Nocturnal Panic Attacks: Symptoms, Causes, and Treatment

Written by Dr. Paul Kelly, C.Psych.              March 12, 2024

Table of Contents

• Micheal’s Story
• Key Facts About Nocturnal Panic Attacks
• 13 Symptoms of Panic Attack
• Is It Nocturnal Panic or a Medical Condition?
• When to Get a Sleep Study
• Self-Help Tips for Nocturnal Panic Attacks
• Supporting Your Partner Through Nocturnal Panic Attacks
• Assessing Nocturnal Panic Attacks
• Medication Treatment for Nocturnal Panic Attack
• Psychotherapy Treatment for Nocturnal Panic Attack
• A Personal Note

 

Nocturnal Panic Attacks: Michael’s Story

Michael woke up terrified and gasping for air. His partner and cats stayed asleep. The room was quiet. Michael was having a Nocturnal Panic Attack. Here is what he said about it:

1. Sudden Awakening

“I was jolted out of a deep sleep. It just happened. I felt terrified.”

2. Physical Sensations

“My heart was pounding. My throat was tight. It was hard to breathe. I was choking. My skin was hot and sweaty.”

3. Flood of Thoughts

“I thought I was going to die. My mind was racing. I had a thousand thoughts. ‘Why is this happening? Am I dying? What if I can’t calm down?’”

4. Duration and Aftermath

“It was over in minutes, but it felt like forever. My heart slowed down. The tightness eased off. I could breathe again. After the terror stopped, I was exhausted and wired.”

5. Struggle to Return to Sleep

“I couldn’t get back to sleep. I was scared of another panic attack.”

 

Has anything like this happened to you or to someone you care about?

If so, let me help you.

This article tells you what you need to know about nocturnal panic – and how to overcome it.

 

Key Facts About Nocturnal Panic Attacks

1. Nocturnal panic attacks are brief. They usually last 2-8 minutes.
2. They usually happen one to three hours after going to sleep.
3. They are common in people who have waking panic attacks or PTSD.
4. Nocturnal panic attacks can cause chronic insomnia. People are afraid to go to sleep.
5. You can learn to cope with them – so they stop or happen less often.

 

13 Symptoms of Panic Attacks

These symptoms apply to both waking panic attacks and nocturnal panic attacks.

Panic attacks are intense episodes of fear or discomfort that happen suddenly and without warning. Mental health professionals use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), to diagnose mental health conditions.

The DSM-5 lists 13 possible symptoms for panic attacks. Check the list. If you have 4 or more symptoms, you may meet the diagnostic criteria for panic attacks.

1. Palpitations, Pounding Heart, or Accelerated Heart Rate: Your heart is racing, thumping, or skipping beats. This is a common start to a panic attack.
2. Sweating: Unexpected, intense sweating unrelated to physical exertion or heat.
3. Trembling or Shaking: Uncontrollable trembling or shaking. Your hands might be the first thing you notice.
4. Sensations of Shortness of Breath or Smothering: You can’t breathe, even with enough air in the room.
5. Feelings of Choking: You feel your throat is closing or you’re choking on something invisible.
6. Chest Pain or Discomfort: You have sharp or persistent chest pain.
7. Nausea or Abdominal Distress: Your stomach is upset. You feel sick or you have abdominal pain.
8. Feeling Dizzy, Unsteady, Light-headed, or Faint: You have a dizzy spell or feel like passing out.
9. Chills or Heat Sensations: You get sudden chills or hot flushes. Your body can’t regulate its temperature.
10. Paresthesia (Numbness or Tingling Sensations): You notice tingling or a numb sensation, often in the hands, feet, or face.
11. Derealization (Feelings of Unreality) or Depersonalization (Being Detached from Oneself): It feels like you or your surroundings aren’t real. It is like you were in a dream or were looking at yourself from outside your body.
12. Fear of Losing Control or “Going Crazy”: You have a strong fear that you might lose control of yourself or your actions. Or you feel close to a mental breakdown.
13. Fear of Dying: You feel that you’re about to die. This is terrifying even though you are actually safe.

 

 

Is It Nocturnal Panic or a Medical Condition?

Nocturnal panic attacks are psychological. They are caused by anxiety. Other conditions can also disturb your sleep. The main ones are night terrors, sleep apnea, sleep paralysis, and seizures. Learn about them to decide if you need to talk to your medical doctor.

