Panic attacks and agoraphobia

What a panic attack is

A panic attack is a sudden surge of intense fear that peaks within a few minutes — usually under ten — and then recedes.

It almost never arrives at a moment of danger. It arrives in a queue, on the metro, in a supermarket, while driving, sometimes while watching television. That's part of what makes it frightening: there's nothing around you that explains what's happening.

A great deal happens in the body, all at once: the heart races, breathing becomes short or laboured, and with it the sense of not getting enough air. Dizziness, light-headedness, tingling in the hands or around the mouth. Sweating, trembling, chills or flushes. Nausea or a tightness in the stomach. Sometimes chest pain or pressure.

And a great deal happens in the mind: the sense that something irreversible is about to occur. Fear of dying, of having a heart attack, of fainting, of losing control, of going mad. Or something harder to put into words — that the surroundings aren't quite real, or that you aren't quite yourself.

People going through it for the first time often call an ambulance or go to A&E. That's a reasonable response: what the body is doing looks a great deal like a medical emergency.

Why the body does this

What happens in a panic attack isn't a malfunction. It's an alarm system firing at full strength, at the wrong moment.

The body is preparing for a threat: sending blood to the large muscles, raising the heart rate, speeding up breathing to take in more oxygen. It's the same response that would be useful if there were genuinely something to run from.

Rapid breathing alone accounts for several of the symptoms. Breathing faster than needed lowers carbon dioxide in the blood, which produces tingling, dizziness, light-headedness, and sometimes the paradoxical sense of not getting enough air precisely while breathing too much.

One thing I say often, because it lifts a weight for many people: during a panic attack blood pressure rises, it doesn't fall. Fainting happens for the opposite reason. That's why fainting during panic is very unlikely — even though the sense of being about to is among the most common symptoms of all.

Why it comes back: the cycle

A single panic attack is an event. What turns it into a disorder is what happens afterwards.

After the first one, attention changes direction: you start monitoring the body. The heartbeat, the breath, a moment of dizziness, a tightness in the stomach. Signals that were always there and went unnoticed become objects of constant checking.

And that's where the cycle closes. A sensation gets read as the beginning of an attack. That reading triggers the alarm. The alarm produces exactly the sensations that were feared. The sensations confirm the original reading.

At that point the fear is no longer of the attack. It's of the next one. And that fear doesn't need an attack in progress to work: it works in the waiting.

Avoidance, and how agoraphobia begins

The next step is reasonable, and it's the one that narrows a life.

You start avoiding the places where it happened. Then places that resemble them. Then situations that would be hard to leave quickly: the metro, the motorway, a flight, a queue at the till, the cinema, a lift. Then you only go out accompanied. Then you go out less.

Agoraphobia isn't a fear of open spaces, as it's often described. It's the fear of being somewhere you couldn't leave, or couldn't be helped, if you felt unwell.

The same applies to panic-related claustrophobia: it isn't the enclosed space itself, it's the idea of feeling unwell and not being able to get out.

And like every avoidance, it works. In the moment the anxiety drops, and that teaches the brain that avoiding was the right call. The field narrows one sensible decision at a time.

Alongside avoidance come the safety behaviours: only going out with medication in your pocket, sitting near the exit, always carrying a bottle of water, checking where the nearest hospital is. These bring relief too. And they keep the fear alive too, because they confirm that without the precaution something would have happened.

Panic and living abroad

A large part of the people I see in English didn't grow up in Italy.

Panic tends to arrive when things are already stretched, and a move stretches most of them: the support network is in another time zone, the health system is unfamiliar, and a first attack means explaining chest pain in a second language, to a doctor you've never met, in a hospital you've never been to.

Several things follow from that. A first attack that got investigated medically and never named. Avoidance that reads as ordinary adjustment — not going out much, in a new city, seems normal. A shrinking world that nobody at home can see well enough to notice.

None of this makes panic different in kind. But it changes what maintains it, and that's worth naming rather than working around.

How I work with panic

The first session is about reconstructing what happens: when it started, what the first minute of an attack is like, what you avoid now that you didn't before, what you take with you when you leave the house.

From there the work runs on three fronts.

Understanding the mechanism. Not panic in general, but yours: which sensations set off the alarm, which interpretations feed it, which strategies are maintaining it. Many people discover here that what they were doing to protect themselves was part of the problem.

Working with the body. In panic the body arrives before the thought. Breathing, attention to bodily signals, how you respond to a racing heart — these can be worked on directly, and they're often where we start.

Recovering the field. Gradually and by agreement, rebuilding access to the situations that have narrowed. Not all at once, and not alone.

I studied Cognitive and Clinical Neuroscience at Maastricht University and worked as a researcher on the mechanisms of anxiety and panic before training as a psychotherapist. That's why the body is central to how I work.

There's another reason. My own first panic attack came in 2001, during a university lecture. I didn't know what it was and had no name for it. Knowing that minute from the inside doesn't replace clinical training, but it changes how you listen to someone describing it.

When it makes sense to ask for help

A single panic attack isn't in itself a disorder. It happens, and for many people it happens once.

The more useful questions are about what came afterwards:

— Has it come back, or am I afraid it will?

— Have I started avoiding places or situations?

— Do I leave the house carrying something I didn't used to need?

— How much time do I spend checking how I am?

If any of those is a yes, it's worth talking about. There's no need to wait for the field to narrow further.

One last thing, if it hasn't been done: medical assessment comes first. Panic symptoms are physical, and telling them apart from other causes takes a medical examination, not a psychological interpretation.