Panic Attacks: Why They Happen and How CBT Can Help
A racing heart. Tightness in the chest. Dizziness, trembling or difficulty catching your breath. A feeling that you might faint, lose control or die.
Panic attacks can be frightening—particularly when they seem to occur without warning. Because the physical sensations are so intense, it is understandable to interpret them as evidence that something is seriously wrong.
The difficulty is that becoming frightened of the sensations themselves can intensify the body's alarm response. This can create a cycle in which anxiety about panic contributes to further panic.
This article explains what happens during a panic attack, why some people become caught in a recurring panic cycle and how Cognitive Behaviour Therapy (CBT) can help. For a broader overview of anxiety and its treatment, see our guide to anxiety treatment and CBT.
What is a panic attack?
A panic attack is a sudden surge of intense fear or discomfort accompanied by strong physical and psychological symptoms. It may occur in an obviously stressful situation, but it can also seem to arise unexpectedly.
Common symptoms include:
a racing or pounding heart
chest tightness or discomfort
shortness of breath or a feeling of choking
dizziness, light-headedness or feeling faint
sweating, shaking or trembling
nausea or abdominal discomfort
hot or cold sensations
tingling or numbness
feeling detached from yourself or that the surroundings are unreal
fear of losing control
fear of fainting, dying or having a medical emergency.
Not everyone experiences panic in exactly the same way. Some people notice one dominant symptom, such as dizziness or heart palpitations. Others experience several sensations at once.
Panic symptoms commonly escalate quickly and then subside. Even when an episode is relatively brief, the experience can leave someone feeling exhausted, unsettled and concerned about it happening again.
Is a panic attack the same as panic disorder?
No. A person can experience one or more panic attacks without having panic disorder.
Panic disorder involves recurrent panic attacks together with ongoing concern about further attacks, their possible consequences, or significant changes in behaviour intended to prevent them. For example, a person might stop exercising, avoid driving, remain close to home or continually monitor their heart rate because they are afraid of triggering another episode.
It is often this fear of future panic—and the restrictions that develop around it—that causes the greatest longer-term difficulty.
Why do panic attacks happen?
The human alarm system is designed to respond quickly to perceived danger. When the brain detects a threat, the sympathetic nervous system prepares the body for action. Heart rate and breathing may change, muscles tense, attention narrows and the body releases energy.
This response can be useful when danger is present. During panic, however, the alarm response may be triggered in the absence of an immediate external threat. Normal or anxiety-related bodily sensations can then be interpreted as signs of catastrophe.
For example:
“My heart is beating quickly. I might be having a heart attack.”
“I feel dizzy. I am going to faint.”
“I feel unreal. I am losing control.”
“I cannot get a satisfying breath. I might suffocate.”
These interpretations produce more fear. More fear produces stronger physical sensations, which can then appear to confirm that the original interpretation was correct.
The panic cycle
From a CBT perspective, panic is often maintained by a self-reinforcing cycle:
Trigger or physical sensation → catastrophic interpretation → increased anxiety → stronger physical sensations → escape or safety behaviour → short-term relief → future fear maintained
Imagine someone notices their heart beating more quickly after walking up a flight of stairs. They think, “Something is wrong with my heart.” Their anxiety rises, their heart beats faster and they begin to feel light-headed. They leave the building, sit down and repeatedly check their pulse.
When the sensations eventually reduce, they may conclude:
“Leaving and checking my pulse prevented something terrible from happening.”
The relief is genuine, but the person has not had an opportunity to discover whether the sensations would have passed without escaping or checking. The next increase in heart rate may therefore feel even more threatening.
Why panic attacks can feel as though they come from nowhere
Sometimes the initial trigger is obvious. It might be a crowded room, driving on a motorway, receiving stressful news or noticing an unfamiliar physical sensation.
At other times, the trigger is subtle. Changes associated with tiredness, stress, caffeine, heat, hunger, exercise or rapid breathing may be noticed only after the alarm response has begun. Attention can also become highly sensitised to small bodily changes, so a sensation that another person might barely register is detected and interpreted immediately.
This does not mean the symptoms are imagined. The sensations are real. CBT focuses on the meaning assigned to them and the responses that may inadvertently intensify or maintain the cycle.
How fear of panic can restrict everyday life
After a frightening panic attack, it is understandable to try to prevent another one. A person might begin avoiding:
exercise because it increases heart rate
coffee because it produces physical activation
shopping centres or crowded places
public transport
driving, particularly on motorways or away from home
being alone
places where leaving quickly might be difficult
situations where help may not seem immediately available.
Other strategies are less obvious. These are sometimes called safety behaviours and may include:
carrying medication, water or another object primarily to feel protected
sitting near an exit
repeatedly checking heart rate or breathing
continually scanning the body for warning signs
only going out with a trusted person
researching symptoms for reassurance
leaving as soon as anxiety begins
trying to force every physical sensation to stop.
These responses make sense as attempts to feel safe. However, they can also strengthen the belief that panic sensations are dangerous and that coping is only possible when the safety behaviour is available.
This is part of the broader pattern described in our article on why avoidance makes anxiety worse and what to do about it.
How CBT can help with panic attacks
CBT does not simply tell someone to calm down or think positively. Treatment involves developing an individual understanding of the panic cycle and changing the interpretations and behaviours that keep it going.
