Nocturnal Panic Attacks

What are nocturnal panic attacks?

Panic attacks can occur during sleep as well as during waking hours. An episode of sudden fear at night should be assessed in context, including whether another health problem could explain the symptoms⁠^[1].

Panic disorder involves recurrent, unexpected panic attacks and ongoing worry or behavior changes related to further attacks. Attacks can occur during the day or during sleep; a nighttime attack alone does not establish a diagnosis of panic disorder⁠^[2][1].

The timing of panic attacks is one part of an assessment. A clinician also considers their frequency, ongoing worry, avoidance, and possible physical causes; nighttime symptoms should not automatically be treated as a separate disorder⁠^[3][4][1][5].

For example, panic disorder is more common in females than males, typically emerging in early adulthood⁠^[2], but nocturnal panic attacks without daytime panic attacks, is more common in males and above the age of 40⁠^[4]. Similarly, people with only nocturnal panic attacks may require different treatment to those with only daytime or daytime and nocturnal panic attacks⁠^[6].

As such, further research into these conditions is required to ascertain a clear picture of the causes, severity, and treatment of nocturnal panic attacks. These differences also highlight the importance of seeking professional advice and treatment to ensure symptoms are managed appropriately and effectively⁠^[4][6].

Symptoms of nocturnal panic attacks

Symptoms of nocturnal panic attacks are similar to those of a daytime panic attack, although studies have found that there is a greater occurrence of breathing difficulties and choking sensations during nocturnal attacks⁠^[3][5][7]. Other symptoms of nocturnal panic attacks may include⁠^[5][1]:

• Frequently waking at night, feeling a sense of intense fear or panic upon waking
• Physical symptoms such as sweating, shaking, chills, nausea, chest pain, dizziness, and rapid heartrate
• Feeling a loss of control
• Preoccupation with the idea of another panic attack occurring, causing fear and anxiety which may increase towards bedtime
• Feeling very tired during the day
• Difficulties with concentration and worsening academic or professional performance
• Mood changes, such as irritability and low mood

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Pat LaDouceur Ph.D.

Anxiety, panic, and relationship stress

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What causes panic attacks at night?

Daytime panic attacks may be caused by an environmental or external trigger or stressor⁠^[8]. However, these triggers do not occur during sleep, so the cause of nocturnal panic attacks is not clear.

While some contributing risk factors may be the same for both day and nighttime panic attacks, some may differ⁠^[4][9]. Risk factors contributing to the occurrence of nocturnal panic attacks may include:

• Coexisting mental health conditions: Panic disorder can occur alongside depression, other anxiety disorders, and substance misuse. An assessment should consider these conditions so that treatment addresses the person’s full needs⁠^[1][5].
• Gender: while panic disorder with night and daytime panic attacks is more common in females, it is more common for males to experience panic attacks only at night⁠^[4].
• Panic disorder: People with this condition may experience attacks at unpredictable times, including during sleep. Daytime attacks do not mean that nighttime attacks are inevitable⁠^[1][4].
• Sleep terrors as a child: research shows that there is a prevalence of childhood sleep terrors in those who experience nocturnal panic attacks as adults, suggesting similarities between the conditions, although night terrors occur in a different stage of sleep⁠^[4].
• Breathing issues: respiratory symptoms, such as shortness of breathand choking sensations, are more common in nocturnal panic attacks than those occurring in the daytime, suggesting that they may be linked to sleep-disordered breathing, such as sleep apnea⁠^[6][7].

What are the possible complications of nocturnal panic attacks?

Nocturnal panic attacks can cause ongoing sleep disruptions and may lead to:

• Severe impairments in concentration and functioning⁠^[6].
• Worsening anxiety, avoidance, or co-occurring depression that interferes with daily life⁠^[1][4].
• A reliance on prescription or illicit drugs to help with sleep.
• A fear of sleep, which can result in further sleep disruptions and insomnia, emerging or increasing prevalence of daytime panic attacks, and poorer quality of life⁠^[3][9].

How to manage nocturnal panic attacks

Many people who experience panic attacks feel reluctant to ask for help from loved ones or professionals because panic attacks are commonly misunderstood⁠^[6]. However, without appropriate treatment panic attacks are likely to continue and symptoms may worsen, so it is important to seek help⁠^[2].

Therapy

Psychotherapy, particularly cognitive behavioral therapy (CBT), can be an effective treatment for panic disorder and can help to reduce the occurrence of panic attacks. CBT aims to alter negative thoughts and behaviors and provide positive coping strategies, which can help to alleviate anxieties that may cause panic attacks and help to manage symptoms during an attack⁠^[1][9].

Medication

A doctor or mental health professional may prescribe medication to help manage the occurrence of nocturnal panic attacks. Antidepressants, such as fluvoxamine, sertraline, and amitriptyline, may be prescribed to help manage symptoms of panic disorder and help to reduce negative emotions that may occur during and following panic attacks⁠^[4][1].

Benzodiazepines, including anxiolytics such as lorazepam and diazepam, or hypnotics such as triazolam and zopiclone, may be prescribed to reduce acute symptoms of anxiety and aid in sedation⁠^[4]. However, these medications can be habit-forming, so are typically not prescribed long-term or may not be prescribed at all.

It is important to take medications exactly as prescribed by your doctor, as taking too much or too little, skipping doses, or suddenly stopping your medication can cause adverse effects and worsen your mental and physical health.

Self-care

If you experience nocturnal panic attacks, you may be able to reduce your symptoms by⁠^[1][8]:

• Avoiding caffeine, alcohol, and sugar, especially before bedtime, as these can all contribute to sleep disturbances and the occurrence of panic attacks.
• Engaging in calming activities such as relaxation exercises, breathing exercises, and meditation, as these can help to reduce feelings of anxiety and improve sleep quality, and can also be used to alleviate symptoms during a panic attack.
• Speaking to others about your symptoms, whether family and friends or professionals, as this can help to reduce negative feelings that may be associated with the condition, such as fear and shame, and can provide a helpful support system.