Unlike many medical and psychiatric conditions, there's nothing particularly arcane about a panic attack. The definition is exactly what you might expect: A relatively short burst of very intense fear or anxiety, accompanied by physical symptoms such as shortness of breath, chest pain or heart palpitations, or nausea. Many people also feel “unreal,” or “detached from” themselves. Dizziness and lightheadedness are common.

The panic attack is the tornado of the emotional landscape: brief, focused, and utterly devastating to experience. Many people report fear that they are having a heart attack, dying, or “going crazy” when having a panic attack. It's not at all uncommon for individuals to be admitted to Emergency Rooms, only to find their symptoms were entirely the result of panic. Some have remarked that they would almost prefer a “real” heart attack to the prospect of enduring another panic attack!

Recurring panic attacks can be associated with almost any anxiety disorder, including Panic Disorder (go figure!), phobias, and posttraumatic stress disorder (PTSD). For many people, recurring panic attacks result in agoraphobia: a tendency to fear and avoid situations from which escape might be difficult, resulting in a strong reluctance to leave one's home or other “safe” areas. “Escape” in these cases usually means “easily get to a private, safe spot in the event that I feel a panic attack coming on.” It's not necessarily bombs or thunderstorms that these people fear so much as the chance that a panic attack might hit them without warning.

What's Going On?

There are a number of studies examining the physiological and psychological processes involved in panic. Perhaps the simplest way to think about what happens is to imagine a kind of chain reaction involving thoughts, emotions, and physiological responses.

First of all, consider just how closely our thoughts and feelings are tied to our physiology—the nerves and fluids and tissues and such that comprise our bodies. Many would argue that thoughts and feelings do not (and cannot) exist apart from bodily activity; they are, as it were, the awareness the body has of its own activity! Rather than review the entire mind-body debate, it's probably enough to recognize that the distinctions we are making between “thoughts,” “feelings,” and “physiological process” are artificial and arbitrary; determining exactly where the activity of my neurotransmitters end and feelings begin is a dicey business. Still, it seems pretty clear that we experience our thoughts, feelings, and bodily reactions as intimately related.

For example, let's imagine that you wake up late at night to hear some strange sounds, as of someone moving about in your house. You will likely become alert very quickly; your muscles may tense, and you may even feel some tightness or churning in your belly. In the blink of an eye, you have appraised the unusual sounds as a possible intruder, and your body has immediately begun preparing to deal with the threat by initiating the “fight or flight” response. Emotionally, you may feel anxious or irritable; afraid or enraged—or a little of everything rolled up together! This kind of “fight or flight” excitement in the body is the physiological equivalent of a “Red Alert” alarm, channeling all resources into readiness for action.

What does this have to do with panic?

 Well, panic attacks are thought to result from a series of catastrophic misinterpretations. (As with so many terms in psychology, catastrophic misinterpretation is just fancy language—in this case, it can be roughly translated as “really big mistake about what you think is going on.” )

 It goes something like this:

 The individual—let's call him Bob—notices something odd or unpleasant; maybe his heart seems to be beating a little more quickly than usual; maybe his arm or leg feels a little tight or numb. Often as not, Bob is already a little bit stressed, and what he's feeling is simply a mild “fight-or-flight”-type of excitement in his body: A “Yellow Alert,” if you will.

 Bob, however, interprets this heightened alert as a signal that “Something must really be wrong with me!” Immediately, this thought (a catastrophic misinterpretation) causes his body to raise the alert status. Maybe he's not up to Red Alert yet, but he's moved from Yellow to Orange, and his body tenses up even more.

What's more, Bob is now actively scanning himself for signs that something is wrong. The increased tension seems to be worsening the initial sensation—his heart seems to be racing now, his breathing shallow—and it seems to Bob that he may be having a heart attack. This new catastrophic misinterpretation of his body's activity further ramps up the alert status: We are now at Red Alert, full-blown fight-or-flight!

“I'm dying!” thinks Bob, and his body immediately responds, shifting the alert status beyond Red: Heart is pounding, breathing fast and shallow; Bob feels tense, helpless. There's no-where to run, nobody to fight, but his entire being is caught up in cascading fight/flight responses. This increasingly intense spiral of Thought (Imminent Catastrophe), Feeling (Anxiety), and Physiology (tension/stress response) is the vortex of the panic attack.

