a complete guide to panic attacks for writers
I’ve seen many posts about this and many of them are either not very complete or somewhat misleading, so here goes, a certified anxious wreck’s guide to panic attacks.
First thing: there isn’t a clinical distinction between a panic attack and an anxiety attack so I’m not sure why everyone is splitting hairs over it. In the DSM “panic attack” refers to the quick, sudden onset of intense fear and stress, the sympathetic nervous system response, and all the associated physical symptoms (that i’m about to get into). “Anxiety attack” isn’t a clinical term, and yet I see all kinds of posts “explaining” the difference and none of them actually agree on what the difference is (duration? severity? trigger or lack thereof? I’ve seen so many different things), so to me it seems like a dumb thing to split hairs over. Generalized anxiety is definitely different, but even then the lines can blur and when we’re talking about a discrete *event* where the symptoms come upon a person, that’s an “attack” and saying panic attack suffices. Or anxiety attack. Just. Whatever.
TL;DR: there is no clinically recognized difference between a “panic attack” and an “anxiety attack,” everything I see explaining the difference has a different idea of what the difference is, and it’s not like, offensive or something to use the “wrong” term so just. Yeah it’s not a big deal.
A panic attack is basically when someone all of a sudden feels extremely terrified and panicked, without being in actual danger. They’re associated with anxiety disorders and post-traumatic stress disorder, though they can happen to someone who doesn’t have a mental illness.
Panic attacks are not just the emotion of fear, though; there are a lot of physical and mental reactions that go along with them. Feeling terror isn’t the only thing that’s happening. When the brain perceives a threat, the sympathetic nervous system causes a bunch of things to happen in the body to prepare the person to either fight or run away from the threat. That’s called a fight-or-flight response. Breathing and heart rate speed up, while digestion is suppressed, and so on. These responses affect almost every system in the body. The person’s mental state also changes. They become very hyper-vigilant to threats and “tunnel-visioned” on whatever it is that seems to be the threat.
A panic attack is basically all this stuff happening, but there’s nothing to fight or run away from. It’s bad.
Symptoms, physical and mental
Some things to keep in mind, that I haven’t seen addressed in any post before: I’ve known a lot of people, including myself, with various anxiety disorders who experience panic attacks and all of them experienced a different grab-bag of symptoms. In some cases, the symptoms could be very weird. It would take forever to exhaust all the possible symptoms of a panic attack, but I’ll do a list and explain (I’ll go into more detail about how to write all this in a bit). There’s a whole range of severity, and the loss of control/thinking you’re going to die happens with the more severe ones. One person can have both small attacks and huge ones that are much worse, and the symptoms they have can change over time.
Intense fear - panic attacks are terrifying. They vary in how terrifying. I know saying “terrifying” is exactly what it says on the tin, but it’s hard to convey to someone who hasn’t experienced this exactly HOW terrifying they can be when they’re really bad. When I was younger, I had attacks that lasted hours wherein it seemed almost as if I had suddenly realized that nothing in the universe is kind or good or safe and nothing I could hold onto for security felt even real. I know that sounds damn dramatic, but it’s what happened. On that note:
Feeling a sense of immediate impending doom. Again, no real way to describe this well but its Bad
Being convinced you are going to die. I mean convinced.
Feeling like you are losing control or going crazy. This goes along with the things I just discussed, and is usually with a severe attack.
Racing or pounding heart - this is one everyone will know. Basically, your body is convinced you need to run from something or fight something.
Feeling that the room is swirling or spinning around you.
Choking/suffocating feeling or feeling like you have trouble breathing - This is scary. Honestly, a lot of why panic attacks are so scary is that the *symptoms* are scary. I used to always feel like I couldn’t pull air far enough into my lungs, or that no breath I took in was deep enough. You might feel like your throat is closing up. Expect a character to possibly gulp or gasp for air that they don’t feel like they’re getting.
Dizziness or feeling lightheaded or faint. Can result from hyperventilating as a result of feeling like you can’t breathe. Your character might need to sit down all of a sudden, or lean against a wall.
Crying, or screaming: Not everyone will respond this way, but a person’s stoic-ness or “toughness” doesn’t have a lot to do with whether they do. Even a strong, tough person can react this way. An emotional person won’t necessarily cry. It depends.
Talking to oneself, babbling, muttering, moaning, really any kind of vocalization. “Ohmygodohmygodohmygod.” That kind of thing.
Pacing rapidly, fidgeting uncontrollably, unable to sit still. Messing with items around you and throwing them aside. Your character might walk around in tight circles or gesticulate frantically, clutch at their hair, etc.
Really any tic or nervous habit that a character has might get worse and possibly harmful.
