Panic Attack Coping Skills: What Helps in the Moment and What Keeps Panic Going

About this tool

Panic attack coping skills are the things you can do during a panic attack to stop feeding it. A panic attack is a sudden surge of intense fear with strong physical symptoms, typically a pounding heart, breathlessness, chest tightness, dizziness, tingling, sweating and a sense that something terrible is about to happen, that peaks within minutes. The skills that help share one principle: they work with the body rather than against it. Anything that treats the sensations as an emergency to be fought, fled or suppressed tends to make the attack stronger and longer. That is not a slogan; it is the mechanism.

The mechanism is the panic cycle, described by David Clark in 1986 and still the basis of the best-supported treatments. A sensation arrives: a skipped heartbeat, a breath that catches, a wave of lightheadedness after standing up. The mind reads it as catastrophic: I am having a heart attack, I cannot breathe, I am going to faint, I am losing my mind. That interpretation triggers the fear response, which releases adrenaline, which produces more of the very sensations that started it. The loop runs faster each time around. Over-breathing often sits inside the loop too: fast, shallow breathing lowers carbon dioxide in the blood, which causes dizziness, tingling and chest tightness, which read as further evidence of danger.

This is why fighting the attack backfires. Gasping for more air deepens the over-breathing. Bracing the muscles increases chest tightness. Fleeing the supermarket ends the attack, but teaches the brain that the supermarket was dangerous and that leaving is what saved you, so the next visit starts from a higher baseline. Repeatedly checking your pulse, or sitting by the exit so you can leave at the first sensation, are safety behaviors; they feel protective and they keep alive the belief that the sensations are dangerous. The honest line that makes the skills possible is this: a panic attack peaks and falls on its own, usually within about ten minutes, because the adrenaline surge is self-limiting. Residual shakiness can last longer, but the peak passes whether or not you do anything. Prescribed medication is not in this category: if you carry rescue medication, that is a treatment decision for you and your prescriber, not a habit to drop on your own.

The skills, then, are about not adding fuel. Slow the exhale: breathe in through the nose for a count of four and out for a count of six, which is the opposite of what panic wants and gently reverses the over-breathing. Ground your senses in the room, naming what you can see and feel, so attention has somewhere to go that is not your heartbeat. Name it accurately: this is panic, it is unpleasant and it is not dangerous. Stay where you are if it is safe to, and let the wave crest and fall. Drop the safety behaviors one at a time. Some people find that focusing on the breath makes them more aware of breathlessness and more anxious; if that is you, use grounding instead and let the breathing take care of itself.

What the evidence supports is clear at the level of treatment and more modest at the level of individual skills. Cognitive behavioral therapy for panic disorder, in the forms developed by David Barlow and Michelle Craske and by Clark, has strong trial support and is recommended as a first-line treatment by NICE in the UK and by equivalent bodies elsewhere. A core part of that treatment is interoceptive exposure: deliberately bringing on the feared sensations (spinning in a chair, breathing through a straw, running on the spot) in a safe setting until the brain learns they are harmless. That is treatment, not first aid, and it is best done with a therapist. Breathing retraining on its own has mixed results, and some studies found it added little to CBT. A longer exhale is still worth doing because it is cheap and interrupts over-breathing, but it is a coping skill, not a cure for the pattern.

A first-ever episode needs a medical check before it is treated as panic. Chest pain, a racing or irregular heartbeat, breathlessness and faintness can also be signs of cardiac problems, thyroid disease, asthma, low blood sugar, anemia, or the effects of caffeine, stimulants, alcohol withdrawal and some medications. A doctor can rule these out quickly, and once they have, you can treat future sensations as panic with much more confidence. Equally, if attacks are already diagnosed and a new symptom appears that does not fit your usual pattern, get it checked rather than assuming.

These skills suit anyone with recurrent panic attacks, whether the attacks stand alone or come with agoraphobia, social anxiety, PTSD or health anxiety. They also help people who have had a single attack and want not to have a second, since fear of the next attack is itself part of the loop. They are not enough on their own for panic disorder, which is defined by repeated unexpected attacks plus at least a month of worry about them or changed behavior to avoid them. Nocturnal panic, attacks during withdrawal from alcohol or sedatives, and panic that comes with thoughts of harming yourself all need a clinician rather than a card.

The common mistakes are predictable. Taking big breaths in through the mouth. Leaving at the peak, which teaches escape. Waiting until the attack is at full intensity before using a skill, when the skills work best at the first signs. Checking the pulse, or the symptoms on a search engine, mid-attack. Avoiding exercise because it raises the heart rate, which shrinks life and makes a raised heart rate feel ever more alarming. Using alcohol to settle the nerves, which rebounds. And treating a coping card as the treatment, so that attacks continue for years when a course of CBT could have ended them.

If panic attacks are recurring, or you have started avoiding places and activities because of them, a therapist trained in CBT for panic can treat the pattern rather than the moment, usually in a matter of months. SSRIs and some other medications are also used and can be combined with therapy; whether to start, change or stop a medication is a conversation with a prescriber, not something to decide from a web page. The Anxiety Cycle page explains the avoidance loop in more detail, the Interoceptive Exposure worksheet shows what the treatment version looks like, and the Grounding Techniques and 4-7-8 Breathing pages give you more to practice while calm.

Reviewed by Michael Callans, MSW
Reviewed the panic cycle explanation, the in-the-moment skills and the medical-first caution for accuracy and fidelity to CBT for panic.

References

1. Clark DM. A cognitive approach to panic. Behaviour Research and Therapy. 1986;24(4):461-470.
2. Barlow DH, Craske MG. Mastery of Your Anxiety and Panic: Workbook. 4th ed. Oxford University Press; 2007.
3. Meuret AE, Ritz T. Hyperventilation in panic disorder and asthma: empirical evidence and clinical strategies. International Journal of Psychophysiology. 2010;78(1):68-79.
4. National Institute for Health and Care Excellence. Generalised anxiety disorder and panic disorder in adults: management. Clinical guideline CG113; 2011, updated 2020.
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed., text revision. American Psychiatric Association Publishing; 2022.

Panic Attack Coping Skills FAQ