Overview

Have you ever had an intense, unexpected feeling of terror, that came on suddenly and was followed by shortness of breath and a racing heart?

Panic attacks are swift periods of extreme fear that cause excessive physical and mental responses. Millions of people experience panic attacks every year, and it may seriously lower your quality of life. Panic attacks can occur at any time, with the two primary types being nocturnal and daytime panic attacks. Nocturnal panic attacks occur during sleep, often waking you suddenly, while daytime panic attacks happen during waking hours, mostly in response to stress or anxiety.

Understanding both nighttime and daytime panic attacks is important to tailor effective coping strategies and treatment approaches. This article will compare nocturnal and daytime panic attacks in detail, focusing on their features, causes, and treatment options.

Daytime panic attacks

Daytime panic attacks, as its name indicates, are panic attacks that happen during the day, when you are awake and usually going about your usual activities. It can cause unanticipated disruptions to your regular functioning, in contrast to nocturnal panic attacks, which occur during sleep. These attacks typically last 5 to 20 minutes, but can occasionally measure up to an hour. Their frequency ranges from once or twice a month to several times a week, depending on the severity.¹

Symptoms 

You may experience these symptoms if you are having daytime panic attacks:¹

• Rapid heartbeat
• Feeling faint and dizzy
• Intense sweating
• Nausea
• Chest pain or sensation of a heavy weight on your chest
• Shortness of breath
• Trembling or shaky limbs
• Hot flushes or chills
• Sensation of choking 
• Numbness or pins and needles
• Dry mouth
• Tingling sensation in the fingers
• Sense of detachment from the body
• Feeling of dread 
• Fear of dying
• Churning stomach
• Daytime tiredness
• Struggling to concentrate, leading to academic or work performance decline
• Mood swings, including irritability and low mood

What are the causes and triggers?

A panic attack occurs when the ‘fight-or-flight’ response is triggered excessively. Various factors can prepare your body for this response:¹

• Experts believe that dysfunction in the amygdala, which processes emotions like fear, can contribute to panic attacks. Moreover, imbalances in chemicals like GABA, cortisol, and serotonin in the brain may also contribute to why some people experience panic attacks
• Panic attacks are more likely to occur if you suffer from anxiety disorders, depression, or other mental health problems 
• Chronic stress causes the body to produce higher levels of stress chemicals like adrenaline, which also contribute to panic attacks
• Acute stress (eg traumatic event) can also influence it by releasing enormous amounts of stress hormones
• Habitual hyperventilation is another factor that disrupts blood gas balance due to low carbon dioxide
• People with phobias may have panic attacks concerning their particular fears
• Family history is another factor. A close family member, such as a parent, raises the likelihood by 40%
• Adverse childhood experiences or traumatic events occurred when you were a kid
• Conditions like diabetes, asthma, hyperthyroidism, and inner ear problems
• Intense physical exercise
• Excessive caffeine intake
• Some medications, like tranquillisers
• An unexpected change in surroundings, such as entering a stuffy, hot, or crowded space

Management and treatment

Cognitive-behavioral therapy (CBT)

CBT  is a type of oral therapy where you work with a mental health professional to identify what triggers your panic attacks, and then practise to modify thoughts, behaviours, and reactions, thereby reducing and eventually eliminating panic attacks.²

Exposure therapy 

It is another type of therapy, where you are gradually exposed to your triggering factors, both mentally and in real-life situations, thereby helping you to progressively build comfort and manage anxiety using relaxation techniques like breathing exercises.²

Medications

Antidepressants

Medications like SSRIs (e.g., fluoxetine, paroxetine) and SNRIs (e.g., duloxetine, venlafaxine) are prescribed to reduce the frequency and severity of panic attacks by affecting serotonin and norepinephrine levels.^1,2,

Anti-anxiety medications

Benzodiazepines, such as alprazolam and lorazepam, are commonly used due to their anxiety-relieving effects, although they should be used cautiously due to their potential for addiction.^1,2

Self-care practices

Healthily handling of stress is crucial for reducing daytime panic attacks. Some self-care practices include:^1,2

• Practising deep breathing: breathing in deeply and slowly via your nose, then softly exhaling the air through your mouth
• Muscle relaxation techniques: Reduce anxiety by progressively relaxing tense muscles, thereby promoting a sense of calm and presence
• Practising Mindfulness: Stay present and grounded during a panic attack by practising mindfulness, which helps anchor your thoughts in the current moment
• Acknowledgement is another practice. Recognise that a panic attack is temporary and not a health emergency to manage fear effectively
• You can also concentrate on something unrelated to your symptoms, and body while having a panic attack 
• Make lifestyle changes, such as paying more attention to sleep, exercise, and food
• Developing problem-solving skills

However, if you experience panic attacks frequently, it's critical to get medical attention, including medication and psychotherapy.^1,2 

Nocturnal panic attacks

Nocturnal panic attacks are sudden episodes of intense fear or discomfort that awaken you from sleep. These nighttime panic episodes can be very disturbing and cause anxiety even after they pass. Among the biggest challenges of these nighttime panic attacks is their sudden onset—one moment you’re asleep, and the next you are engulfed in panic.⁵ 

Symptoms

If you have an attack, it normally passes quickly, in less than 10 minutes. However, because there's a chance for extreme fear and confusion, it might feel longer. After the attack, you may also find it difficult to fall back asleep, and you might feel uneasy or anxious the entire time.

