Exactly What to Do When You Feel a Panic Attack Coming On

Open Minds is a column that explores your most pressing questions about mental health, with the goal of pushing back on stigma and cutting through the confusion. Send your questions to tonic@vice.com.

About 6 million American adults experience a panic attack every year, yet we remain oddly uninformed about what exactly a panic attack is. First off, it’s not interchangeable with being extremely stressed or afraid. It’s a physical process that reaches a peak and then resolves, sort of like an orgasm, except awful. It happens when something trips your survival instinct by mistake; your brain is telling you you’re trapped in a fire, there just doesn’t happen to actually be one. A few months ago I moved into an apartment equipped with a smoke alarm so sensitive that it goes off whenever someone takes too hot a shower. This is similar—except in this metaphor the alarm is the acute internal conviction that your life is in danger.

“Even if you tell yourself you’re having a panic attack, your body is still going through a fight-or-flight response,” says Nicole Hunt, a sales director from St. Louis who has fought panic attacks for 15 years. But there’s nothing to fight or fly from, except the misfiring of the mind’s system for identifying and processing threats.

Panic attacks are often part of larger anxiety disorder and can accompany stress and transition. Hunt dealt with anxiety her entire life, but did not experience an attack until her early 20s, the same time her mother went through a health crisis, a romantic relationship failed and she took a high-pressure job. She started feeling spikes of anxiety in the middle of the night. At one point, she thought her heart was malfunctioning, called 911 and took an ambulance ride to a hospital. “They quickly knew I was having a panic attack,” she recalls.

They’re extremely treatable, though. Therapy often provides huge relief, but not everyone has access to a therapist. To that end, these are some doctor-approved tools to help you get through them, and hopefully make them suck slightly less.

Acknowledge You’re Having a Panic Attack
Panic attacks flood the mind with terrifying thoughts about one’s physical condition and irrational fright about external catastrophes. “It creates this nightmare in your brain that your thoughts go back to,” says Hunt. “Whatever [fear] causes you anxiety—you will die, your house will be set on fire, you’ll lose your job—you keep going back there.”

The first thing you need to know about panic attacks is that even when you feel like you’re about to die, you will not, says Joe Bienvenu, associate professor of psychiatry and co-director of the Anxiety Disorders Clinic at Johns Hopkins. No matter how certain you are that something is deeply, fatally wrong with your body, panic attacks have never killed anyone, and they will not kill you.

The panic disorder hallmark is palpitations, but it’s still possible to experience an attack without them—Bienvenu says a common mistake among medical students is ruling out panic attacks because the patient’s heart wasn’t beating fast enough. Other common symptoms are shortness of breath, sweating, feeling dizzy, feeling like you’re choking, and numbness and tingling in your extremities. This is why people often mistake it for a heart attack and go to the hospital in the first place.

This will also hopefully remind you that, while gut-wrenching, panic attacks are usually brief, typically diminishing within ten minutes, and things will be better shortly. “The most important thing is to remember [is] that anxiety often occurs like a wave, hitting a peak and then slowly decreasing,” says Jason Eckerman, a clinical psychologist who practices in a suburb of Minneapolis. “When you can comfort yourself by knowing it will get better in a matter of minutes, it’s much easier to white-knuckle it.”

Of course, none of that applies if the symptoms do not diminish in good time or you have another medical conditions whose acute symptoms might feel like a panic attack. “[I]f you’ve had a history of major medical concerns, it may be appropriate to go to the hospital,” Eckerman says. “Because so many of the symptoms of a panic attack mimic medical issues, it’s important to have these ruled out.”

If you’re sure it’s a panic attack though, says Courtney Beard, a clinical psychologist specializing in anxiety disorders at McLean Hospital, “the very best thing you can do is actually nothing. I know that’s not what people want to hear, because it’s very scary…but it’s a false alarm, and all those things your body’s telling you to do you don’t actually need to do. If you stay put and ride it out, it will go away.”

Duck Out to a Quiet Place for Temporary Solace
Panic attacks often happen in public or social settings. Once you feel the onset, temporarily retreat to somewhere isolated and quiet. Allison Johanson, a clinical psychologist in Centennial, Colorado, has a solution for even the most bustling environment: Pretend that nature has called. “It is rare that people question your need to go to the bathroom,” Johanson says.

