Work Text:
One morning three years or so ago I was driving to work. I had just dropped my kids off at daycare and was only just leaving the town we live in while singing along (badly, but hey who was there to complain) to Pat Bentar’s Love is a Battlefield” when suddenly my heart was slamming into my chest. And my chest, my god it hurt. There was so much pressure suddenly there on my chest that it felt difficult to breath.
I pulled over, got out of the car and began to pace. About a week ago the same thing happened and I ended up in the ER where they found nothing wrong besides an elevated heart rate that slowly, over time, returned to normal. I paced and paced. Every fiber of my being told me something was horribly, dreadfully wrong. I was dying. I knew I was dying with dead certainty. But I knew I was dying when this happened last week too.
While pacing I began shaking my hands. My fingers were tingly. Was that another sign of a heart attack? Was I having a heart attack in my 30s? My toes tingled too. My stomach had this odd, heavy feeling. I was cold, I was hot. I needed help. I was dying. My heart would not stop pounding. What was happening?
Time seemed to slow, but eventually a police officer stopped by to determine what was happening and he called an ambulance. The ambulance came just as my heart slowly started to calm. I had a panic attack, they said, and I was going to be just fine.
I’ve gone back and forth on how to begin writing advice on panic attacks, something that I’ve become all too familiar with over the past three years. At the height of my panic disorder, I’d have an average of 10 or so a week, so I’ve become very familiar with them. I’ve also come to know others that have panic attacks. The topic seemed so big to me, since it’s become such a common yet demanding part of my life, that it’s taken me a long time to figure out how to discuss it with you. This is my best attempt.
I think it helps a bit to understand first what they are. Panic attacks happen when your mind misinterprets something as a mortal threat that isn’t one at all, causing the amygdala and hypothalamus in your brain to trigger your body’s Fight or Flight response. (By the way, if the threat is real, by definition it isn’t a panic attack.)
Just like any other time your body’s fight or flight response is triggered, a number of real, biological changes happen to the panicking person’s body. Their pituitary gland secretes out large amounts of cortisol and adrenaline which do some real physical things to your body such as increasing your heart rate, slowing your digestive system, potentially giving you tunnel vision, making you shake, dilating your pupils, and altering the blood flow in your body.
If you have an external cause for your fight or flight response, your mind might become fixated on that. If you’re being chased by a bear, it’s hard to focus on anything other than the bear. If you’re being robbed at gunpoint, you won’t notice much else beyond the gun and the person holding it.
But for most people suffering from a panic attack, there is no obvious external cause for their panic attack, and so instead of fixating on something external, the experience of the fight or flight response itself becomes the focal point of our distress. Biological processes that are often unnoticed or barely noticed by someone in mortal danger command our attention: our pounding heart, the disturbance in our breathing, muscle pain as our bodies tense up, the tingling sensations in our extremities. These are easily interpreted as signs of a heart attack or some other dangerous medical event. Even when a person (like me) is fully aware what a panic attack is and that they’re having one, it’s hard to think otherwise because as part of the fight or flight experience your brain is making you feel this overwhelming sense of fear and/or doom.
I do not have panic attacks based on a phobia, but it would not be unreasonable to have a character who has a panic attack triggered by a phobia to be fixated on that object that they’re afraid of. A person phobic of say, snakes, might be fixated on “OMG snake’s gonna kill me” even if the snake is in a cage and they logically know on some level that the snake can’t.
Generally when writing a panic attack, it’s good to keep a number of things in mind. I’m going to organize this by: before the panic attack, during the panic attack, and after the panic attack.
Before the Panic Attack
When setting up a character for a panic attack, you need to make a few decisions. First, has your character had a panic attack before and knows what they are? If so, this will affect how they approach a panic attack before, during, and possibly after the attack. Characters who have already experienced panic attacks, especially more than once, will:
Be more likely to sense one’s coming if it’s triggered by chronic stress or anxiety
Be more likely to know their triggers
Be more likely to have coping mechanism to try to avoid a panic attacks (be they maladaptive or good)
May have a method in place to deal with them
If a character is used to having them, they may have ways of handling panic attacks that can help them but might also have ways of handling them that are harmful. Harmful could be as dramatic as doing drugs to self-medicate or, less dramatically, work themselves up and into that panic attack because they’re so afraid of having one. Or, they could have helpful coping mechanisms like grounding techniques (more on these later). Think about what works for your character and where they are in the story.