Depending on the person, CBT for panic may include the following components.
Understanding the individual panic cycle
The first step is usually to identify:
the situations or sensations that trigger anxiety
what the person predicts will happen
how they interpret physical symptoms
what they do to escape, prevent or control panic
what happens immediately and in the longer term.
This creates a specific formulation rather than assuming that every person experiences panic for the same reason.
Examining catastrophic interpretations
CBT helps a person evaluate beliefs such as:
“A racing heart means I am about to die.”
“Dizziness means I will faint.”
“If people notice my anxiety, I will be humiliated.”
“If panic starts, it will continue indefinitely.”
“I must remain completely in control of my body.”
The aim is not to replace these thoughts with automatic reassurance. It is to examine the evidence, consider other explanations and test predictions through experience.
Interoceptive exposure
Interoceptive exposure involves deliberately and safely bringing on feared physical sensations so they can be experienced in a different way. Depending on a person's health and clinical assessment, exercises might be designed to produce sensations such as a faster heartbeat, dizziness, breathlessness or feelings of unreality.
The purpose is not to overwhelm someone or prove that they should enjoy the sensations. It is to create opportunities to learn that:
bodily sensations can be uncomfortable without necessarily being dangerous
anxiety sensations can rise and fall
the feared consequence may not occur
the person may be more capable of tolerating the experience than they predicted
sensations do not always need to be escaped, checked or neutralised.
Exercises should be selected collaboratively and adapted when there are relevant medical issues. They are not a substitute for appropriate medical assessment.
Situational exposure
If panic has led someone to avoid places or activities, CBT may involve gradually returning to them. This might include exercise, driving, shopping, travelling on public transport or spending time away from a perceived safe place.
Effective exposure is more than simply enduring a situation until anxiety disappears. It involves identifying the feared prediction, approaching the situation in a planned way, reducing unhelpful safety behaviours and reviewing what was learned.
Reducing checking and other safety behaviours
Treatment may also involve gradually reducing behaviours such as pulse checking, sitting beside exits, carrying unnecessary safety objects or relying on another person to prevent panic.
The goal is not to remove every support at once. It is to test whether the support is genuinely necessary and help the person develop confidence in responding differently.
Changing beliefs about anxiety and control
Panic can be intensified by rigid beliefs such as:
“I must not feel anxious.”
“It would be unbearable to lose control.”
“I have to be completely certain that I am safe.”
CBT can help develop more flexible alternatives:
“I would prefer not to feel anxious, but I do not have to eliminate every sensation.”
“Panic is extremely uncomfortable, but discomfort is not automatically danger.”
“I can act constructively without obtaining complete certainty.”
The aim is not to guarantee that panic will never occur again. It is to reduce fear of the experience and increase the ability to respond without allowing panic to dictate behaviour.
What can I do during a panic attack?
Different strategies suit different people, but it can be helpful to:
Name what is happening. If the symptoms are familiar and have been medically assessed, recognising “this may be panic” can be more useful than treating every sensation as proof of catastrophe.
Notice the prediction. Ask yourself what you believe is about to happen. Is the fear that you will faint, die, lose control or be judged?
Avoid fighting every sensation. Frantically trying to eliminate symptoms can communicate to the brain that they are dangerous. Where it is safe to do so, allow some discomfort to be present.
Reduce repeated checking. Continually checking your pulse, breathing or surroundings may provide brief reassurance while keeping attention fixed on threat.
Remain in the situation when appropriate. If there is no genuine danger, leaving immediately can reinforce the belief that escape was necessary. Remaining should be a considered choice, not a rule that overrides safety or medical concerns.
Review what happened afterwards. Compare what you predicted with what actually occurred. Notice not only whether anxiety reduced, but what you learned about the sensations and your capacity to cope.
These suggestions are general information rather than individual treatment instructions. When panic is severe, unfamiliar or associated with health concerns, professional assessment is appropriate.
When should physical symptoms be medically assessed?
Symptoms such as chest discomfort, breathlessness, dizziness and palpitations can occur during panic, but they can also have medical causes. It is important not to assume that new, severe or unexplained symptoms are anxiety.
Seek urgent medical help if symptoms may represent a medical emergency. If you are unsure about recurring physical symptoms, discuss them with a GP or another appropriate healthcare professional. Psychological treatment can proceed alongside necessary medical assessment.
When should I seek help for panic attacks?
Consider speaking with a psychologist or other healthcare professional if:
panic attacks are recurring
you spend substantial time worrying about another attack
you avoid places, activities or physical sensations
you rely increasingly on other people or safety behaviours
panic is affecting work, relationships, sleep or independence
you are uncertain whether the symptoms have a psychological or medical cause.
You do not need to wait until your life has become severely restricted before seeking assistance.
CBT for panic attacks at The CBT Clinic
At The CBT Clinic, our psychologists provide CBT for panic attacks, panic disorder and related anxiety difficulties. Treatment is tailored to the individual patterns maintaining the problem rather than applying the same technique to everyone.
Appointments are available in person at our Warners Bay practice for clients across Newcastle and Lake Macquarie, as well as by telehealth throughout Australia.
You can learn more about CBT and anxiety treatment at The CBT Clinic or book an appointment to discuss whether CBT may be appropriate for you.
