How To Address Nocturnal Panic Attacks

Panic attacks are severe experiences that cause distress, fear, and physical symptoms like shakiness and chest pain. These attacks can seem like a medical emergency, although they are generally physically harmless. Any panic attack can be scary to go through, but some people may experience these attacks at night or wake up to them, which can be disorienting and lead to sleep challenges. To learn more about nighttime panic attacks, as well as helpful strategies to address them, it may be helpful to look at studies on this topic and ways to find help. 

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What are nocturnal panic attacks? 

Nocturnal panic attacks relate to experiencing a state of panic while sleeping and awakening with a host of distressing symptoms. Along with physical symptoms like shortness of breath and an accelerated heart rate, a person experiencing a panic attack may worry that they are in imminent danger.

Nocturnal panic features and symptoms

According to the Journal of Clinical Sleep Medicine, nocturnal panic can be defined as "a panic episode that arises out of the sleep state itself and should not be confused with a panic episode that emerges shortly after waking in response to the content of a nightmare, or regained conscious awareness of a fear-inducing cognition." The Journal also notes that those who experience nocturnal panic may have a longer duration of symptoms. Depressive symptoms and sleep disturbances may also raise one's risk of having a panic attack at night. 

Someone who has a nocturnal panic attack may also experience a daytime panic attack (DP), and in some cases, symptoms may be similar. Panic attack symptoms may include:

• Increased heart rate
• Trembling
• Sweating
• Temperature alterations, such as a sense of being extremely hot or cold
• Tingling or numbness
• Chest pain or discomfort
• A choking or smothering sensation
• Dizziness
• Fear of losing control or "losing one's mind"
• Shortness of breath or difficulty breathing
• Intense fear of having a heart attack or being at risk of dying
• A sense of terror
• Worry that an unfortunate event will happen
• Difficulty falling back asleep
• Nausea or upset stomach

Nighttime panic attacks due to anxiety disorders, mood disorders, substance-related disorders, and medical conditions like hyperthyroidism, among other challenges, according to the APA. 

Night terrors vs. nighttime panic attacks

Night terrors may share some symptoms with nocturnal panic attacks, such as physical manifestations like sweating or a pounding heart. However, the two conditions are distinct. The key difference between them lies in the awareness of one's experience. 

While nocturnal panic attacks cause a person to wake up fully, a person experiencing night terrors may not be fully conscious or aware of what they are experiencing or doing. For example, they might scream or kick without knowing it. In addition, since a person may not be fully conscious when having an episode of night terror, they may not remember the episode in the morning. Unlike those with night terrors, people who experience nocturnal panic attacks are aware of their experience and tend to recall it upon awakening. 

Nocturnal and daytime panic similarities and differences

One 2013 study suggests that primary nocturnal panic may be a "relatively mild subcategory" of panic disorder with common pathophysiology with adult-type night terror, as the survey found that the participants displayed less symptom severity in the Panic Disorder Severity Scale (PDSS). 

Panic attacks at night happen as one transitions from light sleep to deep sleep and tend to arise independent of nightmares and other possible disruptions. A study published in the Journal of Anxiety Disorders suggests that those who experience panic attacks while sleeping may experience more severe cognitive symptoms than daytime panic. These findings "suggest a more significant role of cognitive symptoms in perpetuating nocturnal panic attacks once the individual awakens." 

The study noted that while similar symptoms can occur in episodes of nocturnal and daytime panic attacks, reported physical symptoms such as accelerated heart rate, chest pain, and smothering sensations were more prevalent with nocturnal panic.

Other factors affecting nocturnal panic attacks

Some factors may increase the likelihood of having panic attacks, such as having panic disorder, a mood disorder, a sleep disorder like obstructive sleep apnea, post-traumatic stress disorder (PTSD), substance use disorders, and medical conditions. Other factors may include: 

• Brain chemistry
• Experiencing anxiety, such as bedtime anxiety about one's ability to respond to a possible threat
• Mental disorders like depression 
• Exposure to traumatic events
• Exposure to stress 
• Genes

Possible ways to manage nocturnal panic attacks 

Rousing from a panic attack can be distressing, as these attacks may happen suddenly and without warning. However, one may be able to minimize the effects of these attacks through techniques like the following: 

• Breathing exercises: The triangle breathing technique involves inhaling, holding, and exhaling the breath for four seconds for each stage, which can regulate the nervous system.
• Bodily awareness: This technique involves awareness of sensations, which may involve recognizing your symptoms as though you were an observer.
• Relaxation techniques: Individuals can try relaxation techniques like progressive muscle relaxation, which involves tensing and relaxing different muscle groups alongside deep breathing techniques. 
• Reminding yourself you’re experiencing anxiety: Labeling the panic attack for what it is may remind you that what you're experiencing relates to your symptoms and that these manifestations are not life-threatening.
• Grounding techniques: Grounding could look like going outside for some fresh air, taking a shower, dabbing essential oil on your wrists, massaging your hand, or using other techniques that help you calm yourself.  
• Mindfulness: For some people, fostering mindfulness skills before a panic attack arises may be helpful in preventing them. Mindfulness meditation might involve focusing one’s present attention on physical actions and sensations and letting thoughts pass without judgment. 

Possible ways to prevent panic attacks 

Cognitive-behavioral therapy (CBT), antidepressant medication, and self-care, such as exercise, social support, and lifestyle choices, may all be helpful ways to manage or prevent panic attacks. Cognitive-behavioral therapy (CBT) is an evidence-based form of psychotherapy (talk therapy) that is often considered the gold standard in treating mental health conditions, including panic disorder. 

CBT is based on the principle that psychological concerns are often based on unhelpful ways of thinking and behaving, and by changing these patterns of thinking and behaving, one may cope more effectively with stressful situations and find symptom relief. Other forms of therapy may also be helpful for panic disorder or nocturnal panic attacks. Consult a therapist to learn what modality might be best for you. 

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Therapy options to sleep better 

Panic attacks at night can significantly impact one’s quality of life and well-being. Therapy can introduce helpful strategies to manage symptoms before and during a panic attack. 

However, if attending in-person therapy presents a challenge, individuals might consider online therapy through a platform like BetterHelp. Online therapy allows clients to have sessions with a licensed therapist via phone, video, or live chat. Clients can also send messages at any time, which may be helpful when they struggle to sleep and would like to receive support. The therapist can respond as soon as they are available. 

A narrative review examined the efficacy and acceptability of internet-based treatment options for panic disorder. The review examined eight studies with 1,013 participants and ten interventions, nine of which involved cognitive-behavioral therapy principles. The review referenced findings that suggested that, like CBT, internet-based cognitive-behavioral therapy (iCBT) can reduce the frequency of panic attacks and avoidance behavior in clients.