Therapy for panic attacks

First, the practical point. Chest pain, breathlessness and a racing heart have medical causes as well as psychological ones. If you have not had these symptoms checked by a doctor, do that. Treating a cardiac problem as anxiety is a serious error, and any responsible practitioner will say so before anything else.

Assuming that is done, here is what panic is.

The mechanism

A panic attack is the body’s threat response firing at full strength with no threat present. Adrenaline floods the system, heart rate climbs, breathing quickens, blood moves to the large muscles. Every sensation is a normal component of a system designed to help you escape danger.

The problem is the interpretation. Your body produces a rapid heartbeat; your mind concludes heart attack. That conclusion is itself terrifying, so the threat response escalates, producing stronger sensations, confirming the interpretation. That loop is why panic peaks so ferociously and so fast.

Attacks typically peak within about ten minutes and subside. Adrenaline is metabolised; the system cannot sustain it. Panic is horrible and it is not dangerous.

What turns one attack into panic disorder

Fear of the next one. After an attack, people begin monitoring their body for early signs — and monitoring finds things, because bodies produce sensations constantly. Noticing your heartbeat makes it feel irregular, which triggers alarm.

Then avoidance begins: the metro, the mall, driving alone, anywhere an attack happened or would be embarrassing. The world contracts, and each avoided place confirms that it was dangerous.

What treatment involves

1. 01Understanding the cycle properly. Not reassurance — an actual working model of what your body is doing. This alone reduces frequency for many people.
2. 02Testing the catastrophic prediction. Discovering, deliberately and repeatedly, that the feared outcome does not occur.
3. 03Dropping safety behaviours, which prevent that learning from sticking.
4. 04Interoceptive work. Deliberately and safely inducing the physical sensations — a brief spell of fast breathing, for instance — so they stop signalling catastrophe. Uncomfortable, effective, and always paced with you.
5. 05Returning to avoided places, gradually and in an order you choose.

There is more on how this work is structured on the therapy for anxiety page. Note what is not on the list: breathing exercises as the primary treatment. Slow breathing helps in the moment, but used as a rescue from imminent catastrophe it becomes another safety behaviour. It is a tool, not the treatment.

On medication

Some people benefit from medication alongside therapy, particularly where attacks are frequent. That is a psychiatrist’s decision, not mine; psychologists in India do not prescribe. I will say when I think an assessment is worth having.