Shaking/shivering/trembling uncontrollably: A lot of people will think hand tremors or being “shaky” with nervousness, which I guess happens, but this can be and very often is very intense, teeth-chattering, whole-body stuff. Often seems to happen in waves or spasms, and you can’t stop it. If you’re having a very bad attack, think violent, uncontrollable waves of shivering. It’s very unpleasant.
Tunnel vision or black around the edges of your vision: This is not something I can find on google but I know it’s happened to me at least once.
Goosebumps or chill-bumps.
Chest pains. Not something I have experienced much, so I can’t elaborate too much.
Numb, tingly fingers or hands. I don’t have any personal experience with this, but apparently this happens to people.
Racing or spiraling thoughts. Even if it didn’t have a trigger at all, your thoughts can still be really panicked and disjointed. Expect your character’s internal monologue to be very repetitive and unstructured. If there was a trigger, expect extreme obsessing over the thing that caused the panic. But in some cases, panic attacks can be almost purely physical responses. Multiple times I’ve been overcome by the symptoms and mentally just been like “Oh, this is…happening to me.”
Anger or aggression: The intense feelings of a panic attack can come out in some weird ways, and this is one of them. Snapping, lashing out, irritability, or other ways of responding with anger won’t be out of place. You might be extremely defensive or ready to fight back.
Nausea: Panic attacks always came with very severe nausea for me, though I never actually threw up (that’s rare, but it happens to some people.) This doesn’t happen to a lot of people, though.
Other digestive distress: You can definitely have diarrhea or stomach pains.
Face turning pale/blanching.
A feeling of weakness in your body.
Feeling like what’s going on around you isn’t real; your surroundings seeming surreal. (Derealization. I haven’t experienced this much, so you can do more research on your own if you want to explore this one.)
Feeling detached from your body or like you’re observing yourself from far away. Feeling like you aren’t real. (This is called depersonalization. Not much personal experience with this, either.)
And these symptoms aren’t even close to all of them. Honestly, a lot of weird crap can happen, because panic attacks affect the entire body and everyone’s body is different. Of the list above, I’ve experienced everything at one point or another except depersonalization, stomach upset, and the tingling hands/arms and many of the above symptoms happened to me as flukes (I think chest pains happened like once). Some of the things on the list developed later in life. (I started getting hot flashes due to anxiety when I was 16.) Some symptoms disappeared as I got older. (I haven’t actually experienced shortness of breath much since I was a kid.) Everyone I know has a different set of these traits. I have no idea why. This is all just to show the wide variety of symptoms that can occur, and show that everyone is going to experience it differently. As for your character, you can just pick whatever feels right to you. Racing heart and shortness of breath are pretty much staples of the panic experience, and the shaking/trembling and dizziness are very common as well, but everyone is going to be different.
Now, how does one actually write a panic attack?
If you’re writing about panic attacks, you most likely have a character who has some form of trauma or anxiety disorder. Now, panic attacks can happen totally at random, but there is usually some sort of cause.
When I say “cause,” that can be “the room is too hot” or “I saw something in an article about one of my phobias.” (These examples are drawn from my friend and me, respectively.) Really little things can set the snowball rolling. Stress or anything unexpected will do it, and so will exposure to your character’s triggers.
When I was younger, my triggers were all related to my phobias, which were mostly health-related. That meant reading something about some rare form of cancer, or something like that, could cause me to have an attack. Triggers could be related to a character’s trauma, or they can just be something that scares or stresses out a character. it depends on the character. Trauma related triggers can be very little and random. Anything they associate with their abuse or abuser–a scent, a certain song, a phrase said in a certain way–can set them off.
When I say “snowball,” that’s really how it works. The thing about panic attacks is that the attack itself is absolutely terrifying, to the point that a lot of people who experience them develop extra anxiety just over the prospect of having another one. The hallmark characteristic really is intense terror. When you’re not good and jaded and used to having them, the symptoms themselves will make you freak out more. Panic results in feeling like you’re struggling to breathe, and struggling to breathe results in more panic. I was especially screwed because my main triggers were–guess what–all related to illness. Yay.
Your character is going to be in a very altered state of mind, most likely. They will be obsessing and spiraling and latching onto worst-case scenarios so that they can’t really objectively analyze what is going on with their body. Everything is Bad. Everything seems like it’s as bad as it could possibly be. On this same note, your character is not going to be able to think or reason their way out of this. Their irrational, fearful thoughts are going to be a lot stronger than the reasonable ones and will be flashing like strobe lights on top of it. If that didn’t do it, the extremely powerful bodily response they are dealing with sure would. The “sense of impending doom” or of feeling like you might die is overwhelming and hard to counter with thoughts because it just feels so vast.
Write a severe panic attack as you would excruciating pain, because that’s the best way to put the kind of mental state. It has to stop, it HAS to stop, but it doesn’t stop, there’s nothing you can do because there’s no actual threat.