Night Terrors

Night terrors are also known as sleep terrors. They are episodes of screaming, intense fear and flailing while still asleep. These episodes can be alarming to witness and confusing to experience.

Characteristics of Night Terrors

1. Sudden Awakening

Individuals experiencing night terrors often abruptly sit up in bed. Although they appear to be awake, they are still deep asleep.

2. Intense Fear and Agitation

People feel profound fear and distress. They often scream or cry.

3. Physical Signs

Physical signs such as rapid heartbeat, heavy breathing, and sweating are common during night terror.

4. Limited Responsiveness

People experiencing night terror often don’t respond when you try to comfort them or talk to them.

5. Lack of Recall

People typically have little to no memory of the episode after they wake up. This is different from nightmares.

6. Duration

Night terrors can last anywhere from a few seconds to several minutes. Then, some people can go back to sleep. Others can’t.

 

Sleep Apnea

Sleep apnea is characterized by pauses in breathing or periods of shallow breathing during sleep. These interruptions are known as apneas. They can last from a few seconds to minutes.

They may occur many times throughout the night. The most common form is Obstructive Sleep Apnea (OSA). It involves a physical blockage of airflow.

Another form is Central Sleep Apnea (CSA). In CSA the brain doesn’t send proper signals to muscles that control breathing.

Key Features of Sleep Apnea

1. Breathing Interruptions

Breathing stops completely or becomes markedly shallow. Often a partner notices the breathing problem. The person often does not.

2. Gasping or Choking During Sleep

Sudden gasping or choking noises when breathing resumes. This can disturb sleep.

3. Restless Sleep

Frequent awakenings or tossing and turning in bed. Sleep is disturbed.

4. Daytime Fatigue

People with sleep apnea are often very drowsy or tired during the day. Their sleep quality is poor, so they are not rested.

5. Morning Headaches

People with sleep apnea often wake up with headaches. This is because of low oxygen levels during the night.

6. Difficulty Concentrating

Sleep apnea can cause memory problems or concentration difficulties.

7. Loud Snoring

Loud and chronic snoring are common signs of sleep apnea. However, not everyone snores when they have sleep apnea.

 

Sleep Paralysis

During sleep paralysis, the person is conscious, but they can’t move or talk. Often, they have vivid hallucinations and a sense of dread. Sleep paralysis can happen by itself. Sometimes, it is linked to other sleep disorders, such as narcolepsy.

Key Features of Sleep Paralysis

1. Immobility

During an episode, the person is fully conscious but they can’t move or speak. The paralysis can last several seconds to a few minutes.

2. Transition Phases

Sleep paralysis usually occurs as someone falls asleep or wakes up. The first type is called hypnagogic, and the second is called hypnopompic.

3. Hallucinations

Many people experience vivid and frightening hallucinations during sleep paralysis. It is like being in a Virtual Reality machine that seems real. You can see, hear, and touch in the hallucination. This used to happen to a friend of mine. It really spooked her.

4. Sensations of Pressure

Pressure on the chest is very common. It feels like someone is sitting on your chest. It is hard to breathe. Choking is also common.

5. Lack of Control

People feel wide awake, but they can’t move their body at all. This can be very scary.

6. Brief Duration

Most episodes of sleep paralysis are brief. They usually end on their own. Sometimes, a partner wakes the sleeper.

 

Seizures

Nocturnal seizures are episodes of abnormal electrical activity in the brain during sleep. Focal seizures affect one part of the brain. Generalized seizures involve the entire brain.

Seizures can cause unusual movements during sleep. Sometimes, these movements cause injuries. Seizures can also cause confusion, headaches, or bedwetting.

 

When to Get a Sleep Study

Do you frequently have sleep disturbances? Are they severe? If so, I recommend that you obtain a sleep study. This overnight study monitors various bodily functions during sleep, including brain waves, oxygen levels in your blood, heart rate, breathing, and eye and leg movements.

A sleep specialist can help to clarify your diagnosis and provide advice and treatment recommendations. Mental health professionals like psychologists and psychotherapists can help for nocturnal panic attacks. For the other sleep disturbances, you should get medical advice.

