How to show, not tell, when writing about characters with... panic attacks and panic disorder.
Or, one panic attack does not a disorder make.
Hi all,
Happy Saturday! Thanks for joining me. Today, I’m continuing my series on anxiety disorders. I was originally planning to focus on social anxiety, but felt an urge to sidestep, so here we are.
Panic Disorder
The ongoing theme around writing about anxiety disorders of any type is that you can use your character’s symptoms to highlight aspects of character. The triggers for a character’s panic can highlight very important aspects of past trauma, core fears, even values. The important part is consistency. If you are considering incorporating panic attacks or panic disorder, please carefully craft the character’s triggers, as this can do so many things— reveal backstory, for instance. Read on to see what I mean!
There’s also some important differences between a character who has occasional panic attacks, and one who has panic disorder. I’ll highlight the differences below!
As always, all opinions are my own. Included symptoms can be further studied in the Diagnostic and Statistical Manual of Mental Disorders: DSM-5-TR, available at psychiatry.org.
One more disclaimer— I’m a bit under the weather today, so apologies if I’m a bit (more) rambling than usual.
Okay, let’s get to it!
Panic Attacks
The first thing to note about a panic attack is this: typically, the symptoms come on suddenly, and reach a peak in about ten minutes. This can occur in a situation where the person expects to feel nervous or uncomfortable, or it may not, but there’s always a trigger. Always. True panic attacks will include at least four of the symptoms I’ll list below. That is, to write about panic attacks accurately, you need to include more than just worry, or even a racing heart.
Some ways to write about panic attacks:
FEELINGS:
Characters experiencing panic attacks may FEEL:
Their heart racing (this is a familiar one for writers)
They may struggle to breathe, or feel like they’re being smothered
They may feel like they’re choking
They may sweat
They may experience nausea, or stomachaches
They may feel numb, or experience a tingling sensation
They may feel suddenly hot, or cold
They may tremble, or shake
They may feel dizzy, lightheaded, or faint
Of note— no one has ever died from a panic attack, although that is a common worry that can come up (see the next section on thoughts).
THOUGHTS:
Characters experiencing anxiety may THINK in a few consistent types of patterns.
One is that they may feel like they’re dying, or that they’re going to lose control/are “going crazy.”
One big category of symptom that I’m going to put here, rather than in the physical section above, is derealization. This can be immensely distressing in and of itself. Derealization is terrifying. It’s a detachment from reality, aka feeling that nothing is real (it can also present like depersonalization, or when your character detaches from a core sense of self— for example, they could look into the mirror and not recognize themselves). Derealization can come in a few different flavors. Common ones are the worries that the world is a dream or a simulation (thanks to The Matrix and The Truman Show for spawning that nightmare), or even that death has already occurred. Another flavor is when questions about the nature of the universe become so big and so consuming that nothing makes sense— what I call “getting kicked out into space.” So your character’s thoughts may race, they may jump from thought to thought in a rush that feels uncontrollable and lands them in a place where they’re questioning the nature of reality. This can connect to fears of losing control, or dying, or going crazy, or already being dead, in some cases. Talk about panic-inducing!!!
Derealization is a type of dissociation, which is where someone disconnects from their body. This can come with some physical numbness, as above, but often is simply a… detaching, like floating above the self.
If you want to write about ways another character can help someone experiencing dissociation, the key will be grounding tools. Breathing exercises help, of course, but have you ever been worried/anxious/panicking and had someone tell you to just take a deep breath? Talk about irritating! Instead, think about using the five senses to act as an anchor. Grounding can be physical, mental, or behavioral. You can also use what helps a character ground to reveal aspects of character, by the way. (Sensing a trend yet?) For example, if a character loves music, you can use their favorite song as an anchor. Grounding to sound can be very helpful.
ACTIONS:
Characters experiencing panic attacks may ACT in the following ways:
Oh, hey, we’re at avoidance again! They may avoid anything that might cause a panic attack, or leave a location if they feel one coming on. They might employ what we call “safety behaviors” (e.g., needing to find a small room, or a certain person, or particular item). Again, use aspects of character to identify safety behaviors— for example, know who they might feel is safe (or isn’t!). Searching for safety during a panic attack is often reflexive, a core seeking of comfort. Accordingly, people will gravitate towards that which is instinctively comforting. This also can lead to agoraphobia (see below).
Characters may also try to physically shrink/get closer to the ground, or curl up. They may also rock back and forth, which is a reflexive way to try to soothe.
Typical behavioral responses to anxiety and panic can come in a few flavors: fight, flight, freeze, fawn. We’ll get to the last one, fawn, when we talk about trauma. But the rest are all fair game— but again, have it be consistent with character. A typically passive character would be unlikely to have a primary fight response, for example. Dissociation can also be thought of as a type of flight.
Panic attacks versus Panic Disorder
This is a very important distinction. A character can have occasional panic attacks, or panic attacks linked to another type of disorder (such as generalized anxiety, social anxiety, phobias, whichever), without it rising to the level of panic disorder. So, what’s the difference?
There’s frequency, for one— someone with panic disorder will typically have recurrent panic attacks. But the primary difference is as follows:
In panic disorder, the fear of the panic attack becomes more debilitating than the panic attack itself. (If that phrase sounds familiar, you might have read a similar phrase in Harry Potter— about the fear of the name becoming bigger than Lord Voldemort himself. Same principle.)
So a character with panic disorder should spend a large amount of time worrying about having a panic attack. How will this impact them? What will this cause them to avoid? Will they stop going to work? Stop going out in public? Feel unable to talk to or spend time with friends, or certain people? Stop engaging in particular activities?
Panic disorder shrinks the world.