 Most panic attacks last only a few minutes before burning themselves out—our bodies really aren't set up to sustain this level of excitement for very long. However, some attacks may last ten minutes or more. Regardless, each second of panic can feel like it lasts for hours. Most people feel horribly helpless to stop or even slow down the rushing anxiety and all the physiological changes that build along with it.

Panic Attack Model

 It's fairly common for people who have experienced panic attacks in the past to come to fear that panic will strike them again. Soon, they are constantly on “Yellow Alert” status, scanning themselves for signs of panic—which, of course, actually increases their general level of anxiety, nudging them closer to triggering another panic attack. This creates a kind of self-fulfilling prophecy: “My heart is racing... What if it's a panic attack? Oh God, I can't deal with that...!” Catastrophic thinking ramps up in seconds, and floodgates of fight-or-flight open right up, and voila: we have a panic attack!

 Breaking the Cycle: Let's Get Physical!

 Getting free of panic attacks usually involves working to address the problem on both the physiological (body-based) and cognitive (thought-based) levels. Physiologically, it's a good idea to try to reduce the general level of arousal/physical excitement overall. As noted above, a body that is almost always at least on “Yellow Alert” is already fairly close to “Red Alert” status and panic. A first step is generally to talk with your family physician, both to rule out any medical conditions that may be “juicing up” the old “fight or flight” system and to prepare a reasonable diet and exercise regimen. Yes, diet and exercise can be a royal pain in the... Well, they can be inconvenient—but they work remarkably well to help the body shake off anxiety (and, for that matter, depression!).

 The doctor may also consider prescribing certain kinds of medication to help reduce one's general level of anxiety. Antidepressant medications such as Paxil and Zoloft can be quite effective in treating anxiety as well as mood symptoms. Be aware, however, that most antidepressants will take around four to six weeks to take effect, and may have side effects—usually along the lines of dry mouth or occasional nausea. These side effects usually pass within several weeks of starting the medication, but may recur whenever the dose is changed.

 For severe cases, the doctor may consider prescribing a benzodiazapine, such as Xanax or Ativan to help the individual cope while waiting for longer-term antidepressants, diet and exercise, and other interventions to take effect. Although benzodiazapines are generally quite effective at shutting down acute anxiety symptoms, physicians generally avoid using them long-term as they can be quite addictive. However, short-term use of these medications generally poses minimal risk, so long as they are taken as directed as part of a larger program to address anxiety.

 Challenge Yourself!

 Getting a handle on the body's overall alert level is a good start, but it's still possible to shift into “Red Alert” and beyond if you perceive imminent danger. This is a good thing, really: A panic attack is kind of like an overly sensitive car alarm that blares away any time someone so much as looks in its direction. You don't want the alarm to go off when a butterfly lands on the hood, but you do want to be alerted when somebody tries to pop the car lock and steal the car. We need to be able to experience anxiety to alert us to danger, and we need “fight-or-flight” to give us the energy to deal with a dangerous situation. It's just that we want the “Red Alert” to kick in for actual danger, rather than to butterflies.

 This means that we need to retrain ourselves, taking special care to examine and think through anything that begins to generate anxiety. We have to become more aware of the “inner dialogue”--all those little things that we say to ourselves, and actively question our thoughts and assumptions about the situations we encounter. And in many cases, we have to practice actively reassuring ourselves: “It's going to be all right. I can handle this. I'm a little anxious, but that's ok...”

 Outpatient psychotherapy, meditation, and relaxation exercises can all be helpful in spotting and addressing faulty assumptions and misperceptions. In many cases it's necessary to actually go out of the way to practice approaching and engaging in situations that in the past have provoked feelings of anxiety or panic. And to this end, we have to be willing to risk the occasional panic attack. After all, very few people can learn to ride a bicycle without taking a few spills—it's the willingness to take the risk of another fall that makes learning possible.

 That's the funny thing about dealing with anxiety: At some point, you kind of have to accept it into your life before it will go away and leave you alone.

 Still, it's important to pace yourself: Accepting and coping with anxiety takes time! Patience and persistence are key in this kind of work—and humor can go a long way toward cushioning those falls.