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Waking at Night in a Panic? Tips for Nocturnal Panic Attacks

Written by Dr. Michael Ruscio, DC on May 19, 2022

Written by Dr. Michael Ruscio, DC on May 19, 2022 — Reviewed by Heidi Turner

Why Nighttime Panic Attacks Happen and What You Can Do About Them 

• Symptoms of Nocturnal Panic Attacks|
• Causes of Nocturnal Panic Attacks|
• Panic vs. Anxiety|
• Treatment of Nocturnal Panic Attacks|
• Simple Changes for Less Nighttime Panic|

Do you wake in the night out of the blue — not even in response to a nightmare — feeling panicked, scared, and like you might die? Nocturnal panic attacks occur at least once in over half of people with panic disorder [1], but they’re not often talked about. This article will explore what nocturnal panic attacks are and tips on how to cope with them. 

Symptoms of Nocturnal Panic Attacks

Nocturnal panic attacks, also called nighttime panic attacks, occur when a person wakes suddenly from sleeping in a state of panic. It’s not like a night terror where a nightmare jolts you awake, but rather the trigger for the panic is often unknown. These panic attacks are a mental health condition that falls under the category of anxiety disorders.

You may experience being jolted awake by the following symptoms [2]:

• Racing heartbeat
• Sweating
• Hyperventilation
• Fear of “going crazy” 
• Fear of sudden or impending death 

These symptoms are similar to daytime panic attacks, but come on suddenly in the night. Sometimes people also experience derealization (perception that your surroundings aren’t real) or depersonalization (feeling that your thoughts, feelings, and physical body don’t belong to you; loss of identity) especially when woken up suddenly from a deep sleep. 

Panic attacks in general are often described as a sudden and strong fear of dying, feeling like you’re “losing it,” and a severe loss of control. Physical symptoms people may experience are increased heart rate, sweating, hyperventilation, clenched fists, or a feeling of shakiness. 

Sometimes panic attacks happen in certain situations or in response to phobias. For example, people with social anxiety disorder may have panic attacks before public speaking. Or, if someone has a phobia of germs, they may have a panic attack in a hospital. In these cases, in order to prevent panic attacks a person may avoid situations that could cause another one, which can limit what they want to do in life and negatively affect their quality of life. 

In nocturnal panic attacks though, the exact trigger is unknown because the person is asleep when they start. 

Nocturnal panic attacks are fairly common. In fact, 44-71% of people with panic disorder have had at least one nocturnal panic attack [1]. Some people only have nighttime panic attacks and don’t experience panic attacks while awake.

What Causes Nocturnal Panic Attacks?

It’s not completely clear what causes these nighttime attacks. The working theory is that they occur from the fear of being in a state (such as sleep) when you can’t react to danger or protect yourself from threat — otherwise known as a loss of vigilance [3]. It’s posited that people panic because they can’t tolerate uncertainty or feeling responsible for harm that might occur while they weren’t aware or in control, which causes them to jolt awake [3].

One study found that people who have daytime and nighttime panic attacks may have a more severe form of panic disorder, whereas nocturnal panic by itself may be a milder subcategory partially related to adult night terrors [1].

In all forms of anxiety, other underlying conditions can produce panic-like symptoms, so a doctor may order a complete blood count (CBC) and thyroid function tests to rule out other conditions [4]. Patients could also be dealing with a sleep disorder that mimics panic attacks and can cause people to jolt awake, such as sleep apnea. These aren’t nocturnal panic attacks, although sleep disorders are associated with higher rates of general daytime anxiety [5].

Panic vs. Anxiety

The terms “panic” and “anxiety” are often used together, but they’re not the same thing. It’s helpful to know the difference, especially when talking about nocturnal panic attacks as opposed to anxiety at night. 

Anxiety is an umbrella term, meaning that the one term encompasses many different types of anxiety disorders, and panic falls under the umbrella of anxiety. A person can have an anxiety disorder, but not all people with anxiety have a panic disorder or panic attacks [4].

In anxiety, the brain is always on the lookout for danger and ready to react at any time. A bit of anxiety is not a bad thing. A healthy amount of fear keeps us safe and helps us know if we’re in danger and then if we need to fight or flee to stay safe [4].

In generalized anxiety though, fear is chronic, meaning that the brain assesses almost everything in life as a possible danger rather than only sensing fear when danger is present. This leads to repeated anxiety attacks of fight, flight, or freeze reactions, even when we’re not in an emergency. For example, this may show up as behaviors such as extreme fear in social situations, quick anger, or repetitive/ritualistic behaviors.

Panic disorders are one of the nine anxiety disorders listed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [6]. With panic disorder, you may have repeated panic attacks. Panic attacks are when you have an extreme feeling of fear that comes on quickly, often without a clear trigger. An attack happens fast and peaks in a few minutes. The frequency of panic attacks can vary from multiple times a day to only a few throughout the year. 

Anxiety at night more often keeps you awake from repetitive negative thoughts about fear of what might happen in the future, whereas nighttime panic jolts you awake with a fast heartbeat, sweating, and often a fear of death. 

Treatment of Nocturnal Panic Attacks

The best intervention researched specifically for nocturnal panic attacks has been cognitive behavioral therapy (CBT.) However, other treatment options, such as brain retraining and lifestyle changes, have been used to improve anxiety in general and may be helpful for nocturnal panic attacks as well. 