They might avoid going to that party because they know their social anxiety triggers panic attacks. Another example of a method for handling panic attacks is seen in someone I know who drives around with Xanax in their car and when they panic while driving (and it’s always while driving for them) they pull off, pop a Xanax and call for their husband to get them. They have the Xanax in their car as part of a carefully planned approach for handling their panic attacks.
If your character’s never had a panic attack or they happen infrequently, they might notice some mounting anxiety, but they’re likely to be blindsided and not have anything set up in preparation and no established coping mechanisms for handling them. Your first panic attack is usually a real doozy for this reason.
It’s also worth making sure you as the author know what’s triggering the panic attack and making it clear in the story (unless the character has panic disorder which is marked by seemingly random panic attacks). Panic attacks can happen immediately in response to the trigger or shortly after the trigger. The trigger could be an acute event or caused by mounting or continued stress. You, as a writer, need to establish this though before the panic attack happens.
It’s also worth noting at this point that panic attacks can happen to anyone. Your character does not need to have any mental health issues to have a panic attack, but they’re also more common with certain mental health issues, especially anxiety disorders and they’re also common with PTSD. BUT! character could have PTSD or an anxiety disorder and never have a panic attack. And a character with no mental illness certainly can. Of course, if your character’s panic attack is linked to a mental health issue, you should establish that before the panic attack or show other signs of their mental illness if they’re not diagnosed yet.
Bad: This person just had a random panic attack so they must have PTSD!
Good: I’ve shown how this character struggles with hypervigilance and nightmares and how that affects their daily life. Now, this panic attack they had during the firework display is yet another signal that this veteran has PTSD.
During the Panic Attack
So, now the panic attack has started. Your character will experience a SUDDEN onset of INTENSE fear or doom along with a number of real biological symptoms. Panic attacks, even if you sense you’ve got one coming, tend to hit like a bus. One minute you're doing your thing, the next your pituitary gland’s just released all the adrenaline: your chest is TIGHT and often painful. The air feels thin or you feel it’s hard to breath. Your stomach’s heavy (thanks to your digest system slowing to a stop), fingers and/or toes or tingling, you feel lightheaded or dizzy, the you’re sweating, your feeling hot or cold or going back and forth between the two.
Not only should you be aware of these symptoms but of how it might make them act. For example:
Adrenaline gives your body energy! Your character won’t act hyper but they will appear agitated. They might pace. If they’re in a situation they have to sit (say on a bus) they might do things like bounce their leg or frequently shift position.
Tingly fingers might make them shake their hands or beat their hands together to try to increase blood flow or rub them together or grip them.
Slowing metabolism means if your character was eating, they can’t now. If they were just eating, they might also vomit (though vomiting isn’t that common...just hope you never have a panic attack right after a huge Thanksgiving dinner).
Racing heart/chest pains? Your character might be checking their pulse, talking about their heart racing, complaining about chest pain, or they might suspect a heart attack.
Shallow breathing? Your character might complain that it’s hard to breath or that the air feels thin
What tends to get over exaggerated in fiction is the hyperventilating. It’s often not obvious at all. Characters that are close to the panicking character may notice a change in breathing patterns as well therapists and medically trained characters, but let me tell you, I have panicked publicly more often than I’d like to admit and like 95% of the time no one appears to notice that I am.
People panicking will very likely display safety seeking behaviors. Personally I look for tight spaces, small rooms, but I have a friend who NEEDS to get outside when she panics because she feels trapped. It’s also not uncommon to seek out people to help, be it a good friend or professional medical help. Many people experiencing their first panic attack end up at the ER.
This all said, a subset of people experiencing panic attacks freeze. They have a hard time talking or in more extreme situations, even moving.