But don’t empower your anxiety by ghosting from an event or halting your day entirely. “While it might feel like a good idea in the short term,” Eckerman says, “this only reinforces the belief that the situation is dangerous and makes things harder in the long run.”

Get Back in the Moment by Focusing on Something In Front of You
Anxiety represents the invasion of the future—or some dark, twisted, uncontrollable prediction of it—into the present, so do something to keep yourself in the moment.
Johanson recommends “finding something about your surroundings [that] can not only distract you from worry thoughts about the panic.”

If you’re with a friend who knows the deal, it might help to have them say these things to you, too. Breathe deeply, from your abdomen, as I’m always hearing about from women who look like they do yoga. Be present with the sensations, as colossally shitty as they are. Acknowledge that you’re having a panic attack, and remind yourself it’ll be over in ten minutes or less.

One of the more actionable things to come out of anxiety research in the last few years is a technique called “anxiety reappraisal.” The idea is that when your mind and body are extremely hyped up, it’s easier to redirect that energy than try to quash it. If you feel your heart beating out of your chest, try channelling it into a project instead of meditating. This method is intended for generalized anxiety, and its core logic is useful if you’ve tried your best to sit on your hands and ride the wave and ultimately found it too much to bear.

If you are a true patriot and have watched every episode of Orange is the New Black, you’ll recall the scene where Daya has a panic attack and Bennett, instead of letting her rest, orders her to do jumping jacks. This is actually a medically legit suggestion. Exertion forces you to breathe deeply instead of hyperventilating, and helps reconnect you to the physical reality around you, not the one in your head where everything is on fire, Beard says.

Do the Right Kind of Breathing Exercise
Breathing exercises have long been a stock remedy for anxiety, from guided meditation to the TV trope of an overwhelmed character huffing into a paper bag. There’s some debate about their effectiveness. Deep breathing can cause a person to expel too much carbon dioxide, leading to symptoms like dizziness and numbness, and reinforcing shortness of breath.

“Trying to take a deep breath can make panic worse because it is hard to take a deep breath in the moment,” says Johanson. “Concentrating on the exhale allows you to focus on a different part of the breath without having to take a deep breath.” This allows you to focus on your breath’s natural course, instead of giving into anxiety-recycling pressure to rush into another deep intake of air.

Knowing that deep breathing has been shown to be misguided during a panic attack, researchers at Stanford and Southern Methodist universities developed the CART (capnometry-assisted respiratory training) method, which utilizes shallow, consistent breathes. This technique, often done with the aid of a computer or app timer, teaches normalized breathing during a panic attack, which seems to help stabilize anxiety levels, when learned as a coping method.

Keep a Reminder of Helpful Techniques
If any technique has helped in the past, knowing that you have it in your proverbial back pocket is comforting in itself. You might want to carry it with you, literally, suggests Johanson. She recommends traveling with “a written list of skills that you can use that is small enough you can carry it in your purse or wallet.”

As is often the case, prevention is the best medicine. Hunt has restructured her routine to avoid behaviors she’s found to be anxiety-provoking and cultivate habits she’s found helpful in keeping panic at bay. She has adjusted her diet (no caffeine and limited sugar), tends not to watch violent TV and movies, and now includes exercise and meditation in her daily schedule.

You might think the best approach to recurring panic attacks is to avoid that which makes you panic. But your triggers could be so random you can’t even isolate them, let alone avoid them, and anyway, prophylactically hiding from all the parts of the world that might mess with you is usually no way to live. If you can stomach it, the common and effective treatment for panic disorder is essentially exposure therapy, which involves subjecting patients to things they fear or that trigger them.

“It’s confusing to people,” Bienvenu says. “‘You want me to make myself more anxious? That doesn’t make any sense.’ But exposing themselves to the symptoms of anxiety in a safe setting and just being with that sensation until it passes helps…and that’s what’s so remarkable, it really does pass every time if we don’t run away from it.”

Try recreating the sensations of a panic attack that freak you out, in the absence of an actual panic attack. If they make you dizzy, spin around. If they make you hyperventilate, breathe through a straw. Gradually, your body will associate those things with being safe and okay.

“It’s important for people not to tell themselves that they’re weak or defective in some way,” Bienvenu says. “There’s something about panic attacks that’s just completely natural, how they flow from the rest of our biology. People who get them aren’t broken in any way, they still work fine.”

Read This Next: This Is How It Feels to Live with Severe Anxiety