Have you ever been awoken from sleep for no apparent reason (neither in response to a nightmare nor in response to any external event such as an alarm ringing or a bed-partner’s sudden movement)? Were you gripped by fear that you couldn’t explain, your chest tight, your heart racing, your breathing fast and uneven? Were you unable to return to sleep that night? Were you even afraid of going to sleep the next night due to the memory of that experience?
If so, what you experienced was probably a nocturnal panic attack. But what are they exactly? What causes them? And, perhaps most importantly, how can you cope with them and prevent them from occurring in future?
In this article, I’ll discuss the above questions and more. Although there are still many unanswered questions about these episodes, even in the scientific and medical communities, I’ll discuss what answers we do have in order to help you understand and deal with these terrifying experiences.
1. What is a nocturnal panic attack?(NPA)
A NPA is just like a daytime panic attack, except that it begins while you’re asleep: usually during non-REM sleep, and usually between a half hour and three and a half hours after falling asleep. Note that NPA’s are not the same thing as “night terrors”: people who have night terrors generally experience amnesia concerning these terrors and are able to return to sleep afterwards. In addition, unlike NPA’s, night terrors are often associated with physical activity—tossing and turning in bed, kicking and thrashing, and even screaming or running from the room are common reactions during night terrors.
2. Symptoms of NPA’s
If you have an anxiety disorder that causes you to experience panic attacks during the day, symptoms of NPA’s are usually the same as or very similar to those of your regular panic attacks: these symptoms can include increased heart-rate, hyperventilating, difficulty breathing, tightness in the chest, sweating, trembling, flushing, chills, and an inexplicable sense of impending doom.
Nighttime panic attacks can sometimes involve more breathing-related symptoms than daytime panic attacks—these include heavy breathing, rapid breathing, uneven breathing, and/or difficulty breathing. In addition, though not technically a symptom, NPA’s can be much more terrifying than the daytime variety. There are several reasons for this: first, since you’re immediately panicked upon awakening, your thoughts don’t have a chance to form clearly before the attack. In addition, you don’t have any warning signs preceding the attack that might allow you to prepare yourself or practice preventative tactics.
If you do not have an anxiety disorder and don’t suffer from daytime panic attacks, it is extremely unlikely that you will experience a panic attack at night. Among people with anxiety disorders, though, NPA’s are quite common. Though overall, they occur far less frequently than panic attacks during the day, 40-70% of patients who suffer from panic attacks will have at least one attack at night. Also, if you have an anxiety disorder and your usual panic-attack symptoms include breathing problems, you’re more likely to experience NPA’s than other anxiety-disordered individuals.
Finally, there are certain health conditions that, when coupled with a panic disorder, make a person more likely experience attacks at night. These health conditions are discussed in the next section.
4. What are the causes of NPA’s?
The causes of panic attacks in general are not fully understood. Among people with panic disorders, though, there are several possible causes. These causes include the following:
1. Obstructive Sleep Apnea
Obstructive sleep apnea occurs when a person’s upper airway is blocked during sleep, causing the person to stop breathing for as long as 30 seconds. In many cases, this is caused by excess fat and tissue around the neck area that, when not held in place by the throat muscles (for example, when the throat muscles relax during sleep), put pressure on the airway. The resulting increased carbon dioxide and lack of oxygen can cause symptoms that mimic those of heart disease.
While most people with obstructive sleep apnea wake up and go back to sleep when this happens (often without even realizing it), those with anxiety disorders can wake up in a panic due to symptoms like shortness of breath, tightness in the chest, etc.; triggering a full-blown panic attack.
2. Gastroesophageal Reflux Disease (GERD)
GERD, or acid reflux disease, can also cause symptoms that mimic more serious health problems: chest pains, difficulty breathing, night sweats, hyperventilation, etc. Again, these symptoms can cause people with anxiety issues to wake up in a panic, triggering a panic attack.