Medication treatments, such as antidepressants, benzodiazepines, or sleep medicines, have shown inconsistent results for treating nocturnal panic attacks and greatly depends on any underlying conditions that may be contributing to anxiety in each individual [1].

We don’t have as much research on nocturnal panic attacks specifically as we have about general anxiety. While we hope for more research in the future, some of the interventions that have been most helpful at improving anxiety and mental health will probably also be helpful for nocturnal panic attacks, as they’re a form of anxiety. 

Let’s look a bit closer at some of those interventions.

CBT for Improving Anxiety 

In nocturnal panic attacks and all other forms of anxiety, most research supports cognitive behavioral therapy for treatment. CBT is a form of talk therapy where a clinician helps patients learn how to more correctly assess current risks to safety. This involves looking more in depth at and improving the fearful negative thoughts that are causing the brain to perceive fear [4].

Some forms of CBT also work to help patients process and resolve the physical sensations that come with a panic attack, such as hyperventilating, chest pain, feeling a pit in the stomach, or sweating. Rather than directly working to calm the amygdala of the brain (also often called the fear center of the brain) to decrease anxiety, CBT works with the prefrontal cortex to improve reason and decision-making. This helps people assess risk more realistically and theoretically stops over-activation of the amygdala that leads to the panicked fear response [2].

Cognitive behavioral therapy is a widely studied form of psychotherapy that has a good body of evidence showing that it can be an effective treatment for panic disorders, on par with how effective medication treatments are [7, 8, 9, 10, 11].

Limbic System Retraining 

The limbic system is the part of the brain where the amygdala lives. It’s responsible for assessing our environment for safety. If it perceives danger, it will trigger our fight, flight, or freeze response [12]. If the amygdala is highly sensitive or overactive, it can contribute to panic, particularly if nocturnal panic attacks are linked to the brain perceiving fear when we’re asleep and in a less protected state [13].

Limbic system retraining is a form of neuroplasticity healing that can help with many mental health concerns. While limbic system retraining (any intervention that trains the brain to calm the response from the amygdala) hasn’t been specifically studied for nocturnal panic attacks, it shows good results in improving anxiety and panic symptoms [14, 15], and may be worth trying to see if it can help nocturnal panic attacks. 

These trainings utilize many different mindfulness, breathing, and neuroplasticity techniques to calm the amygdala and rewire fear responses in the brain. 

At our clinic at the Ruscio Institute for Functional Medicine, we’ve seen good improvements in anxiety with the Gupta Program Brain Retraining™, which is a form of limbic system retraining. It’s a highly accessible program that you can do on your own at home.

Diet and Probiotics to Improve Anxiety

We now know that the brain and gut are linked through the gut-brain axis. Issues in the gut can contribute to issues in the brain, such as anxiety and panic. 

While gut imbalances and inflammation can cause inflammation in the brain, we aren’t sure which happens first — if anxiety causes gut imbalances, or if imbalances in the gut lead to anxiety. We do know that the gut-brain connection is always communicating back and forth; it runs in both directions. This suggests that rather than one issue causing another, they both combine to contribute to anxiety. 

There are several lifestyle changes that can help improve gut health, decrease inflammation in the gut and brain, and improve mental health conditions such as anxiety and depression — the most significant of which may be diet and probiotics [16, 17, 18, 19, 20, 21].

Probiotics and diets that improve leaky gut, which is when the lining of the gut weakens and toxins from foods get into the body and brain causing inflammation, can both help improve symptoms of anxiety [20, 22, 23]. For this reason, combining a better diet with probiotics is best for improving anxiety.

One type of diet that has been found to be particularly effective is a low FODMAP diet. A low FODMAP diet is low in carbohydrates that are fermentable oligosaccharides, disaccharides, and monosaccharides and polyols, such as cruciferous vegetables, onions, some fruits, and sugar [23].

For probiotics, rather than trying to focus on one strain, the best improvements in gut health have been seen with a multi-strain probiotic.

Our patients with anxiety who have combined a low FODMAP diet and multi-strain probiotics have seen good results at improving symptoms of anxiety. 

In the midst of a panic attack, some people may use benzodiazepines for short-term panic relief. However, using benzodiazepines long-term comes with a high risk of dependence.

Simple Changes for Less Nighttime Panic

Being jolted awake in extreme fear can greatly decrease your quality of life. Not only is it emotionally and mentally taxing, but you can also lose a lot of sleep, which can decrease cognitive and physical functioning on a daily basis. 

While you may feel alone in experiencing nocturnal panic attacks because they’re a condition of anxiety that we don’t often hear about, they’re more common than many realize. Just like all anxiety disorders, they can be improved.

Because these attacks happen while sleeping, when the brain is functioning on a subconscious level and we’re not awake to assess risk, a brain retraining program to calm the amygdala can be an especially great place to start. 

Since many people with nocturnal panic attacks also have daytime anxiety, trying a low FODMAP diet and multi-strain probiotics can really help improve the gut-brain connection and decrease any daily anxiety you may be experiencing.

I hope that these suggestions help you to stop waking up in a panic and get you feeling better during the day as well, so that you can focus on living the life you want. 

If you would like personalized help with improving your anxiety, our clinic at the Ruscio Institute for Functional Medicine is open to new patients and we would be glad to help you feel and sleep better.

The Ruscio Institute has developed a range of high-quality formulations to help our patients and audience. If you’re interested in learning more about these products, please click here. Note that there are many other options available, and we encourage you to research which products may be right for you.