Panic Attacks: Understanding Panic Through a Psychodynamic Perspective

Written by Thomas Day, Clinical Professional Counselor in Nevada

A panic attack can feel terrifying.

The heart races. Breathing becomes difficult. The body may shake, sweat, or feel suddenly hot or cold. Some people experience dizziness, chest discomfort, nausea, or a sense that something is profoundly wrong.

For others, the most frightening part is psychological: What if I’m losing control? What if I’m dying? What if this happens again?

A panic attack can seem to arrive without warning. But from a psychodynamic perspective, the experience can also invite a deeper question:

“Why did my body react as though I was in danger when nothing around me seemed dangerous?”

Panic is not imaginary, and it is not a sign of weakness. The physical experience is real. Understanding what happens during panic—and what may contribute to vulnerability to it—can make the experience less mysterious and less frightening.

What Is a Panic Attack?

A panic attack is a sudden period of intense fear or discomfort that reaches a peak relatively quickly and is accompanied by physical and psychological symptoms.

These can include:

Racing or pounding heart
Shortness of breath
Chest discomfort
Dizziness or lightheadedness
Trembling
Sweating
Nausea
Chills or hot sensations
Numbness or tingling
Feeling detached from yourself or your surroundings
Fear of losing control
Fear of dying
A sense of impending catastrophe

Panic attacks can occur unexpectedly or in response to particular situations.

Having a panic attack does not necessarily mean someone has Panic Disorder. Panic Disorder involves recurrent unexpected panic attacks along with persistent concern about additional attacks or significant changes in behavior related to them.

When the Fear Becomes Fear of Panic

One of the most difficult aspects of panic is what happens afterward.

A person may begin monitoring their body for signs that another attack is coming.

“Is my heart beating faster?”

“Why do I feel dizzy?”

“Was that a strange sensation in my chest?”

Normal bodily sensations can then become sources of alarm.

A small increase in heart rate may be interpreted as evidence that another panic attack is beginning.

Fear increases physical arousal.

The increased arousal creates additional sensations.

Those sensations are interpreted as further evidence of danger.

The cycle accelerates.

“The first attack was terrifying. The attacks afterward were terrifying because I was constantly waiting for the next one.”

This anticipatory anxiety can eventually become more disruptive than the original panic attacks.

Beyond the Physical Symptoms

Panic attacks are often explained in terms of the body’s fight-or-flight response.

That explanation is important. Panic involves a powerful activation of the body’s threat-response systems.

But it does not necessarily explain why one person becomes particularly vulnerable to panic during a particular period of life.

A panic attack might occur during a period of relationship conflict, major responsibility, grief, professional pressure, or significant change.

Sometimes the person is consciously aware of the stress.

Sometimes they are not.

Psychodynamic psychotherapy can explore the emotional context surrounding panic without assuming that every panic attack has a single hidden cause.

A Psychodynamic Understanding of Panic

From a psychodynamic perspective, anxiety can emerge when emotional experience exceeds a person’s current capacity to process or regulate it.

This does not mean that panic is “all in your head.”

The opposite is true: psychological distress can be expressed powerfully through the body.

Someone may consciously feel relatively composed while experiencing considerable internal conflict.

For example, a person might believe:

“I’m handling everything fine.”

while simultaneously carrying grief, anger, fear, dependency needs, or a sense of helplessness that has not been consciously acknowledged.

Panic may become one way that overwhelming arousal enters awareness.

“I thought I was fine. Then my body seemed to tell me something I hadn’t been letting myself know.”

This is one possible psychodynamic formulation—not a universal explanation for panic.

Panic and the Fear of Losing Control

A recurring theme for some people with panic is the fear of losing control.

This can mean different things.

Someone may fear losing control physically.

Another person may fear becoming emotionally overwhelmed.

Someone else may fear saying something they cannot take back, making a mistake, or becoming dependent on another person.

Sometimes the effort to maintain complete control becomes part of the problem.

The person monitors themselves constantly.

They suppress uncomfortable emotions.

They anticipate every possible problem.

They try to prevent uncertainty.

The result can be a life organized around preventing the very feelings that eventually become overwhelming.

Childhood and Attachment

There is no single childhood experience that causes panic attacks.

Panic Disorder is influenced by multiple biological, psychological, and environmental factors.

However, early relationships can influence how people learn to experience distress, dependency, uncertainty, and emotional regulation.

A person who grew up needing to remain highly attentive to other people’s moods may become particularly sensitive to internal and external signs of danger.

Someone who learned that strong emotions were unacceptable may have difficulty recognizing or expressing distress until it becomes overwhelming.

Someone who experienced unpredictable caregiving may develop a heightened need to anticipate what might happen next.

These experiences do not mean that childhood “caused” the panic disorder. They may instead form part of the psychological context in which anxiety and panic become more difficult to regulate.