Panic attacks during the night have symptoms, that might include:^1,3

• Chest pain
• Chills /hot flashes or extreme sweating
• Extreme feelings of terror or  disorientation
• Trembling and shaking
• Rapid heart rate
• Dizziness
• Tingling or numbness sensation in the fingers or toes
• Nausea and feeling like you are about to vomit

What are the causes and triggers?

Common causes and triggers include:^3,4

• Sleep disorders like sleep apnoea or insomnia
• Anxiety and panic disorders: If anxiety persists during waking hours, it may extend into your sleep causing panic attacks
• Depression:  impacts both mental and physical health, potentially heightening nocturnal panic attack occurrences
• Intense emotional stress: feelings of stress, anger, or hostility, may not dissipate at bedtime and can manifest as nocturnal panic attacks
• Obsessive-compulsive disorder (OCD)
• Problems related to substance use, especially alcoholism
• Sleep terrors as a kid
• Breathing issues 

What are the complications?

Nocturnal panic attacks can lead to several potential complications, including:^3,4

• Impaired concentration and functioning
• Severe dysfunction and focus deficits
• Lowering mental health and a higher chance of suicidal thoughts
• Dependence on illegal substances
• Fear of going to sleep, which can lead to more sleep disturbances, insomnia, the occurrence of panic episodes throughout the day, and a worse quality of life 

Management and treatment

Cognitive-behavioral therapy 

CBT is successful in treating nocturnal panic attacks and lowering the frequency of panic episodes.^2,4  

Medications

Medications can be a helpful component of treatment for nocturnal panic attacks.^1,2,4

• Antidepressants (e.g., fluvoxamine, sertraline, amitriptyline) can assist in managing symptoms and lowering negative emotions both during and after panic episodes
• Benzodiazepines (e.g., lorazepam, diazepam) may be prescribed to aid with sleep and provide instant relief from anxiety. However, since benzodiazepines can be addictive, they are often taken sparingly and for short periods

When you take these prescriptions, carefully follow your doctor's recommendations. Inappropriate dosages, missed doses, or abrupt stops may worsen side effects, and impair your physical, and emotional well-being.

Self-care practices

Some self-care practices that can be useful are:^1,2,4

• Avoid caffeine, alcohol, and sugary foods before bed, since these can disrupt sleep and trigger panic attacks
• Practice calming activities like relaxation exercises, deep breathing, and meditation to lessen anxiety, enhance the quality of sleep, and assist in controlling the symptoms of nocturnal panic attacks
• Don't be afraid to discuss your experiences with others, such as friends, family, or professionals. By doing so, they can offer important support and can also help to lessen unpleasant emotions related to these attacks, like guilt and fear

Comparative analysis

Nocturnal panic episodes can cause sleep disruptions and change sleep patterns, which can lower the quality of sleep overall and increase the risk of insomnia. Whereas, daytime panic attacks disrupt everyday routines, may lead to avoidance behaviours, and have a different impact on social interactions and productivity at work than nighttime attacks. An average of 71% of individuals who experience panic episodes during the day also report having at least one nocturnal panic episode.⁴

Studies reveal that while the symptoms of daytime and nocturnal panic attacks are similar, those who have panic attacks at night report more severe physical symptoms, such as intense breathing symptoms, elevated heart rate, chest discomfort, and suffocating sensations. Moreover, while panic disorder with nocturnal and daytime panic episodes is more common in women, men have more nighttime panic attacks.^3,5

Summary

• Daytime panic attacks are sudden episodes of intense fear or discomfort during waking hours, often triggered by stress or anxiety, while nocturnal panic attacks occur during sleep, abruptly waking the individual and affecting sleep quality
• While the symptoms and triggers of both daytime and nocturnal panic attacks are mostly similar, the way they appear varies, affecting daily activities and sleep patterns 
• Both forms of panic attacks require tailored treatments such as cognitive-behavioral therapy, medications, and self-care practices
• Understanding the causes of these panic attacks facilitates the creation of individualised coping mechanisms, which in turn enhance the quality of life for individuals impacted