Key Points: If panic attacks seem to come out of nowhere, fear of normal bodily sensations may be to blame. The solution involves learning to not react to feelings of panic, which can reduce hypervigilance over time and prevent future panic attacks.
When I have my first session with a new client with panic disorder, one of the first questions I ask is whether they notice anything in particular that tends to trigger their panic attacks. Sometimes people can identify triggers like being in certain situations (e.g. in crowds), certain times of day, or certain moods.
But a common response clients give to this question is, "I don't know what triggers them, they just seem random! That's part of what is so frustrating about them." This makes panic even scarier because it feels like your body is doing something for no reason.
If you feel concerned because you can't identify an immediate cause when you have a panic attack, I can explain what is going on.
Not All Panic-Attack Triggers Are Obvious
The simple answer is that your attacks are likely triggered by internal rather than external cues.
Triggers like being at the grocery store or on a crowded airplane are external cues for panic—they have to do with the environment around you. But for many people, panic is all about fear of what is going on inside you.
Panic disorder is really anxiety about anxiety itself. It involves a fear of the internal bodily sensations that indicate that a panic attack might be about to start. People may fear these internal sensations for a variety of reasons (e.g., fearing that the symptoms could kill them, that the panic will never stop, or that the symptoms will cause them to "go crazy").
For instance, let's say the first thing you notice when you have a panic attack is that you start to feel a little lightheaded or dizzy. You may not have realized it before you started having panic attacks, but people have all kinds of bodily fluctuations throughout a normal day. If you've never had a panic attack before, you probably don't think twice about feeling slightly lightheaded for a moment and you just move on with your day. It barely even registers.
But once you've had your first panic attack, you start to become hypervigilant about the physical sensations of panic.
So now if you start to notice that you're feeling a little lightheaded, your mind goes, "Oh no, that means I might be about to have a panic attack!" And you start to feel anxious.
But because that lightheaded/dizzy feeling is itself a symptom of anxiety, feeling anxious about it ends up making the symptom worse—and now you feel more dizzy!
And now that you feel more dizzy, you get more anxious because it's looking more and more like it really is going to be a panic attack. And that increase in anxiety feeds even more dizziness, which makes you more anxious. Which makes you more dizzy… and so on until it escalates into a full-blown panic attack.
That is not a random process: The trigger was that first slight hint of dizziness and things snowballed from there.
So what do you do about it? You can't help noticing your feelings, but you can control what you do in response to them.
How to Respond to Internal Triggers
To put it simply: don't do anything about the fact that you're panicking.
Let yourself panic but don't let it stop you from doing anything. Act as if you weren't panicking: Continue on with whatever you would be doing with your time in that moment if the panic feelings weren't there.
Avoidance maintains anxiety, so anything you do to try to fight or get rid of the panic will make it worse in the long run even if it makes you feel better right now. You want to teach your brain that these internal sensations are not actually dangerous. For your brain to learn that, it must repeatedly register that you can do absolutely nothing in response to the sensations and nothing actually happens. This is the basis for Exposure Therapy, a very effective treatment for panic disorder.
Part of doing nothing to fight the panic means redirecting your awareness back towards whatever else you are actually doing in the present moment. You may not be able to stop yourself from noticing when these feelings are coming up, but when you do catch yourself noticing and focusing on them, you can work on giving them less attention.
Remember, the best thing to do with a feeling is to just feel it.
That's how you keep the panic from stopping you from engaging in life and that's how panic actually gets better in the long run, as your brain learns that it is okay to feel panic. Once it learns that, there is nothing to be hypervigilant about and panic naturally subsides over time.