3. Hyperventilation Disorder
Many people who suffer from panic attacks develop hyperventilation disorder, a chronic breathing problem. Hyperventilation is a common symptom of panic attacks, and it’s also responsible for many other common panic attack symptoms. Although many people with hyperventilation disorder are able to breathe normally during relaxation (especially during sleep), for those individuals whose breathing problems are so severe that they hyperventilate in their sleep, this hyperventilation often causes them to wake up in the midst of a panic attack.
Note that none of these conditions alone can cause NPA’s. However, when these issues occur in individuals with panic disorders, the chances of having a nighttime attack increase significantly.
5. How to cope
Coping with an attack is after you have awoken from sleep is way more difficult than coping with panic attacks that occur during the day, because there is no warning and no time to prepare. However, traditional panic attack coping techniques can help with them as well.
When you wake up in a panic, don’t try to force yourself to ignore your symptoms and go back to sleep: this will only lead to frustration, failure, and aggravated symptoms. Instead, turn on a light and focus on the symptoms that you’re experiencing. Remind yourself that this is a panic attack, that there’s nothing truly life-threatening causing your symptoms. It can help to talk to yourself (even if you feel stupid); talking forces you to regulate your breathing and stops hyperventilation. It can also help to keep a “panic journal,” where you write down everything about your current attack: when it started, how you’re feeling, the symptoms you’re experiencing, any triggers you can think of, etc. This allows you to focus on your current experience as it is, rather than worrying about what it means (health conditions you’re afraid you have, your worries about future attacks, etc.).
One helpful tactic is to try to concentrate on your breathing and nothing but your breathing: draw in a deep breath through the nose, paying attention to the sensation of oxygen filling your lungs so that your belly and ribcage expand; then, slowly exhale through your mouth until your belly and ribs contract again. Continue this exercise until you can feel your heartrate begin to slow and other symptoms subside.
If you have been prescribed anti-anxiety medication to take as needed (certain fast-acting benzodiazapines, for example, can help stop your panic symptoms during an attack), take your medication as soon as you realize what’s happening to you. Unless you’re prescribed these specific as-needed anti-anxiety meds, though, do not try to self-medicate in an attempt to make your symptoms go away or to make yourself fall asleep. Again, this will only lead to failure, frustration, and further anxiety. The best thing you can do is whatever makes you most comfortable: in addition to the aforementioned breathing exercises, you might drink some soothing herbal tea, take a warm bath, etc. Your overall aim is to refuse to let your anxiety lead to any further panic (about the fact that you’ll be tired during work the next morning, etc.).
Unfortunately, the only way to prevent an attack is to treat the underlying medical conditions that cause them. Exercising, eating well, and losing weight can be extremely helpful. Losing weight can sometimes (though not always) prevent sleep apnea. In addition, if you’re tired at the end of the day from regular exercise, that can help you sleep through the night without hyperventilating.
Take GERD medications regularly to prevent attacks triggered by acid reflux disease if you’re worried that that’s a reason for your symptoms. Practice yoga and breathing exercises so that you’re more aware of your breathing throughout the day—this reduces the likelihood that hyperventilation disorder will wake you at night.
Finally, the best, most helpful thing you can do to prevent—or, at least, to mitigate the effects of—NPA’s that doesn’t involve treating underlying medical conditions is to practice controlling your daytime panic attacks. Whenever you have an attack, keep track of your symptoms, what triggered them, how long they last, what helps them, and so on; you can also work with your psychiatrist or psychologist to develop tracking and coping mechanisms. The better and more effective you are at dealing with daytime panic attacks, the more familiar you’ll be with your symptoms and the better you’ll be able to cope with any future nocturnal attacks.
NPA’s are one of the most terrifying experiences you can have; however, the more informed and prepared you are—about the disorder in general as well as your own particular reactions, symptoms, and triggers—the better you’ll be able to handle one if it does happen, and the more likely you’ll be to prevent them occurring again in future.