Diagnosis And Differential Diagnosis Of Nocturnal Panic Attacks

Introduction

What are nocturnal panic attacks (NPAs)?

Panic attacks happen when a person has a sudden feeling (mental or physical) of intense panic which can be very distressing.¹ 

Nocturnal panic attacks (NPAs) are when these symptoms happen at night, waking you from your sleep.² They are different from night terrors, nightmares or sleep apnoea.³

Panic disorders can have a big effect on the quality of life, leading to a lower feeling of overall health, trouble with relationships in one's personal life, difficulty maintaining employment, and trouble with finances. Therefore, panic disorders should be treated to help improve this as much as possible.⁴

Prevalence

NPAs are common in people who have panic disorder, with 44-71% of people who suffer from panic attacks during the day having at least one nocturnal panic attack.³ Panic disorders can come on at almost any age, but often they will become noticeable at about 30 years old.⁵

Understanding nocturnal panic attacks

What happens in a nocturnal panic attack?

If you have a Nocturnal Panic Attack, it will wake you suddenly from your sleep.²

Common symptoms include:¹

• Feeling as though you aren't in your body
• Fast heartbeat
• Pins and needles in your fingers
• Feeling like you are going to faint
• Feeling like you are dying
• Feeling like you are about to vomit
• Dry mouth
• Chest pain
• Feeling that you cannot catch your breath
• Dizziness
• Feeling as though you are choking
• Shaking
• Chills
• Hot flushes

Attacks like this usually last between five and twenty minutes. Some people have them several times a week, but others will have them much less regularly.¹ 

NPAs can feel horrible, but they are not dangerous and you do not normally need medical attention there and then.¹ People with NPAs may be more likely to feel as though they are choking than people having panic attacks during the day.⁶

Who is more likely to develop nocturnal panic attacks?

Panic disorders are more common in:⁵

• People with a stressful life
• People who are assigned female at birth (AFAB)
• People who are in poor health

Causes of nocturnal panic attacks

Some things can make NPAs more likely. These risk factors are discussed below.

Health problems

People with health issues (for example heart problems, asthma, and longstanding pain) are more likely to experience panic attacks.⁶

Childhood trauma

Patients who have a traumatic childhood are more likely to develop panic attacks than those with less stress in their early life.⁸

Family history of anxiety

If you have family members with panic disorders, it is more likely that you will develop them yourself.⁸ 

Relationship to parents

People who describe their childhood as lacking in love and affection, or who say that their parents restricted the things they could do during their childhood, are more likely to develop NPAs.⁸

Drugs and medications

People who drink lots of caffeine (eg. in coffee or energy drinks) or consume lots of nicotine (eg. from cigarettes or vapes) are more likely to have panic attacks.⁶

Diagnosis

You should make an appointment with your GP if you have symptoms of panic attacks as they can help you find treatment and also rule out other problems which could cause the above symptoms.¹

Medical history

Your doctor will ask you questions about your symptoms to help them to know how severe your panic attacks are.¹ Some people may experience panic attacks without having a panic disorder. These people are usually people with phobias (extreme fear) of certain things, eg. claustrophobia (fear of small enclosed spaces).⁷If someone with a phobia has a panic attack when they are faced with the thing they are afraid of, this is known as an expected panic attack and is not considered part of a panic disorder.⁷

Panic attacks in people with a panic disorder can happen at any time with no obvious cause.⁷ These are the kinds of panic attacks experienced by people with panic disorder.

Your doctor may diagnose you with panic disorder if you have unexpected panic attacks which come back several times, followed by at least one month of worrying that you may have more panic attacks.⁷

Health check

Your GP will also examine you physically to make sure that there is no other cause for the symptoms you are getting.¹

Differential diagnosis

There are many other issues which may disturb your sleep. Your doctor will help you work out which problem is causing the symptoms you are having. Here are some of the things your GP will rule out:

Post-traumatic stress disorder

Post Traumatic Stress Disorder (PTSD) is caused by very stressful or upsetting events in a person's past which the person may relive over and over again.⁹

People with PTSD may struggle to fall asleep and have nightmares about the incident which caused their PTSD.⁶ 

Night terrors

Night Terrors, like NPAs, can cause physical symptoms like hyperventilating (breathing too fast), fast heartbeat, sweating and the other problems listed above.⁶ People sometimes think that they are having night terrors when they are having NPAs, but they are different things.

