What Happens in Your Body During a Panic Attack
During a panic attack, your body experiences an abrupt surge of intense fear that triggers a "sympathetic storm"—a massive activation of your autonomic nervous system that peaks within minutes, producing a cascade of physical symptoms across multiple body systems simultaneously. 1, 2
The Physiological Process
Autonomic Nervous System Activation
Your body launches a fight-or-flight response during a panic attack, even without actual danger present. 1 This creates:
- Cardiovascular changes: Racing or pounding heart (palpitations), accelerated heart rate, elevated blood pressure 2, 3
- Respiratory distress: Shortness of breath, smothering sensations, feeling of choking 2
- Thermoregulatory responses: Sweating, hot flashes, or chills 2, 4
- Gastrointestinal symptoms: Nausea, abdominal distress, dry mouth 2
- Neurological manifestations: Dizziness, lightheadedness, faintness, paresthesias (numbness or tingling) 2, 4
Temporal Sequence of Symptoms
Panic symptoms follow a predictable crescendo pattern, unfolding in three distinct phases: 4, 5
- Early symptoms (first to appear): Difficulty breathing, palpitations, chest discomfort, hot flashes 4
- Intermediate symptoms: Trembling/shaking, choking sensation, feelings of unreality (derealization), sweating, faintness, dizziness 4
- Late symptoms: Intense fear (of dying, losing control, or going insane), paresthesias 4
The attack typically reaches peak intensity within 10 minutes and is self-limited, often leaving you feeling weak or shaken afterward. 2, 5
Psychological and Cognitive Changes
Catastrophic Cognitions
Your mind experiences intense catastrophic thoughts during the attack: 1, 2
- Fear of dying 2
- Fear of losing control 2
- Fear of "going crazy" 1
- Depersonalization (feeling detached from yourself) 2
- Derealization (feelings of unreality) 2
Hypervigilance
Your attention becomes hypervigilant, constantly surveying your body for feared symptoms, which paradoxically intensifies the physical sensations through positive feedback mechanisms. 1
Stress Hormone Response
Importantly, real panic attacks do NOT significantly activate your hypothalamic-pituitary-adrenal (HPA) axis, despite causing major sympathetic nervous system activation. 6 This distinguishes panic attacks from generalized anxiety:
- Panic attacks produce massive sympathetic activation but minimal cortisol/ACTH elevation 6
- This differs from generalized anxiety, which activates both the HPA axis and sympathoadrenal system 6
Muscle and Motor Effects
Your muscles experience significant tension and involuntary movements: 2
The fight-or-flight response causes increased muscle tension throughout your body, which can manifest as spontaneous muscle contractions. 7
Heterogeneity of Panic Presentations
Not all panic attacks look identical—they vary in intensity, frequency, and symptom presentation. 5, 3 Three subtypes exist based on physiological versus subjective arousal:
- Prototypical panic: High subjective anxiety with high physiological arousal (most common in panic disorder patients: 33%) 3
- Cognitive panic: High subjective anxiety with low physiological arousal (37% of panic disorder patients) 3
- Nonfearful panic: Low subjective anxiety with high physiological arousal (more common in non-clinical populations: 42%) 3
Cultural Variations
Certain symptoms may be more prominent depending on cultural background: 1
- Specific body sensations like neck soreness, tinnitus, or headache are prominent in some Asian populations 1
- Uncontrollable screaming or crying may occur in Caribbean Latino populations (ataque de nervios) 1
- Feelings of heat in specific body parts (head, chest, neck) are common across multiple cultural groups 1
Common Pitfalls
Do not confuse the 10-minute peak criterion with total duration—while symptoms peak within 10 minutes, the attack itself and residual effects last longer. 1, 5 Additionally, panic attacks can arise from either a calm baseline or from an already anxious state, not just "out of the blue." 1