 

 

Self-Help Tips for Nocturnal Panic Attacks

You can do things to cope with nocturnal panic attacks. I’ll break it down for you: What to do when you wake up in a panic. How to prepare for sleep. What to do after the panic attack eases off.

Try these tips. My clients use them, and they feel more in control and less scared about panic attacks.

Immediate Steps During a Nocturnal Panic Attack

1. Recognize and Accept: When you first wake up, say these 3 things out loud: 1) You are having a panic attack. 2) It will pass soon. 3) You are safe.This self-talk will help you regain control. When you talk to yourself, use the pronoun ‘you’ rather than ‘I.’ It will work better.
2. Focused Breathing: You can help your body calm down by doing a breathing exercise. Try this “4-7-8” technique. Inhale through your nose to a count of 4. Hold your breath for a count of 7. Then exhale through your mouth to a count of 8. Repeat the cycle 4 times. Try it now while you are awake and calm. Are you willing to practice a bit more? Think about a panic attack, so you feel a little upset. Then, do the breathing exercise again. Keep repeating it until your mind and body are calmer.
3. Grounding Techniques: It helps a lot to remind yourself that you are physically safe. Use a grounding technique to remind your brain that you are not in danger. Touch your bedding. Feel the texture of the cloth. Say, ‘I am here. I am safe.’ Give yourself a gentle hug. Say, ‘You are in your room. It was just a scare. It will pass.’

 

Preparing for Sleep

1. Establish a Relaxing Bedtime Routine: Create a pre-sleep ritual that promotes relaxation. Read a physical book. Take a warm bath, or do a few gentle yoga stretches. This can signal to your body that it’s time to wind down. Avoid screen time for at least 30 minutes before sleep.
2. Limit Stimulants: Avoid caffeine, nicotine, and heavy meals close to bedtime. They can exacerbate anxiety and disrupt sleep patterns.
3. Create a Comfortable Sleep Environment: Set your bedroom up so it is cozy. Try one of the sleep podcasts with gentle music or nature sounds. Use a sleep mask or blackout curtains to darken the room.

 

Strategies for Post-Attack Calm

1. Mindfulness and Relaxation Techniques: Practice mindfulness or meditation to calm your mind. Apps or guided audio recordings can be helpful tools.
2. Journaling: Keep a notebook by your bed. If you’re too agitated to return to sleep, write down what you’re feeling and thinking. This can help you to process the experience. When you write it down, it is out of your head. Tell yourself that you will look at it in the morning. Then do one of the exercises like focused breathing or use a calming app.
3. Gentle Activity: Get up until you feel sleepy. Make a cup of herbal tea or warm milk. Sit in a chair to read a physical book or listen to soothing music. You will be tempted to look at your phone or another screen. Scrolling on a screen will keep you awake longer. Try something else instead.

 

More Self-Help Tips for Nocturnal Panic Attack

I know you wish that the nocturnal panic attacks would just stop happening. However, if you try to push them away or ignore them, they will keep happening.

Instead of avoiding them, try to accept them and work with them. Acceptance does not mean that you ‘like’ it. It just means that you face it and try some new things to help yourself.

First, review the Recognize and Accept tip: Say these 3 things out loud:

1. You are having a panic attack.
2. It will pass soon.
3. You are safe.

These are acceptance statements. Stop reading and say them out loud now. When you do this, you are giving your brain instructions.

Why talk out loud to yourself? It works better than just saying things in your head. Use a calm, steady voice like you are talking to the child part of yourself.

Then try the other tips. It is also okay to get some support from other people. We discuss this in the next sections: how your partner can support you and how to pick a therapist or other treatments.

 

Supporting Your Partner Through Nocturnal Panic Attacks

Partners often wake up when they hear their loved one panicking at night. If they know what to do, partners will be less afraid. They can also really support the panicky person with some simple steps. Here is what to do and what to avoid doing.

How to Help Your Partner During a Nocturnal Panic Attack

1. Stay Calm: Your calmness will help them get their bearings sooner.
2. Offer Reassurance: Remind them they are safe. Tell them the panic attack will pass soon. Use a soothing tone of voice.
3. Focus on Breathing: Encourage them to do the 4-7-8 focused breathing from the Tips section. Breathe with them. That helps a lot.
4. Create a Comforting Environment: Dim the lights. Play soft music. Offer a comforting touch. Remind them to be mindful of sensations and their surroundings. You can help them feel grounded.
5. Be Patient: It might take some time for the panic attack to subside. Offer your presence and support, and don’t pressure them to snap out of it.

