Nocturnal Panic Attacks: Symptoms, Causes, and Treatment

A nocturnal panic attack appears in the middle of the night and causes us to wake up in anguish, fear and intense discomfort. What other symptoms are associated with them? Why do they appear? Find out this and more!
Nocturnal Panic Attacks: Symptoms, Causes, and Treatment
Laura Ruiz Mitjana

Written and verified by la psicóloga Laura Ruiz Mitjana.

Last update: 19 April, 2023

Nocturnal panic attacks appear in the middle of the night. It’s the sudden appearance of fear and intense discomfort upon awakening, together with other types of symptoms. These types of attacks usually appear in the NON-REM phase of sleep, when we’re calmer and more relaxed.

They’re brief attacks, but when we wake up we can have the feeling that we’ve been like this for a long time. It isn’t about nightmares or night terrors and we must make a good differential diagnosis in this regard. What else are they characterized by? Let’s get to know its causes and treatment.

Nocturnal panic attacks: what is it?

Nocturnal panic attacks appear during the night, either at the beginning, during it, or when we’re about to get up. Its nature is the same as a regular panic attack, but what changes is the time of onset.

Panic attacks are sudden episodes of intense fear that cause severe physical reactions, when there’s no real or apparent danger. If they occur at night they’re called nocturnal.

In a panic attack, intense fear or discomfort appears temporarily, accompanied by another series of symptoms that start suddenly and reach their maximum expression in the first 10 minutes, as described in the Statistical Manual of mental disorders (DSM). The symptoms that accompany the episode are of 5 types:

  • Cardiopulmonary: the sensation of suffocation, for example
  • Autonomic: sweating, chills
  • Gastrointestinal: nausea, choking
  • Neurological: tremors, shaking
  • Psychiatric: derealization
Man with nocturnal panic attack.
During the night or before waking, this variety of panic attacks interrupts sleep.

Panic attack symptoms

There must be a minimum of 4 symptoms of a nocturnal panic attack in order to clarify the diagnosis. These signs are the following:

  • Palpitations: pounding of the heart or rapid heart rate.
  • Sweating: with trembling and shaking.
  • Choking: the feeling of difficulty breathing or choking.
  • Pain: discomfort in the chest or abdomen.
  • Nausea.
  • Dizziness: with unsteadiness, lightheadedness, or fainting.
  • Chills: or a sensation of heat.
  • Paresthesias: numbness or a tingling sensation.
  • Derealization: a feeling of unreality or depersonalization (separation from oneself).
  • Fears: of losing control, going crazy, or dying.

The fifth version of the DSM adds that the sudden onset of these symptoms can occur from a state of calm or from a state of anxiety. Depending on the intensity, the attack will vary in how disturbing it is and in how it interferes with the quality of the person’s sleep.

In order to speak of nocturnal panic attacks, it’s logical that the symptoms must appear throughout the night. The person who suffers from it wakes up anxious and afraid, manifesting some of the above signs.

You may feel out of place and confused, with anxiety, palpitations, and a feeling of uncertainty. After the attack, depending on the intensity of it, you may or may not be able to go back to sleep.

Causes of nocturnal panic attacks

We’re now going to talk about the explanatory models that have been proposed for anxiety. There are different types of these models, depending on their nature, orientation, and characteristics.

Biological models

On the one hand, we find biological models, which speak of a possible genetic predisposition to suffering from an anxiety disorder. In this sense, evidence is proposed in favor of the influence of hereditary factors as triggers of certain anxious episodes.

For example, in monozygotic twins, the chance of having a general anxiety disorder is 34%, against 17% in the case of dizygotic twins.

Within this group, we also find neurobiological models that establish alterations in some brain substances in people with anxiety disorders. These affect GABA (gamma-amino-butyric acid), noradrenaline (noradrenergic hypothesis) or serotonin (serotonergic hypothesis).

Learning theories

Learning theories have also tried to explain anxiety disorders, such as nighttime panic attacks. We always talk about a global look, but that could be applied to the alteration we’re dealing with now. In this case, there are four major models:

  • Classical Conditioning (Watson-Rayner): Anxiety is learned through a process of classical conditioning.
  • Bifactorial model (Mowrer): This states that anxiety is maintained by a combination of classical conditioning and operant conditioning procedures.
  • Law of incubation (Eysenck): This overcomes the limitations of the two previous models.
  • Theory of preparation (Seligman): The organism is phylogenetically prepared to associate or learn the relationship between stimuli with ease and this also applies in the case of anxiety.

Cognitive models

Cognitive models speak of certain attentional biases that make us pay more attention to threatening stimuli. This would explain some anxiety disorders. There are other models within this group that propose concerns associated with difficulties in inhibiting unpleasant stimuli as the cause.

Woman wakes up afraid at night.
The explanatory models of the disorder are varied and none have full validation to determine the etiology.

Possible treatments for nighttime panic attacks

We must state the difference between having a night panic attack and suffering from panic disorder. In the second case, it’s necessary for two or more attacks to have appeared, and that these have been unforeseen (as in the case of nocturnal ones).

It won’t be the same to treat someone with an isolated nocturnal panic attack (with which relaxation techniques can be used, for example, in addition to working to find the possible cause of the attack), as to treat someone with a panic disorder of that’s already been established.

In the case of panic disorders, the treatment of choice is one with a cognitive-behavioral multi-component. It includes different elements or techniques, such as live exposure to interoceptive stimuli and cognitive restructuring.

Other equally effective treatments for panic disorders (from the most to the least effective) are cognitive behavioral therapy, applied relaxation, exposure therapy, and pharmacotherapy. SSRI antidepressants (selective serotonin reuptake inhibitors) are used above all.

Talking to a professional is the correct approach

As we said, in the case of having nocturnal panic attacks from time to time (and if the diagnosis of panic disorder can’t yet be made), the approach will be different. It’s best to go to a specialist who can analyze the specific case and work to find the cause.

On the other hand, relaxation and breathing techniques (for example mindfulness, meditation, and diaphragmatic breathing) can be useful. Although, we insist, an optimal intervention will be one that’s provided by a specialized professional.

“Fear is not always bad, sometimes it works as a warning.”


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