And yet, if your character has experienced this many times, they may be able to hold onto sanity and control their physical responses. I’ll get into coping skills in a bit, but I’m putting this out there to say that the first time and the fiftieth time might be really different.
The first time people experience a panic attack, they often call 911. I’m serious. The thing is, you have to learn that what you’re physically experiencing is a result of panic; you don’t just instinctively know that. The first time I had one, I was 10 and the shaking and spasming didn’t feel like an emotional response, it felt like what in the actual hell is going on? Am I dying? It takes several more times experiencing this to figure out how your body reacts during a panic attack and several MORE to be able to piece yourself together enough during it to say to yourself, “I am having a panic attack,” and identify the symptoms.
That said, even when you know what’s going on with you, it’s still very scary because what do you do when you feel like you have to run, but there’s nothing to run from? Or you feel like you can’t breathe, but you know you’re taking in air?
All that to say: the emotional response of fear isn’t the central thing your character will be conscious of. Their thoughts, and their physical reactions, are as important and they might even seem detached from the feelings of fear. So don’t just have your character being like “I’m terrified, I’m terrified, I’m freaking out…” It feels like some kind of medical disaster. I wasn’t always able to identify my attacks as fear at all. Obviously your character is scared. But show that through their thoughts (spiraling, disjointed, obsessive, babbling) and what’s going on in their body (cant breathe, sweaty, shaking uncontrollably).
Panic attacks can last anywhere from a few minutes to hours. When you get to ones that are hours long, usually it’s happening in multiple “waves.” Your character can start to calm down, and then they can start to think about stressful things again and hyperventilate and go back into it. A lot of definitions list them as “brief” but the briefest one I’ve ever had probably was no less than 20 or 30 minutes. Again, it will vary with the character.
After your character starts calming down (this can just happen due to utter exhaustion, getting the symptoms under control, or just realizing that it’s been two hours and they’re not dying), they will feel exhausted. Especially if it’s a long attack. If they’ve been in panic mode for hours expect them to be feeling like a beaten rug hanging on a porch. Panic attacks are draining. They probably won’t feel up to much after. Their energy will be gone. They might feel a sense of calm and security after they’re done, or they might feel very sick and bad. It just depends.
The best coping skills usually target the body itself and focus on slowing down the fight-or-flight response. This is why breathing exercises are recommended. But they don’t always work. Being super aware of my breathing would always make me freak out more. The mental and physical aspects bounce off one another and if something that’s helping in one area is making it worse in another, it won’t help overall.
In my experience, knowing what was happening to me, all the causes of the physical things I was feeling, and that they were all just results of the panic attack helped me fend off the worse things–feeling like I was going to die, et cetera. It may not be that way for everyone. But just knowing what is happening to you, or not knowing, makes a lot of a difference.
What not to do: I know it’s hugely tempting to have your character be held and reassured by their love interest and calm down, but…really, with a panic attack, you’re not going to pull someone out of it. It has to pass. Especially once the snowball is already rolling, it needs time to pass. Even the best damn coping skills in the world aren’t going to erase this and neither is a hug from someone cute.
Different people will need different things. Some people will be helped by being hugged or held tightly, but that’s not everyone. Some will want to be left the hell alone. Some people will want you to be near them and talk to them, but not touch them. For some people, holding their hand is enough.
There’s a post going around somewhere saying that grabbing someone and holding them tightly to you will stop a panic attack. This goes for both real life and fiction–DO NOT DO THAT. Ask!! Ask!! if it’s okay! to touch them!!!!!! Never ever ever ever ever touch someone who is in this sort of distress without permission and especially don’t keep doing it even if they struggle. They could feel trapped and start to feel even worse, or if their panic is trauma related, they might have a flashback to an assault. In either case they might fight back and hurt you or themselves. Don’t put this in a book and show it actually working and being a good thing because NO.
If you want to indulge some hurt/comfort or fluff, just show the love interest character staying with them, asking what they need, doing what they can to help. Your frightened character’s love interest can coach their breathing, bring them a blanket or a glass of water, or just talk to them. They can remind the character that they aren’t suffocating. I mean, sure, they can hug if you like. Some people are comforted by being hugged. Just don’t portray it as some kind of cure or instant fix. Someone who is having a panic attack isn’t going to just immediately calm down upon falling into the arms of the right character. They may not calm down at all. The love interest might feel very inadequate. The most comforting things in the world are not going to be that comforting right then. Anyway, showing the love interest sticking through and being compassionate and attentive through ugly, scary hours of terror, even if there’s not a lot they can do, is sexy.
If you wanna do cuddles, put those in post-attack, when your character is mostly calmed down and now is just spent and tired. They probably need the comfort and a long hug or back rub might do them good.
On the topic of hugs, give someone with an anxiety disorder a hug for me today, will ya? (Ask first.) This was emotionally exhausting. Whew.
