Panic Attacks: What Happens and What to Do

Ten video lectures in English, a free 47-page guide, and exercises you can start today.

André Fleshel, psychotherapist, hypnotherapist, breathwork and somatic practitioner. 25 years of practice in Ukraine and the USA, 8 of them in American clinics and crisis centers.

What a panic attack is

An ancient survival program. It fires faster than thought: fight, flight, freeze. Before you have time to figure out what is going on, the body is already running.

It is never one thing. It is a bouquet: body reactions, emotions, impulses you swallow before you notice them, helplessness, catastrophic thoughts, and the conclusions you draw about yourself, people and life. Usually irrational. Always very convincing.

The body: pounding heart, or a heart that “stops”. Heaviness and pain in the chest. Shaking, chills, sweating, heat in the face. Dizziness, cotton legs, the feeling you are about to faint. Nausea, a lump in the throat, the sudden urge to run to the bathroom. Numbness and tingling in the fingers and lips, hands cramping.

The breath: fast, shallow, spasmodic. You can’t get enough air, so you grab for more, and hyperventilation spins the head even harder.

The world goes strange: as if you are cut off from everything, or this is happening to someone else. Time stretches. The body betrays you.

The thoughts: “I’m going crazy.” “I’m dying.” “It’s a heart attack.” “I’m losing control.” “I’m about to scream.”

One panic attack is a normal reaction to an extraordinary stress. When they come back again and again, sometimes out of nowhere, we call it panic disorder. It is common, and it often shows up in people who are, psychiatrically speaking, perfectly healthy. A strange diagnosis.

Two paradoxes I see in practice. First: anxious waiting for the next attack is exactly what brings it back. Second: strong-willed, stubborn people who despise weakness get caught as often as anxious ones. They fall straight into the trap of this “treacherous weakness”.

Three circles of hell

The first circle: the attack

Something feels dangerous. Adrenaline and cortisol, the heart races, vessels tighten, muscles get ready to fight or run. But fighting or running is impossible, or seems even more dangerous, and all of this happens below awareness. The tension has nowhere to go. Breathing breaks into hyperventilation: dizziness, weakness, distorted perception, loss of control.

The body fails. The mind fails. Old reactions wake up, some animal, some from childhood: freeze, cry, rush around. No memories, only emotions and verdicts. And strangely, a thought like “this proves I’m a born loser” brings a little relief. At least something is explained.

The second circle: the aftermath

The situation is over, but the hormones keep the body revved up. The heart pounds, the body doesn’t listen. Now there is distrust of your own body and irritation at your not very heroic reaction. On this background anything, even harmless, feels scary or infuriating, and spins the whole thing up again.

The third circle: the trigger

Weeks later something innocent, the smell of burning rubber, unpacks the whole kit. Images, sounds, smells and feelings got stamped into memory as one package with the label DANGER, AVOID. You don’t even know what set it off, and one more nightmare joins the kit: “it can happen any moment”.

The mind can’t stand uncertainty, so it runs through explanations. The champions of this race: “I’m going crazy”, “heart attack”, “I’m dying”. Avoiding the triggers turns into avoiding everything that stirs emotion, sometimes all the way to agoraphobia. From now on people fear not events, but their own reactions. The body stays on guard, the breath stays shallow, as if afraid to wake up any feeling. And round again.

Video lectures

Ten episodes, about two hours in total: how panic works, breathing that helps, the paradox of control, avoidance, and a rule for stopping an attack. Watch in order, or start with the one that hits closest.

Lecture 1 · Exercises, Facts and Paradoxes

Part 1 · Therapy and Self-Help

Part 2 · Therapy and Self-Help

Part 3 · Therapy and Self-Help

Where to start

Start soft. No special effects, no hyperventilation, no extra stress. The goal at first is not to provoke the nervous system but to let it adapt. Softness and care, your own pace, and permission to feel what you feel.

Gentle first steps

• Resonance breathing. Slow, even, about 5 seconds in and 5 out. If you can, watch your HRV: apps and smartwatches usually call it “stress”. Don’t do it through tension, freezing or hurry. Breathe only as long as you can stay soft and unfrozen.
• Grounding. Press lightly with your feet into the floor and your palms into your thighs. Not as a formality: to feel your body and find a relaxing pace.
• Orienting. Breathe and slowly turn your head. Look at things you hadn’t noticed, on both sides, further away.
• Neck and shoulders. Let them go with the breath and with sighs, a little at a time, never to the point of hyperventilating. Small doses.
• Yawning. Yawn until the first reactions come, then slow down.
• Warm touch. Soft, warm, tender touch to your thighs, face, heart. A soft Buddha smile.
• Voice. Speak, hum, talk to yourself softly. The voice is wired to the vagus nerve, the body’s brake.