Night Terrors usually happen in children five years old or under and they normally become less frequent as the child grows up.⁶ People with NPAs can be of any age.

When having Night Terrors, the person experiencing the problem does not wake up (even though they may move around, shout, open their eyes, sit up and appear very frightened). They also normally do not remember their terrors when they wake up in the morning.⁶ People with NPAs wake up when their symptoms kick in and they can remember the episode when they wake up in the morning, which can sometimes lead to a fear of sleeping.⁶ 

Obstructive sleep apnoea

People with obstructive sleep apnoea (OSA) struggle to breathe while sleeping. This is due to the muscles in their neck relaxing, which narrows (or even closes) the windpipe.⁶

Due to this lack of air, you will either come out of deep sleep to a lighter sleep, or wake up completely.⁶ Most people with OSA do not remember waking up in the night, so they may not know they have the condition.⁶ People with NPAs remember waking up in the night.⁶

People with OSA are more likely to develop NPAs than other people.⁶

Hyperthyroid problems

Some symptoms experienced in panic can be similar to symptoms that people go through if they have an overactive thyroid. These can include:¹⁰

• Difficulty sleeping
• Anxiety
• Tiredness 

Your GP may take a small blood sample of you to check your hormone levels to find out if there is a problem with your thyroid.¹¹

Heart attack

Sometimes someone having a heart attack has similar feelings to someone having NPAs. These symptoms can include:¹²

• Wheezing
• Pain or tightness in the chest
• Anxiety
• Dizziness
• Being unable to catch your breath
• Sweating

If you think you are having a heart attack, you should go to the hospital immediately.¹³

The doctors will usually perform tests where they measure how well your heart is working via small discs that they attach to your body, called an Electrocardiogram. This test doesn't hurt and takes about five minutes.¹³

They may also take a blood sample for you to test in the lab to see if you are having a heart attack.¹³

REM sleep behaviour disorder

When you are in deep sleep, which is usually when you dream (REM sleep), you cannot normally move. However, some people do move during this time and physically act out their dreams. This is REM Sleep Behaviour Disorder.¹⁸

This is different from NPAs as people with NPAs wake up, whereas REM Sleep Behaviour Disorder sufferers do not wake.

Reflux

If you have gastrointestinal reflux (heartburn), this can cause a burning feeling in the chest that wakes you up at night when stomach acid comes into the oesophagus (the tube from your mouth to your stomach).¹⁹ This is not the same as NPA.

Low blood sugar

If you are diabetic, hypoglycaemia (low blood sugar) can happen at night.²⁰ This can cause symptoms like: 

• Fast heartbeat
• Waking up from sleep regularly
• Nightmares
• Sweating
• Breathing faster or slower than normal
• Shaking

Your GP may do a blood test to see if you may have trouble with your blood sugar to rule this out.²¹

Treatment

There are a few ways that your doctor may treat your NPAs, once your diagnosis has been confirmed and they have ruled out other causes for the problems.¹⁴

Medications

Your GP may prescribe you medication to help reduce the number of panic attacks you experience.¹⁴ Some medication options are listed below.

Beta-blockers

These medications can reduce the heart rate, one of the physical symptoms of NPAs.¹⁵

Anti-depressants

Your doctor may prescribe anti-depressant tablets to help reduce your anxiety and hopefully reduce your panic attacks.¹⁴ 

Benzodiazepines

These medications are a mild sedative which helps to reduce symptoms of anxiety.¹⁶ However, they can only be used short-term as they can be addictive.¹⁴

Cognitive Behavioural Therapy (CBT)

CBT involves you talking to a counsellor who can help you to update your behaviour and thought process to reduce anxiety and control symptoms.¹⁷

Treating underlying problems

As covered above, some things make it more likely that you will experience NPAs. If your GP finds that you have one of these conditions, they may treat that first as a way of trying to reduce the chances of you experiencing NPAs again.³

Summary

NPAs are not fully understood and there is not much awareness of them. Further research is needed to better understand and treat NPAs.

However, diagnosis and treatments to help manage are available. Please speak to your GP if you feel you suffer from NPAs.