The Five (Unofficial) Levels of Panic Attack

Not all panic attacks hit the same. I determined five distinct categories of panic attack that I use to relate my experience to those who are fortunate enough not to know the perils of these episodes.

(One) – Is this panic or indigestion?

While this is the most mild of the levels, it may also be the most dastardly. At this deceptively low level, somatic symptoms of other conditions may mimic anxiety and symptoms of anxiety may mimic other conditions. I do not mean a serious condition like a heart attack – we’ll get to that – but rather things like allergies, a cold, general fatigue, or even indigestion.

I have encountered moments where my internal dialogue would hone in a heaviness in my chest and I would start to worry if I’d been hyperventilating (one of my typical personal moves is to breathe shallow when stressed, which can set off an episode). One belch later and I realise it was just a combination of the ginger ale I had at lunch mixed with bad posture while working.

Other times I might feel like I have a cold coming on because I feel groggy and like I am unable to breathe well because my nose is stuffy. Thirty minutes later the whole thing is gone. Ah, that was panic creeping in and it passed.

What makes this level so dastardly is that even if the somatic symptoms are not related to anxiety, the intense focus on them can trigger a panic attack or escalate the severity of one already in progress.

From my experience, it’s possible to move a panic attack into a higher level but not possible to move it down until the entire episode ends.

(Two) – Whatever.

This is where I spend a lot of my time these days. You might call it my discomfort comfort zone.

The notable difference between levels one and two is the self-awareness. At level two the symptoms are not terribly severe, but it is definitely a panic attack. One of the skills I developed related to my personal brand of anxiety is a litmus test to separate physical conditions from psychological ones.

It works like this. Panic attacks tend to have a sudden onset, while many of the somatic conditions with similar symptoms have a more gradual onset. If I went from absolutely fine to “Wow, my allergies are terrible as of 3 minutes ago” then it’s probably anxiety.

With other symptoms, I rely on my illness anxiety and medical phobia. Sometimes comorbidity can be a good resource. Whenever I feel I should see a doctor, that’s my irrational brain turning panic into a crisis (illness anxiety). Whenever I have an actual condition and should see a doctor, that’s my irrational brain justifying why it’s not necessary (medical phobia). Knowing which comorbid condition is triggering the panic can often keep me calm.

(Three) – I think I need to sit down for a minute.

But not always.

Thankfully, this is where I tend to peak anymore, but even this level is not great. Here we are still aware that panic is doing the damage but the symptoms are getting too severe to ignore them. The consolation of this level is the conscious sense of “this is bad, but I will be okay.”

I imagine this level will also have the most dissent. My contention is that level two is the max for pretending one is fine. Those with anxiety, like those with other psychological conditions, can become expert at masking their condition because of the stigma society associates with it. People often think I am doing much better than I am.

At level three the symptoms start to show through though. An observer will likely not recognise what is happening as a panic attack or even something serious, but the attack is now severe enough that it’s pulling your attention away from the world.

Somatic symptoms like sweating or trembling might be noticeable. Sometimes I feel a compulsion to change my circumstance altogether – going out of my way to find a seat, taking a knee, or unexpectedly removing myself from an area. I know I will be okay, but I need to hit the pause button for a moment and let my body ride out the attack.

(Four) – I think I’m dying.

If you suffer the tragedy of moving to level four, I feel for you. The change here is that, to a large degree, rationality goes out the window. This is the point where people become convinced that something serious is underway and no amount of evidence to the contrary will convince them otherwise.

This is the level that results in emergency room visits and other medical intervention. I have been to three emergency rooms in my life and had medics called to my attention a half dozen other times purely for panic attacks. The embarrassment at discovering I was in no immediate danger and wasted their time is another thing.

<<An irrational one. If you think you are in need of emergency services – seek them. The tragic reality is that the somatic symptoms of other conditions, like heart attacks, are similar to those of panic attacks. Far better to be wrong and a little embarrassed than correct and dead.>>

I did make one recent trip to this level. Following my COVID vaccine I had about 36 hours of mild fever and sleepiness. That went away and life felt good even though I still had most of the two weeks to go before I would be fully vaccinated.

Three days shy of the two week mark, I developed mild hives on my arms and legs (a very minor immune response). When I woke up in the middle of the night covered in hives and feeling unable to breathe, my brain went immediately to “this is an anaphylactic reaction and I have minutes at best.”

While my rational wife tried to calm me and explain that it was anxiety, the 95% of my brain that felt convinced I was down my last minutes of oxygen continued to panic. We needed to get to an emergency room or at least get medical personnel en route to my location to resuscitate me.

Twenty minutes and a bracing cup of chamomile tea later, I was fine and heading back to sleep.

(Five) – I wish I were dying.

TW: dental procedure

Now I would like to say that, “JFC, I’m dying!” is as bad as panic attacks get. For the longest time I assumed that would be. It’s not that I think death is the single worst thing that can happen to a person, but it was the worst I imagined a psychological condition that posed no physical danger could muster.

Then came the day of my dental procedure. It was not a planned event. Some years earlier I had suffered a trauma to my lower jaw and needed a root canal to save a tooth. We thought that was the end of it, but suddenly I was in severe pain because the adjacent tooth was having root problems.

I do not know what it’s like in other countries, but with American healthcare this is an expensive procedure in two parts: an expensive root canal and then an expensive crown. I also did not want to suffer through two appointments again, so I discussed the option of having the dentist extract the tooth. It was towards the back and that one visit would be it.

As the procedure was coming to a close (fully numb, tooth still in mouth but about ready for extraction) my anxiety must have caused me to stop breathing. I cycled quickly through the earlier levels:

“Huh, that’s weird. The anaesthetic usually doesn’t affect me this much. I guess they had to use more because it’s an extraction.”

“This isn’t the anaesthetic. Something else is happening here.”

“They aren’t worried. Whatever this is exists in your head. You’ll be fine in a minute.”

“No, something is horribly wrong. I cannot breathe and I feel like I’m disconnecting. Is this…am I dying?”

That’s when the remarkable happened. I hung out in that fourth level for what felt like an eternity. Death would take me at any moment. Except it didn’t, and that awful feeling was still there. Now? Nope, just more of this terrible feeling. It continued until I had a terrifying thought:

“I wish I would just die already. Either snap the **** out of this or die. Anything but this.”

It might even be understandable to have that thought and then snap out of it, like a moment of zen that makes you aware enough of the panic to treat it as something irrational. Nope. I just set up camp and lived with that feeling for what seemed to be an eternity (I imagine it was mere seconds in reality).

Transcendental panic attack?

Anxiety only hit me at this level one other time in my life. I never developed a suicidal ideation from my mental health issues, but during this second attack I kept having the thought, “I want to get away from here” and “here” was life. I didn’t want to die and have things be over for good; it was a sense of wanting to step outside existence the way one might leave a room, collect myself, and then come back.

So those are my five levels of panic attack. What do you think? Have you experienced them all or know someone who has? Are there additional levels?