Clinical Vignette

A client experiencing recurrent panic attacks described herself as someone who “never falls apart.”

She was highly competent, dependable, and accustomed to managing difficult situations without asking for help.

During therapy, however, she began recognizing how uncomfortable she felt when she needed other people. Vulnerability felt dangerous. Depending on someone else felt almost intolerable.

Her panic was not simply reduced to this pattern. But understanding it gave the panic a broader psychological context.

Common Patterns Around Panic

People who experience panic attacks may also notice:

Hypervigilance to bodily sensations
Fear of uncertainty
Perfectionism
Excessive self-monitoring
Difficulty asking for help
Fear of dependence
Avoidance of situations associated with previous attacks
Fear of embarrassment or losing control
Difficulty recognizing emotional distress until it becomes intense

These patterns do not necessarily cause panic.

They can, however, influence how someone responds to panic and whether occasional attacks develop into a broader cycle of fear and avoidance.

When Avoidance Takes Over

After experiencing a panic attack in a particular location, a person may begin avoiding that place.

Then another place.

Then another.

Someone might stop driving on highways, exercising, flying, attending crowded events, going to restaurants, or being far from home.

The avoidance can provide immediate relief.

But relief reinforces avoidance.

Over time, the person’s world can become smaller.

“I wasn’t afraid of the grocery store. I was afraid of having a panic attack in the grocery store and not being able to escape.”

This distinction matters.

The fear may gradually shift from the original situation to the possibility of experiencing panic itself.

How Psychodynamic Psychotherapy Approaches Panic

Psychodynamic psychotherapy can explore both the immediate experience of panic and the broader emotional patterns surrounding it.

Treatment may involve exploring:

What was happening in a person’s life when panic first appeared
How they understand vulnerability and dependence
Their relationship with control and uncertainty
Emotions that are difficult to recognize or express
Recurring relationship patterns
Fears about separation, abandonment, or loss
How anxiety emerges within the therapeutic relationship

The therapeutic relationship itself can become a place where anxiety is observed rather than immediately acted upon.

For example, a client might become anxious when the therapist is unavailable, or when therapy begins to feel emotionally intimate.

Rather than treating that anxiety as something to suppress, therapist and client can become curious about what the experience represents and how it connects with other relationships.

Regulation Before Interpretation

Psychodynamic therapy does not require someone to analyze the deeper meaning of panic while they are in the middle of an overwhelming attack.

Sometimes the first task is simply helping the person become more regulated.

Once the nervous system settles, there may be greater capacity for reflection.

This principle is particularly important when panic occurs alongside trauma or significant emotional dysregulation.

“I don’t need to figure out why I’m panicking while I’m panicking. I need to learn that I can come back down.”

Understanding and regulation can therefore work together.

What Recovery Can Look Like

Recovery from panic does not necessarily mean never experiencing anxiety again.

Instead, the relationship with anxiety can change.

A person may begin to recognize:

“My heart is racing, but that doesn’t necessarily mean I’m in danger.”

“I feel anxious, but I don’t have to escape immediately.”

“I can experience uncertainty without solving it.”

“This sensation will pass.”

Over time, panic can become less mysterious and less powerful.

The goal is not necessarily perfect control over the body.

It is greater confidence in the ability to experience uncomfortable sensations and emotions without automatically interpreting them as catastrophe.

When to Seek Professional Help

A first or unexplained episode of intense physical symptoms should be medically evaluated when appropriate, particularly when symptoms could indicate a medical condition.

Professional mental health support may be helpful when panic attacks become recurrent, lead to significant avoidance, create persistent fear of another attack, or interfere with work, relationships, travel, exercise, or daily activities.

Panic Disorder is treatable. Evidence-based treatments include cognitive behavioral therapy, particularly approaches involving exposure, as well as medication for some individuals.

Psychodynamic psychotherapy may provide another avenue for exploring the emotional and relational patterns surrounding panic, particularly when panic occurs alongside broader difficulties involving attachment, relationships, self-esteem, trauma, or emotional regulation.

Learning That Panic Is Not the Same as Danger

A panic attack can create an extraordinarily convincing sense that something is terribly wrong.

The heart races.

The body changes.

The mind searches for an explanation.

Fear amplifies the sensations, and the sensations amplify the fear.

Breaking that cycle can involve learning to respond differently to both the physical sensations and the emotional experience surrounding them.

For some people, behavioral approaches such as exposure are central to treatment. For others, understanding the emotional patterns surrounding anxiety becomes an important part of longer-term therapeutic work.

Either way, the experience of panic does not have to define the boundaries of a person’s life.

“I still know what panic feels like. I just don’t automatically believe it means something terrible is happening.”

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787

Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). Guilford Press.

Craske, M. G., & Barlow, D. H. (2007). Panic disorder and agoraphobia. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 1–64). Guilford Press.

McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process (2nd ed.). Guilford Press.

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. https://doi.org/10.1037/a0018378