If you tend to freeze, thaw out slowly, without forcing. If you tend to fuss and rush, make your breath and movements flowing and unhurried.

When this starts to work, add what comes next.

Then: an active part

Panic can’t be treated without the person taking an active part. Whoever that person is: a client, a relative, a friend, or you. You will have to change habits and do things that bring up “not me”, “no strength”, “I can’t”, “what’s the point”. Stay in the comfort zone and nothing changes.

One task, every day

Put 5–10 minutes in your schedule. You can move it within the day. You can’t cancel it.

• Squats and push-ups until the muscles tremble. No strength? Push up from a table or a chair.
• A cold shower, until goosebumps and shivering.
• When the body wants to tense and freeze, breathe and let the muscles go.

Minimal effort, maximum return. This unfreezes the muscles tied to stupor and helplessness, the ones that wanted to hit, break free, run. A morning shot of adrenaline resets anxious and depressive reactions. It trains the vessels, and a good part of the dizziness and fainting in panic comes from vessel spasm. And every time you choose to move despite “no strength”, you train the habit of not losing heart.

The core of panic

At the core of panic there is always avoidance of the unpleasant and the unclear, at any cost. Trying to get rid of it, instead of letting it pass.

Every time a person in the middle of an attack, with all the “terrible” sensations and thoughts, keeps doing what matters and treats the attack as an annoying side effect, it weakens and leaves. “This is just a chain of sensations for 3 to 15 minutes.” “These thoughts aren’t the truth, they’re the state talking.”

Helplessness is a state, thoughts and emotions, but above all it is behavior. In hysteria you can still choose to act sensibly. That is where the chain breaks.

Under the shell of freeze

Under stupor and helplessness there are always suppressed emotions and impulses. Usually one of three: fear, anger or grief. Recognize it and let it out, and the freeze usually lets go.

• Sigh out loud, 20–40 times.
• Let out anger and helplessness: shout, growl, beat a pillow, stomp, until the body comes alive.
• If anger doesn’t come, let out fear and sadness, preferably to someone who listens.

Paradoxical versions, in imagination: three minutes of rage, carrying out your revenge on the enemy in detail. One minute of hysteria, running in circles screaming “Aaaa! We’re all gonna die!”. Then become a helpless child who is allowed to cry, and sob for 3–5 minutes until it eases. Twice through, and finish with one more minute of rage. Can’t do it? Simply name what you feel to the person next to you.

People who suppress anger, who sincerely believe they are angry at no one, are among the most vulnerable. Next come the controllers: those who can’t stand unpredictable situations and unfamiliar reactions of their own body and mind.

Can you treat panic attacks with breathing?

“Breathe deeper” can help. It can retraumatize. Sometimes — it can heal completely.

Heart pounding. Not enough air. Head spinning. Lips and fingers tingling. Feels like you’re about to die or lose your mind. You grab for air, faster and deeper — and it only gets worse.

First — medicine. These symptoms can show up with endocrine, neurological, cardiac, lung issues, or sleep disorders. Panic can be a symptom of something else, or go hand-in-hand with other psychiatric diagnoses. So: clinical specialists first, then breathing methods — with your doctor’s approval, and with someone who knows what they’re doing.

Neurophysiology

During panic, we breathe like there’s a catastrophe: fast and shallow. Sometimes you gulp, sometimes a spasm blocks the inhale or exhale. Swings in CO₂ and oxygen trigger a storm: dizziness, numbness, tingling — and the feeling you can’t get enough air.

These reactions set off more panic — in the body and the mind. The sense of losing control makes it worse. Now come the panic thoughts: fear of dying, heart attack, even going crazy. Tight, spastic breathing muscles, including the diaphragm, pile on the fear of suffocating. That’s the loop.

In the perfect world of neurophysiology, you’d just slow your breath, pause, breathe into a bag, raise your CO₂, do “box” breathing, take a physiological sigh. In the lab, this works. Scientists say: it’s simple — if you panic, do this.

