Did You Know It's Possible to Have a Panic Attack In Your Sleep?
It's the middle of the night, you're fast asleep and suddenly — you're jolted awake. Your heart is racing, you're shaking and sweating, and it feels as though the walls are closing in around you and you can barely breathe. What the hell? You may have just experienced a specific type of panic attack, similar to a night terror, known as a nocturnal panic attack.
The good news? Nocturnal panic attacks aren't necessarily going to hurt you — they're just scary and uncomfortable — and there are several treatment options to target this specific type of episode. Ahead, mental health experts break down everything you need to know about nocturnal panic attacks.
Alex Sandoval
What Is a Nocturnal Panic Attack?
At its most basic, a nocturnal panic attack is just that: a panic attack that happens at night. Sometimes known as sleep or nighttime panic attacks, a nocturnal panic attack occurs in lighter stages of sleep (vs. deep sleep) without any obvious triggers and often wakes the person up from their slumber, says Alex Dimitriu, M.D., founder of Menlo Park Psychiatry & Sleep Medicine. And unlike when you wake up from a nightmare, "there will be no recall of the dream" or what was making you panic while catching Z's, he explains.
Just like daytime episodes, nocturnal panic attacks typically fall under the panic disorder category, says psychiatrist Leela Magavi, M.D. ICYDK, panic disorder is a type of anxiety disorder characterized by unexpected and repeated episodes of intense fear that can technically occur at any time, according to the National Institute of Mental Health. These episodes (aka panic attacks) are typically accompanied by physical symptoms such as shortness of breath, chest pain, heart palpitations, dizziness, or abdominal distress. All of the above can occur during a nocturnal panic attack, but these nighttime occurrences can also involve sweating, trembling, chills, and a sense of impending doom, according to the Mayo Clinic. While daytime panic attacks "may sometimes have a clear trigger, it's not always clear what leads to a nocturnal panic attack," says Dr. Dimitru. However, "having panic attacks by day, and elevated anxiety and stress, will predispose people to nighttime panic attacks." (Related: Why You Should Stop Saying You Have Anxiety If You Really Don't)
It's important to note that nocturnal panic attacks are not specifically defined by the Diagnostic and Statistical Manual of Mental Disorder, the catalog of psychological conditions widely used by clinicians to diagnose patients. But research suggests that they "could be a relatively mild subcategory [of panic disorder] that may partially share common pathophysiology [psychological processes] with a night terror." (FTR, night terrors are defined by the Mayo Clinic as episodes of screaming, intense fear, and flailing while asleep. Unlike nocturnal panic attacks, they occur in deeper stages of sleep and won't necessarily wake someone up.)
In other words, it's unlikely (though not impossible) that you would only have panic attacks at night. This may be a helpful differentiator between night terrors and nocturnal panic attacks: Night terrors can exist on their own (sans a panic disorder or sleep issues), while nocturnal panic attacks tend to coexist with panic disorder and daytime panic attacks. If you have no history of anxiety and find yourself waking up shaking and rife with dread, it may have just been a stressful, scary dream — especially if you can recall some or all of the dream. If you experience a nocturnal panic attack, odds are you won't be able to remember exactly what precipitated the dreadful feeling. (Related: How to Sleep Better When Stress Is Ruining Your Zzz's)
Why Do Nocturnal Panic Attacks Occur?
It's "multifactorial," says Dr. Magavi, and it differs from person to person, based on underlying conditions, medical disorders, and psychiatric and family history. Nighttime rumination and stress, as well as anticipatory anxiety about what's to come tomorrow, can all contribute to and may precipitate a nighttime attack, she notes. (Related: Panic Attack Warning Signs — and How to Deal)
"If you leave stress and anxiety unaddressed or unmanaged because there is a physiological component to our flight or fight response, your body adjusts to living in hypervigilance and high alert mode," explains clinical psychologist Alfiee Breland-Noble, Ph.D. Your fight-or-flight responses — aka when your body's flooded with hormones in response to a perceived threat — aren't limited to our waking hours, she adds. If you turn on this response before sleep it can end up impacting your heart rate, breathing, sweating, and, yes, sleep. You might think of it as your body getting "stuck in overdrive," and that "the symptoms and triggers that you ignore or fail to respond to during the day can potentially begin to impact you at night," says Breland-Noble. (And while an ongoing fight-or-flight response can wreak havoc on your health it actually might be one of the reasons why one Shape editor was able to deal with COVID-19 panic.)
Anxiety, in general, can disrupt "sleep architecture" — aka the basic structural organization of typical sleep (e.g. REM, non-REM) — "and prompt individuals to wake up easily," she explains. Additionally, you could be actively suppressing stressful and anxious thoughts during the day, but you can't do that while you're counting sheep. "Individuals cannot consciously repress or suppress thoughts while they are sleeping," says Dr. Magavi. However, "dreams and nightmares can trigger panic attacks while sleeping."
