatric nurse practitioner, psychiatrist, or other physician that can assess for the need or benefit of medication support. Personally, I offer my clients the option to sign a Release of Information (ROI) to speak with said provider and/or review records as a complementary service, because I want to make sure everyone is on the same page when it comes to improving my Montana and Florida clients’ mental health outcomes.
The good news is, with proper attention and resources, you likely won’t have to deal with panic attacks forever.
If you’re reading this and feeling the urge to reach out, feel free to fill out this contact form so we can quickly connect!
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