Psychotherapy

But therapy and psychiatry know the real world is messier. In panic, time warps, your body and mind don’t listen, memory fails, even the exercise itself can crank up the symptoms until they’re unbearable. You get a neurotic conditioned reflex — that frozen terror. Sometimes the exercises can swing you the other way — not enough O₂ or CO₂ — and you get stuck in that horror.

Old trauma wakes up: despair, helplessness, the feeling you can’t control yourself. It feels very real, like it’s happening now, not then. The mind tries to explain it.

You start to fear triggering an attack — that’s the worst part: living in fear. The body gets scared, barely breathes, hiding, listening for any sign of another attack. People, emotions, life itself — you start to avoid them all.

Panic attacks and disorders don’t come out of nowhere: they usually have a long history of exhaustion, tension, and feeling powerless to change anything.

How I work

First, we learn to see these mechanisms and what they mean. You’re not broken — one of the defense systems just glitched.

1. Exercises to calm the nervous system — done regularly, when you’re calm.
2. Exercises to weaken an attack and give you some control even in the middle of it: slow breathing, box breathing, pauses, belly breathing. The skill to spot an attack coming — and at least turn down the volume, or let it run its course.
3. Exercises to build tolerance for strong body reactions: relaxing during a racing heart, shaking, dizziness, and putting panic thoughts on the shelf for a while.
4. Switching into a parasympathetic shift that can wipe out an attack completely — usually only after you’ve practiced the basics.

All by Occam’s razor: start simple, then add complexity. Sometimes one or two sessions with the first three types are enough.

There’s a separate layer of breathing methods, too: they help bring up and discharge old emotional tension, like in hypnotherapy. I use these rarely, only when needed.

And yes: people who tried to “breathe deeper” through tight, spastic muscles ended up hyperventilating. Or they got burned out, unable to steer their breath — slow it down, breathe into the belly — and got no relief as the panic avalanche grew. That’s how the method gets a bad reputation.

So the task is the opposite: not deeper, but slower. Inhale for 4, exhale for 6. The long exhale turns on the parasympathetic system — the body’s relaxation switch. At the bottom of a slow exhale, there are no thoughts at all.

What evidence-based medicine says

It lags behind somatic psychotherapy, but here’s what we know. Capnometry breathing training: four weeks learning to slow breathing and raise CO₂. Panic drops as much as with cognitive therapy; at home, 83% improve, 54% go into remission (Kim, Wollburg, Roth, 2012; Tolin et al., 2017). Resonance breathing — about 6 breaths per minute — syncs breathing and pulse; a meta-analysis of 24 studies showed a big effect on stress and anxiety (Goessl, Curtiss, Hofmann, 2017).

If your doctor says you’re healthy, but the attacks keep coming — breathing and nervous system work give the fastest results, and fit well with psychotherapy. A structured, systemic approach helps balance the nervous system, build coping, restore wholeness, calm, balance.

Who to go to

Many people with panic don’t trust psychiatrists or psychologists, and I understand why. Some were burned by treatment that didn’t work. Some fear a psychiatric record. Many fear being medicated into a fog. Many simply don’t know whom to call.

The unpleasant truth: most specialists can’t diagnose and treat panic well. There are psychiatrists who only prescribe, and good therapists who are strong in other areas but not in this one.

The good news. In most cases panic responds well to treatment without medication. You can get diagnosed and still decline medication. You have the right to a written report with your diagnosis and recommendations. You can get a second opinion and compare before you decide.

A red flag in a psychiatrist: contempt for psychotherapy. A red flag in a therapist: contempt for psychiatry, and not knowing the limits of their competence.

The free guide

Forty-seven pages based on my book Panic Attacks: Short-Term Therapy and Self-Help: the mechanism of a panic attack, breathing that helps (including resonance breathing), what to do and say to yourself during an attack, the Safe Place exercise, facing triggers safely, self-investigation worksheets, the fears behind panic, changing the habits of panic, working with root causes.

Other ways to work with me

For practitioners: learn Somatic HypnotherapyCertified by EEAHP. Starts November 8: Sundays in person in Huntingdon Valley, PA, plus online evenings.Somatic Hypnotherapy 101 →

This material does not replace medical or psychiatric diagnosis and treatment. If symptoms are severe, persistent or new, see a doctor first. The exercises above are not for people with heart conditions, epilepsy, pregnancy or recent surgery without a doctor’s approval.