This can create:
Agoraphobia
For some reason, the literal meaning of the word “agoraphobia” has always tickled me. Agora- the word for a central marketplace in ancient Greek city-states, and phobia- fear. I’m a big ancient history geek (as anyone who someday reads my novel will be able to attest), so I think I just appreciate the “agora” part. Unamusingly, the meaning is also very on the nose. Fear of the marketplace— aka, fear of going out, particularly to public spaces. Agoraphobia occurs in panic disorder when the worry of having a panic attack and what will happen becomes so strong that leaving the house feels increasingly impossible. If your character suffers from agoraphobia, it’ll be important to think about why. Is it because they fear they’ll have a panic attack and will be judged? Will never be able to break out of it? Will be unsafe? Think about your character and use their core traits to inform how their agoraphobia presents. This will allow you to create a character with consistent psychological acuity.
Triggers
And now, a note on triggers. This is a term that appears frequently, these days. I do appreciate the normalization of it.
But let’s clear up any misconceptions.
A trigger is when something in the present activates distressing emotions and memories from the past, aka responding emotionally to something from the past, in the present. So if a character previously got in a car accident, seeing one on tv may trigger similar feelings and sensations, because the nervous system is predisposed to form associations to try to protect us. So, in this example, seeing a car after an accident would naturally activate flashing internal alarms! It’s not always a direct 1-1 either. Triggers can attach onto surprising things. Like, for example, something that sounds like a car, or the smell of a particular type of tea that was in the car at the time of the accident. So you can be subtle and deliberate in how you build this in.
For example, let’s say you decide to create a character who suffers from panic attacks. A long time ago, she experienced bullying. Her bully liked to wear a particular type of hat— bucket hats, let’s say (please go back to the fashion past, bucket hats). One day, when scrolling idly on social media, she flashes past an influencer wearing a bucket hat. Within the next ten minutes, she has a panic attack that feels like it came out of the blue. She doesn’t have to be able to put the connection together— but you should know exactly why that’s there, and have it relate to the story (e.g., maybe you’re writing a coming of age romcom in which this bully ends up falling in love with her, or something).
EXAMPLE
Delightfully, anxiety is increasingly showing up in literature. I say delightfully because such depictions are important— after all, that’s my entire reason for writing this newsletter!
As I was looking around and thinking about panic, I came across this book, We Are Okay by Nina LaCour. I’m still reading it, but I’m so impressed with the way she’s captured this aching swirl of depression and anxiety. And yes, panic, with lots of avoidance. Check out this section—
I have only just learned how to be here. Life is paper-thin and fragile. Any sudden change could rip it wide-open.
The swimming pool, certain shops on a certain street, Stop & Shop, this dorm, the buildings that house my classes— all of these are as safe as it gets, which is still not nearly safe enough.
When leaving campus, I never turn right because it would take me too close to the motel. I can’t fathom boarding a plane to San Francisco. It would be flying into ruins. But how could I begin to explain this to her? Even the good places are haunted. The thought of walking up her stairs to her front door, or onto the 31 bus, leaves me heavy with dread. I can’t even think about my old house or Ocean Beach without panic thrumming through me.
“Hey,” she says, voice soft. “Are you okay?”
I nod but I don’t know if it’s true.
The silence of my house. The food left, untouched, on the counter. The sharp panic of knowing I was alone.
“You’re shaking,” she says.
Let’s dissect the above. First, the writing is gorgeous. The whole book (at least as far as I’ve read), sparkles on a line level. Second, the word choice here lends itself well to describing anxiety and growing panic. Here are a few specific words that stood out to me: paper-thin, fragile, ruins, haunted, thrumming, sharp. Even out of context, that combination of words exudes pain and terror.
But in context— the ways in which these words depict the anxiety flowing through MC is simply perfection. MC describes things that she realizes are triggers, and there are likely more she isn’t aware of. From what I’ve read, her triggers are related to grief, but this is also a good example of the ways in which triggers can be seemingly random things. This is partly why fear around having panic attacks builds and morphs into panic disorder— when even a set of stairs can set of anxiety, why wouldn’t one worry about what’s coming next?
Next, there’s the clear jumping around in MC’s thoughts. This is a good example of racing thoughts, the way they jump and connect. The jumps are always meaningful, even if they don’t seem to be. Think of racing thoughts like a tornado, starting off wide at the top, then funneling down and down, tighter and tighter— until panic is all consuming and things are moving so fast and feel so sharp that you can’t breathe—
See what I did there?
Lastly, there’s a nice example of incorporating physical symptoms— the shaking. As called out by another character! Masterful. And this is one snippet. From what I’ve read so far, this book is a beautiful portrait of grief, depression, anxiety, and friendship.
And with that, I come to the end of this newsletter!
Thank you for reading all of this, and I hope this is helpful!
Questions?
Comments?
Please let me know! And stay tuned for my next post, which will be about how to show, not tell, how characters may struggle with social anxiety (probably)!
And now, as a picture of two very relaxed kitties (I should probably start identifying them, since you’ll be getting familiar with them. On the left- Marceline, on the right- Starfox. Tiny kitten and old man, respectively.)
This article is very, very helpful. If a person is subject to panic attacks, (i.e. everything the author threw at her is too much - grief, illness, fear of dying, etc.) would it be reasonable for her to carry Ativan and use it during an attack? Anxiety isn't my particular mental health issue and I've only had Ativan during the two surgeries when i had to lie awake and listen to the cornea specialist use a medical-grade Dremel on my eye... sorry for that image. Ativan worked, though, got me to stop almost fainting on the table. And my eyeballs responded by reforming themselves without the scar tissue so my vision improved. Similarly, when my character comes out the other side, the panic attacks will subside.