 

What to Avoid During a Nocturnal Panic Attack

1. Don’t Dismiss Their Experience: Don’t minimize their feelings. Don’t say that it’s ‘just in their head.’ Let them have their experience and gently direct them to start the breathing exercise.
2. Avoid Overwhelming Questions: Asking too many questions during the attack can increase their panic. Save discussions for later, when they are calm.
3. Don’t Be Pushy or Aggressive: Unless they are in danger, don’t restrain them or be too forceful in your attempts to help. Gentle guidance is best. Use a calm voice. Be reassuring. Guide them to do focused breathing.

 

What to Do After a Nocturnal Panic Attack

Your role is to support your partner, not to fix them. Give them a safe place to talk about their experiences and fears. If you think that they need professional help, encourage them to find an effective therapist.

 

Assessing Nocturnal Panic Attacks

Health professionals all recommend assessment methods. These assessments help them understand you and your problem. I have included this list so you will know what to expect.

Recommended Assessment Methods

1. Detailed Medical History: The first step is a thorough review of your medical and psychological history. This includes any past or present mental health conditions, medications, and a detailed account of your sleep disturbances and panic episodes.
2. Symptom Diary: You might be asked to keep a detailed diary. It would cover your sleep patterns, panic attack occurrences, and any potential triggers or preceding events can be incredibly informative.
3. Physical Examination: A physical check-up can rule out other conditions that might mimic or contribute to the symptoms of nocturnal panic attacks, such as thyroid issues or heart conditions.
4. Psychological Evaluation: A psychologist might do a formal diagnostic assessment. This could include a detailed interview and psychological testing. The assessment would clarify whether you have a panic disorder or another kind of anxiety disorder. It would also help to make sure that nothing was missed.
5. Sleep Study or Polysomnography: This overnight study monitors various bodily functions during sleep, including brain waves, oxygen levels in your blood, heart rate, breathing, and eye and leg movements. Understanding these aspects can help differentiate between panic attacks and other sleep disorders, leading to more effective treatment strategies.

 

Medication Treatment for Nocturnal Panic Attack

The National Institute of Mental Health (NIMH) mentions several types of anti-anxiety medication. These include Selective Serotonin Reuptake Inhibitors (SSRIs), Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs), benzodiazepines, and beta-blockers. For medication advice, consult with a physician, psychiatrist, or nurse practitioner.

Most people prefer to try psychotherapy rather than medication. Psychotherapy is not addictive. Psychotherapy does not have any side effects. Psychotherapy also continues to help after you stop treatment. You get to keep using your new skills and insights to live better. Symptom relapse is very common after people discontinue anti-anxiety medication.

Psychotherapy Treatment for Nocturnal Panic Attack

Why This Matters: This advice will help you make a good choice for yourself.

There is no shame in asking for professional help. I worked with a therapist when I hit a tough patch in my life. It was a good choice. Read on and learn more, so you can make a good choice for yourself.

Here is the Good News: Psychotherapy is a very effective treatment for Nocturnal Panic Attacks. Check the list below. Which type of therapy feels right for you? They are all safe choices. All these types of therapy can help you overcome your panic attacks. They all work by helping you to recalibrate your brain. Then, your emotional reaction to situations will be appropriate to the situation—not an anxious or panicky overreaction.

Here is a Tip: Your nocturnal panic attacks can start to improve when you give your brain new experiences to learn from. This means trying new things before you go to sleep and after you wake up from a panic attack. Your therapist can help guide you – what to start with and how to build on success. When you experiment and try something new, then your brain changes. This change is possible because of neuroplasticity. You are never too old to learn something new.

Here is Second Tip: Make sure you find a therapist who feels right for you. Who your therapist is matters more than the type of therapy. If your therapist is rigid, passive, cold and distant, or disorganized, then you need a new therapist. Check my article about this for more advice.

Here are some helpful types of psychotherapy for anxiety problems including nocturnal panic attacks.

