Nocturnal Panic Attacks
Nocturnal Panic Attacks can disrupt your daily life and get you caught up in chronic sleep anxiety. Here I'll explain how to ease these problems out of your life.
A nocturnal panic attack is a panic attack which occurs in the midst of your sleep, waking you up for no apparent reason.
Not very much is written about nocturnal attacks, so people are usually dismayed and worried when they experience a panic attack at night. They often think it means that the panic problem is spreading, and they worry about having some new or particularly ominous form of panic.
However, studies suggest that between 50%-70% of people with Panic Disorder will experience at least one panic attack at night. So it's not the unusual, ominous problem that it seems that first time you're awakened at 2 a.m.
Naturally, it's a terrible feeling to be awakened by a panic attack at night. It has all the major upset and confusion of a daytime attack, coupled with the fact that you're barely awake enough to know what's happening. You also probably feel more vulnerable because it's dark and the middle of the night.
Getting stuck on the "why" question ("why is this happening to me?") is a problem for people with panic attacks, and this applies doubly so to people struggling with nocturnal attacks. My patients have struggled with questions like "I'm not thinking while I'm asleep, so how can this be happening?"
Not very much is known about precisely what causes panic attacks at night, but we know that the brain doesn't turn off during sleep. It's reasonable to assume that the process is pretty much the same as the process of a daytime attack, just that it happens in a less conscious manner. And the symptoms of a nocturnal attack are pretty much the same symptoms you get during the day.
So it makes sense to turn your attention away from the "why" question, and work instead with the questions of "what's happening?" and "how will I respond?".
How to Respond
Get Up, Stand Up, Wake Up
If you've just been awakened by a nocturnal panic attack, the chances of your quickly falling asleep again are pretty low. If you want, give yourself a minute to see if you're lucky enough for that to occur, but I wouldn't wait any longer than that. The longer you lie there and wonder, the more panic and frustration you'll probably experience.
So I suggest you get up and out of bed. Fully wake yourself. Splash some water on your face, have a drink of water, check on the dog, cat, or parakeet. Do a few ordinary things to help yourself wake up. A nocturnal panic attack is not the same thing as a nightmare, but you can treat it like one.
Don't turn on the TV, start reading, or try other things in an effort to fall right back asleep. A lot of people try to distract themselves from a nocturnal attack, but I don't put much stock in this, because distraction works best when it's spontaneous. With a nocturnal panic attack, you're liable to try too hard to distract yourself, and get into a struggle with your thoughts. If distraction is going to help, it should help right away. Give it a minute, at most.
Work with the Panic
Let go of sleep, and trying to return to sleep, for a little while. Work with the nocturnal panic attack, instead of against it.
The best responses to nocturnal panic attacks are those that rely on acceptance and observation, rather than resisting and ignoring.
Switch to belly breathing. Follow the AWARE steps. Fill out a panic diary as part of the "Wait & Watch" step (diary instructions are here).
Let the panic fade in this manner.
After the Panic
Return to bed when you feel ready for sleep. If you continue to feel energized after a nocturnal panic attack has ended, you might be better off first doing some boring, menial chore, like scrubbing the tub. Pick a chore that's boring, laborious, and uncomfortable, something that will not motivate you to stay awake. Watching that movie you've been eagerly awaiting would not be a good choice, because it will promote staying awake.
If you feel more or less ready for sleep, but still want a transitional activity, pick one that isn't so interesting or stimulating that it keeps you awake. A brief relaxation exercise, or just a few minutes of deep breathing, will often work better than TV or reading. You're getting ready for sleep now, so pick something that's passive.
The Next Day, and Beyond...
Someone who just had a first nocturnal panic attack is likely to find himself worrying about having another one. The thought "what if I have one tonight?" is likely to occur to you the next day. That's a natural, ordinary response. It's just you experiencing a little nervousness, and it will be best to allow yourself to notice that thought without getting into a struggle with it.
People often respond to this worry by focusing more on their prospects for sleep. They think a lot about what time to go to bed; try to tire themselves out during the day; think about taking sleeping medication, or alcoholic beverages, to ensure sleep; review all the important activities they have scheduled at work, home, or school, and worry that they'll be unable to function if they don't sleep, and so on.
It's these very efforts which lead to more trouble with sleep anxiety.
Thoughts About Sleep
We're a species that makes things happen. We drive to work, make sure the kids get to school on time, write a term paper, put the trash out in time for pickup, make dinner, and so on. We make stuff happen.
Sleep isn't like that. Sleep is something you allow to happen. If you try to "make yourself fall asleep", what you'll probably find is that you're a person who's aggravated with himself because he can't sleep.
You can't make yourself sleep. You might as well try to make yourself get more flavor out of your dinner. Enjoying your dinner is something you allow to happen. You don't make it happen.
It's the same with sleep. You create the right circumstances, of a quiet, dark, comfortable place. Then you lay down and allow yourself to drift into sleep. Sometimes it goes more smoothly than others. That's okay, it'll even out.
"What if I can't sleep?"
Sometimes people find themselves in a state of worry about sleep, constantly trying to fend off, or refute, a refrain of "what if...?" questions about sleep. In response, they imagine all kinds of dire circumstances - not sleeping for 7 days in a row, going crazy, being unable to maintain their job, and so on.
That's what arguing with "what if...?" thoughts will do for you. It gets you more embroiled in arguing with yourself. This thought about sleep is just a variation of the usual panic thoughts: "what if I have a heart attack?", "what if I faint?", "what if I go crazy?", and so on.
So the challenge here is to recognize "what if I can't sleep?" as a symptom of nervousness, nothing more or less, and to treat it that way. It's not an important message or warning. It's just you being nervous.
"What if I don't sleep?". For the most part, the answer is that I'll get sleepy. And when I get sleepy enough, I'll sleep. This is a self correcting problem.
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