Who Might Experience Nocturnal Panic Attacks?
While they can happen to anyone ("all ages and backgrounds"), some people are more predisposed to experiencing nocturnal panic attacks, including:
Those who suffer from PTSD-related nightmares. "Individuals with PTSD [post-traumatic stress disorder] may have nightmares about their trauma; these nightmares essentially replay what they endured," which may cause them to wake up "in a frightened state as they feel like they are reliving this trauma," explains Dr. Magavi. The nightmares could "lead to panic attacks while they are sleeping."
People who have general anxiety and panic disorder. "About 18 percent of panic attacks will occur during the night," adds Dr. Dimitriu, who says that nocturnal panic attacks are "common in people who also experience daytime panic attacks."
Those with sleep disorders. "Sleep apnea can result in sudden awakening due to inability to breathe, which could cause sweating, palpitations, and panic attacks," says Dr. Magavi. "Sleep-initiation and sleep-maintenance [forms of insomnia] can cause panic attacks as individuals begin to experience significant anxiety when they are unable to sleep." (Related: Could Sleep Anxiety Be to Blame for Your Tiredness?)
Treatment for Nocturnal Panic Attacks
If any of the above rings true for you, or you're interested in exploring nighttime anxiety further, it might be time to consult your practitioner. "Physicians and clinicians can diagnose panic disorder during an appointment based on the information the patient provides," says Dr. Magavi.
Some info you'll want to have on hand to share with your doc, according to Dr. Magavi: "When the symptoms originated, any potential triggers or life changes, family and personal history of anxiety disorders, somatic [meaning of or relating to the body] and psychiatric symptoms experienced, duration and frequency of attacks, anticipatory anxiety about having future attacks, etc." (Related: What Is High-Functioning Anxiety?)
A potential treatment plan could likely be similar to that for general anxiety and panic disorder, says Breland-Noble. "Typically, we encourage people to undertake the same practices they would for panic attacks and anxiety, like (possibly) seeing a professional who practices culturally-relevant cognitive behavioral therapy to learn coping and management skills, using contemplative practices like yoga and mindfulness meditation, or finding a close, trusted friend to decompress with after a hard day or moment," she says. Depending on the severity of your symptoms and overall mental health, a doctor might also prescribe medication to fight against generalized anxiety and, in turn, nocturnal panic attacks. (Seeing a therapist? Then they might recommend an M.D., who can determine the best pharmacological course of action in tandem with your other treatments, such as CBT.)
"With medication and therapy, panic attacks can resolve over time," agrees Dr. Magavi. "While anxiety disorders can cause distressing effects and affect one's daily functionality, it is important to remember that evidence-based treatments are available."
With that in mind, the following at-home tips may help address the anxiety that's could be causing your nocturnal panic attacks:
Diaphragmatic breathing. This type of breathing "can slow down some of the pathways implicated in anxiety, and help patients alleviate their fear," says Dr. Magavi. In fact, studies have shown that deep, belly-based breathing can actaully slow the autonomic nervous system, which regulates bodily functions (think: heart rate, blood pressure), thereby decreasing symptoms of stress and anxiety, according to the Mayo Clinic. (Related: Train Your Body to Feel Less Stressed with This Breathing Exercise)
Use anti-anxiety sleep tools. "Weighted blankets and white sound create a sense of safety and can psychologically mimic the feeling of being held and loved," says Dr. Magavi. "We all have our inner child who wants to feel safe and secure, and such extraneous factors help you achieve this feeling because they dissipate the impending sense of doom experienced during panic attacks."
Create a relaxing bedtime ritual. "Listening to calming music and recounting positive memories from the day can also help individuals attain a sense of peace," she says, "which in turn can focus one's mind on positive aspects of life and decrease ruminative thoughts that can trigger panic attacks." (BTW, reading these sleep books can also help you achieve a more zen mindset to score optimal shut-eye.)
Breland-Noble says she also encourages patients to incorporate "active coping" into daily life. "[This] simply means that one directly acknowledges and works to address their concerns, rather than averting one's attention from the problem to focus on other things that might not be as helpful (aka avoidant coping)," she explains. "Some examples of active coping include things like exercise, practicing good sleep and eating hygiene, and simple activities like journaling."
Dr. Drimitriu echoes these sentiments, emphasizing that day-to-day management can help. "Relaxing, de-stressing, exercising, meditating, and keeping a regular bed and wake schedule can help [with nocturnal panic attacks]," he adds. "Working on daytime panic attacks through both therapy and medication would be of benefit to people with nighttime panic attacks."