1. Cognitive Behavioral Therapy (CBT):This practical therapy helps you challenge negative thoughts. Then you can make better choices and try new things. Your mental wellbeing will improve.
2. Acceptance and Commitment Therapy (ACT):ACT uses acceptance and mindfulness strategies. You learn to live according to your personal values, with kindness for yourself. ACT can be very helpful for anxiety problems.
3. Unified Protocol for Transdiagnostic Treatment of Emotional Disorders:(I wish this treatment had a shorter name!) It combines mindfulness with CBT, behavioral activation, and acceptance. It is a structured therapy and can be very helpful for anxiety problems. I teach this approach to all of my new therapists.

 

All three of these types of therapy can help for nocturnal panic attacks. Research shows that these approaches are safe and effective. The therapists at my Clinic have had good success with these approaches. When you meet with a therapist, ask them what approach they use. They should be able to explain how the approach will help with your problem.

 

A Personal Note

I have not had nocturnal panic attacks, but someone close to me had a terrible time with them. She had a sleep study, and it showed that she had sleep apnea. She needed a CPAP machine, not psychotherapy.

After she started using the machine, her breathing improved, and she stopped having panic attacks. Her story shows that it is important to get a proper diagnosis.

If a sleep study confirms that you have nocturnal panic attacks, don’t despair. Find a good therapist and learn how to overcome panic symptoms.

I care a lot about helping people with anxiety problems because I had phobic anxiety when I was a kid. When I was 9 years old a car hit me while I was riding my bicycle. I was almost killed. After I got out of the hospital, I could not cross the road if I saw any cars.

My brain was hypersensitive to danger. It predicted that any moving car would hurt me. My parents were not therapists, but they gave me some practical advice. They told me to try crossing when a car was far away.

I was anxious, but I still started to try something new. Little by little, my fear decreased. My brain learned how to recognize a safe car distance. I was doing exposure therapy, and I didn’t even know it.

Eventually, the phobic anxiety went away, and I could buy ice cream without having it melt before I got home. You have my sympathy if you have nocturnal panic attacks. Remember, this problem can be tamed so it doesn’t control your life.

Improvement is possible. You can learn to have fewer attacks and to be less distressed by them. You have a right to enjoy your life. I wish you well.

 

Sources

It is important to me that you find practical and trustworthy information. That is why I personally selected and reviewed all the sources for this article. My advice is also based on my own experience with anxiety and my decades of experience. I have treated thousands of clients and trained and mentored hundreds of therapists and psychologists. The therapy approaches I recommend are used at my Clinic. We track progress, so I know that the techniques can help.

• Craske, M.G. & Tsao, J. Assessment and treatment of nocturnal panic attacks. Sleep Medicine Reviews. 2005. Retrieved from: https://www.sciencedirect.com/science/article/abs/pii/S1087079204001078
• Kaczkurkin, A. et al. The association between insomnia and anxiety symptoms in a naturalistic anxiety treatment setting. Behavioral Sleep Medicine. 2020. Retrieved from: https://doi.org/10.1080/15402002.2020.1714624
• Nakamura, M. et al. Is nocturnal panic a distinct disease category? Comparison of clinical characteristics among patients with primary nocturnal panic, daytime panic, and coexistence of nocturnal and daytime panic. Journal of Clinical Sleep Medicine, 2023. Retrieved from: https://jcsm.aasm.org/doi/full/10.5664/jcsm.2666
• Smith, N. et al. Comparing symptom networks of daytime and nocturnal panic attacks in a community-based sample. Journal of Anxiety Disorders. 2022. Retrieved from: https://doi.org/10.1016/j.janxdis.2021.102514
• Vanek, J. et al. Obstruction sleep apnoea and panic disorder. 2023. Retrieved from: https://www.nel.edu/userfiles/articlesnew/1685917487_44_2_vanek_86-pdf.pdf
• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (fifth edition.). Arlington, VA.
• Barlow, D.H. et al. Unified Protocol for Transdiagnostic Treatment of Emotional Disorders, Workbook. Oxford University Press, 2018.
• Barlow, D.H. (Editor). Clinical Handbook of Psychological Disorders: A Step-by-Step Treatment Manual, (sixth edition). The Guilford Press, 2021.
• National Institute of Mental Health. Anxiety Disorders (April, 2023). Retrieved from: https://www.nimh.nih.gov/health/topics/anxiety-disorders.