It is also not uncommon for people panicking to disassociate in some way. Either they feel that they’re not real or the world around them isn’t real. This usually comes with an emotional numbness where they’re feeling the physical symptoms but they’re just...emotionally numb to them and everything else.
If your character has been to therapy and the story takes place in (or after) modern times, it’s very likely your character’s been given a valuable tool to manage panic attacks called grounding. Ground exercises come in many forms and help someone experiencing a panic attack work through it and self calm by forcing them to focus on the present moment (and something other than their panicking!). Panicking characters might need someone to prompt them to do it or might be able to remember to do it on their own (it’s surprisingly hard to remember to do it though when you’re in the midst of a panic attack). There are many kinds of grounding techniques and you can look for them on google, but the most common I’ve seen are 54321 and 5-7-9 breathing.
54321: You look for and list five things you can see, four you can feel, three you can hear, two you can smell and one you can taste. (My personal favorite)
5-7-9 breathing, or 4-6-8 breathing, is when you take a breath in while counting to the first number, hold that breath while counting to the second number, then blow out to the count of the third.
Other Characters’ Reaction
Other characters may or may not notice the panicking character is having a panic attack. You’ll have to determine this based on how close the characters are, what’s happening around them (that might distract them from noticing), how dramatically your panicking character’s behaving, and whether or not the other characters have life experiences that would make them more attuned to someone in this state. It is completely possible for no one to pick up on the fact that someone is panicking, especially if this is not the panicking person’s first panic attack. (Help seeking behavior is likely to be most extreme in your first panic attack because you don’t know what’s happening to you.)
It’s also worth thinking whether or not the other character is any good at helping someone through a panic attack. Are they going to say “Woah heart pain? We’re going straight to the ER!” Do they know grounding techniques? Are they trying to help but really bad at it i.e. telling them to calm down? It’s also possible for people to react with some variation of “There's nothing wrong with you; you’re just freaking out” which is not nice but it happens. If your story has a character having multiple panic attacks over time those close to them may slowly improve in their ability to help them.
After the panic attack
This is where stories usually get it wrong: the person stops panicking and then...everything returns swiftly to normal. Truth is, since panic attacks aren’t just a mental thing but a major biological event as well, things don’t just get back to normal, though it’s very possible your recently panicked person might try to act that way. Consider, how quickly does your character calm after the panic attack? I’ve calmed quickly at times, but other times it’s like a gradual thing. I’d buy either way but you’d want to be mindful of that. Are they shaken by the panic attack? Anxious about it? They’re more likely to be if it’s their first or if they feel like they’ve embarrassed themselves. Do they engage in any other self-calming behaviors? Are they good self-care things or maladaptive coping mechanisms?
Now you don’t necessarily need to include this in fiction but for full disclosure, you know that phrase “scared the crap of me?” Yeah, I learned why it exists when I developed panic disorder. About five minutes after it’s over, I’m usually attempting to discreetly make my way to the bathroom. Going off the “collect myself” is a good excuse if people know I panicked without spelling it out.
Since we’re on embarrassing after effects, all that shallow breathing from before also makes me burp a bunch sometimes!
But, most importantly, panic attacks are fucking exhausting. The bigger and longer they are, the more tired your character should be. If they’re not too anxious to be sleepy afterwards, they’re probably looking for a nap. They are not up for mountain climbing or running or wild sex. They’re fantasizing about laying down on the couch. I’ve had to go through a whole workday post panic: it sucks.
The thing is, panic attacks use a LOT of energy. Besides being exhausted, I’m often hungry after one too, though it takes a few minutes for me to feel ready to eat (after all, my stomach just had an emergency shutdown). This means post panic I’ve got a real interest in carbs over protein for the next hour or so.
Panic attacks are hard to explain to those that have never had them, but I do think there's a great value in accurately depicting them in fiction and fanfiction. By doing so, you help others understand that panic attacks are real and can have a dramatic affect on people’s lives. I hope this helps you craft more believable panic attacks going forward. I look forward to reading them!