Nocturnal panic attacks

What nocturnal panic attacks are

They are panic attacks that occur during sleep: the waking is abrupt, the body is already fully activated — racing heart, short breath, sweating — and there is no mental content to have been frightened by.

That absence is what makes them so disorienting. During the day an attack at least arrives inside a situation; at night it arrives out of sleep, and the missing cause becomes a reason for alarm in itself.

Why it happens in sleep

It is not a nightmare. Nightmares belong to REM sleep and have a narrative: you wake knowing what you were dreaming. Nocturnal attacks appear more often in deep sleep, with no dream content at all.

What wakes first is the body. The mind arrives afterwards, finds an activation already under way, and tries to explain it — and at night the worst available explanation is never far off.

The waking, and the fear of going back to sleep

After the first episode something changes that has nothing to do with the night it happened and everything to do with all the ones after: going to bed stops being neutral.

People describe putting off bedtime, leaving a light on, checking their pulse before closing their eyes. These bring immediate relief and hold the level of alertness exactly where it is least useful.

What has to be ruled out first

Medical assessment comes first, and in this case more than in others. Sleep apnoea produces abrupt awakenings with a sense of suffocation, and it is common and often undiagnosed. Reflux, some arrhythmias and thyroid conditions also produce overlapping pictures.

Night terrors are a different thing again: people who have them usually do not remember the episode in the morning, whereas a nocturnal panic attack is remembered in full.

Telling these apart is not a psychological task. The first step is a family doctor, who can advise whether a sleep clinic assessment is needed.

The loop with insomnia

Once the investigations are done and the episodes remain, a second problem often sets in: difficulty falling asleep. The tiredness that follows lowers the threshold, and a lower threshold makes episodes more likely.

At that point there are two things to address, and it helps to know which one is being treated at any given moment.

How the work goes

We start from what happens in the half hour before sleep and in the minutes immediately after waking — not from the episode itself, which is brief, but from what surrounds it.

Then we work on gradually reducing the checking behaviours, and on how bodily sensations get read, which is the point at which a waking stops turning into an attack.