If somebody near you is having a panic attack, the most useful thing you can do is stay, keep still, and let it peak. A panic attack is defined by an abrupt surge of fear that reaches its maximum within minutes and then subsides, so it is going to end whether or not anyone intervenes. [dsm-panic-help]
That is an uncomfortable instruction, because it asks you to do much less than the situation seems to demand. Almost everything people reach for instead, the bag, the breathing coaching, the reasoning, is either neutral or actively unhelpful.
What to do in the first minute
Stand or sit near them, at a normal conversational distance, and stay there. Then say three things and repeat them: where they are, that you are not leaving, and that this will pass in a few minutes.
Keep your sentences short. Someone at the peak of an attack is not processing explanation, so “you are in the car park, I am here, this will pass” works and a paragraph about adrenaline does not. Repeat it calmly rather than escalating your volume or your urgency.
Move them only if the move is easy. Somewhere with less noise and fewer people helps, but being steered by the elbow through a crowd is worse than staying put. Ask before touching them at all, because unexpected contact can register as another threat.
An author-supplied illustration of the shape described in the diagnostic definition, which specifies an abrupt surge peaking within minutes. Not measured data.
The gap between those two lines is the whole problem. The attack peaks and comes down on its own, but from the inside it feels like a curve with no ceiling, which is why people become convinced they are dying rather than frightened.
What a panic attack is doing to the body
A panic attack is the body’s threat response firing at full strength with no threat in front of it. Adrenaline goes up, the heart speeds, breathing becomes fast and shallow, and blood is redirected towards the large muscles, which is what produces the tingling hands and the cold, unsteady legs.
Our overview of panic attacks and panic disorder sets out that response in more detail. None of that is damage. The system is doing exactly what it evolved to do, at the wrong moment, and it is self-limiting because the body cannot sustain that output for long. Reviews of anxiety describe this heightened threat response as central to why panic attacks occur in people who are not in danger. [craske-2016-anxiety-help]
Knowing this changes what you say afterwards more than what you do during. In the moment, a person who believes their heart is failing will not be argued out of it. Our guide to what a panic attack feels like covers the sensations in order, which is often more convincing read later than anything said at the time.
The paper bag is a myth, and it carries a real risk
Do not offer a paper bag. Breathing into one lowers the oxygen content of the air being inhaled, and a 1989 report in Annals of Emergency Medicine described three deaths among patients given this treatment whose breathlessness turned out to have a different cause. [callaham-1989-paper-bag]
The logic behind the myth is not absurd, which is why it survives. Rapid breathing does lower carbon dioxide, and some of the unpleasant sensations in an attack come from that. The problem is what happens when the assumption is wrong: breathlessness is a symptom of cardiac and respiratory emergencies too, and from across a room you cannot tell which one you are looking at.
So the calculation is straightforward. The upside is small and the downside is a person with a genuine oxygen problem being handed something that reduces their oxygen. Leave the bag out of it entirely.
Coaching their breathing is less useful than you think
Telling someone to take deep breaths is the most common intervention and one of the least supported. A controlled trial that removed breathing retraining from a cognitive behavioural treatment for panic disorder found results more consistent with treatment equivalence than with any added benefit from including it. [schmidt-2000-breathing-retraining]
There is a second problem specific to the moment itself. A person mid-attack often feels they cannot breathe properly already, so an instruction about how to breathe can land as a correction, and failing at it becomes one more piece of evidence that something is badly wrong.
If you want to offer something, breathe slowly and audibly yourself and let them join in or not. That gives them a rhythm to borrow without turning it into a task they can fail. It also keeps you calm, which matters more than it sounds: your visible alarm is information they will use.
If you want something to hold on to: ten minutes
The peak of an attack is usually described as arriving around ten minutes in. Start this, stay where you are, and check the clock rather than your instincts.
5:00
Nothing to do. Stay nearby, keep your voice level, and let the timer be the thing that is counting.
Most attacks have started easing by now.
What to say, and what to avoid saying
Short, concrete and repeated works. “You are safe”, “I am staying”, “this peaks and then it drops”, said two or three times in a level voice, gives the person something stable to orient to while their own thinking is offline.
Avoid four things in particular. Do not say “calm down”, which names the one thing they cannot do on request. Do not ask a run of questions, because each one demands processing they do not have available. Do not tell them there is nothing to worry about, since the fear is about their body rather than about the room. And do not announce the attack to everyone present, which adds an audience to an experience many people already find humiliating.
Silence is allowed. Standing quietly beside someone is a complete response, and it is frequently the one people say afterwards that they wanted.
After it passes
Expect exhaustion and expect embarrassment. The adrenaline surge is followed by a long flat tail of shakiness and tiredness, and if the attack happened in public most people are more preoccupied with who saw it than with the attack itself.
Make practical offers instead of analytical ones: water, a quiet room, a lift, a few minutes of ordinary conversation about something else. Asking someone to talk through what triggered it, while they are still shaking, is a demand dressed as care.
Later, when they are steady, one question is worth asking: has this happened before? Repeated attacks plus a month of worrying about the next one is the pattern that separates panic attacks from panic disorder, and clinical guidance treats that combination as the point at which treatment is indicated. [nice-cg113-panic-help] Our guide to how often panic attacks happen sets out what the frequency does and does not tell you.
When it is not panic, and needs medical attention
Treat it as medical the first time, every time. Chest pain, breathlessness and a hammering heart are shared by panic and by conditions that require urgent care, and panic is properly a diagnosis of what remains once those have been excluded.
Contact emergency services rather than waiting it out if the person has any cardiac history, if the chest pain spreads to the arm, neck or jaw, if they are confused or lose consciousness, if their lips or fingers look blue, or if the symptoms are still building after fifteen to twenty minutes without any sign of easing. An attack that keeps escalating past that window does not match the usual shape.
Nobody will think worse of you for calling and being wrong. The reverse error is much more expensive.
When to seek help
Encourage them to speak to a doctor if they have had more than one attack and have spent weeks worrying about another, or if they have started avoiding places because of them. Avoidance is the part that narrows a life, and it is also the part treatment reaches most reliably.
Suggest they ask about cognitive behavioural therapy by name. The version with the best evidence for panic deliberately brings on the physical sensations the person is frightened of, which sounds backwards and is the active ingredient, so it helps to know that going in. Our guide to CBT for panic attacks describes what those sessions look like.
Get a first episode of chest pain or breathlessness checked medically, even when panic seems obvious afterwards.
Go urgently if they have thoughts of harming themselves. Contact your local emergency services or a crisis helpline.
How MyFreud can help
Most of what a clinician needs to know about panic is the part nobody remembers accurately afterwards: how often the attacks come, what was happening beforehand, and how much of the week is spent bracing for the next one. MyFreud gives daily mood tracking that shows the pattern over time, so that record exists before the appointment rather than being reconstructed during it.
For the person doing the supporting, the useful part is different. Watching someone have a panic attack is frightening, and it repeats, and there is no obvious place to put that. Guided reflections give you somewhere to notice what it costs you, which is what makes it possible to keep being the steady one.
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