Theory of loss of alertness and characteristics of those suffering from night panic attacks

Theory of loss of alertness and characteristics of those suffering from night panic attacks

More than half of panic disorder sufferers also experience nocturnal panic attacks (AP) (Smith, 2019).


The DSM-5 classifies nocturnal panic attacks into the broadest category of unexpected panic attacks, that is, they occur independently of situational triggering factors (APA, 2013). Nocturnal panic attacks exhibit the same symptoms as daytime, but occur in the transition from lighter to deeper sleep (Craske & Rowe, 1997). This means that those who experience nocturnal panic attacks wake up in the middle of a panic attack (Craske & Rowe, 1997).

Suffering from night panic can lead to a tendency to avoid falling asleep, for fear of waking up in a state of panic. Therefore, some consequences of nighttime panic attacks are insomnia and sleep deprivation (Craske & Tsao, 2005). Different possibilities have been explored to understand what differentiates those who have only daytime panic attacks from those who also experience them in sleep. According to the fear of loss of vigilance theory; Tsao & Craske, 2003), those who suffer from night panic fear the situations in which the attention paid to the surrounding stimuli is reduced, such as in states of hypnosis , in moments of relaxation and, precisely, during sleep. In fact, in such situations it can be more difficult to protect yourself from threats.

Smith, Albanese, Schmidt and Capron (2019) have expanded the theory of fear of loss of alertness, trying to further outline which features are specific to those with nighttime panic attacks. The authors hypothesized that people suffering from nocturnal AP manifest greater intolerance than uncertainty, that is, they find it more difficult to sustain unpredictable and uncertain situations. This is because they would be more afraid that an unexpected event, such as a heart attack or a natural disaster, could happen overnight, to which they would not be ready to react.

In addition, night panic sufferers may have a greater tendency to feel responsible for causing harm, a tendency that can also be understood as an inability to prevent harm. So he may be more afraid of not being able to protect himself from any threats while sleeping.

Finally, a greater sensitivity to anxiety, in particular with respect to the tendency to interpret unpleasant bodily sensations as more dangerous than they are, could be peculiar to those who have nocturnal panic attacks.

To test these hypotheses, Smith and colleagues (2019) conducted a study on a sample of individuals aged between 18 and 79 years. The sample was divided into three groups: people with both nocturnal and diurnal panic attacks, people with only daytime panic attacks and controls, i.e. people without panic attacks.

Participants completed self-report questionnaires on the three dimensions mentioned above: Intolerance of uncertainty scale, IUS-12; Carleton et al., 2007); responsibility for causing harm (Dimensional Obsessive Compulsive Scale, DOCS; Abramowitz et al., 2010) and sensitivity to anxiety (Anxiety sensitivity index-3, ASI-3; Taylor et al., 2007).

The results indicate that both those who suffer from exclusively daytime panic attacks, and those who suffer from panic attacks even at night, are equally afraid of situations of uncertainty. However, in addition to this, nocturnal panic sufferers also feel less able to act in unpredictable situations.

Furthermore, those who suffer from nocturnal panic attacks are more afraid of being unable to prevent harmful events and therefore to protect themselves from their unpleasant consequences. One hypothesis that future research could test is that the concern that he has not done everything possible to protect himself is connected to nocturnal hyper-surveillance. Night hyper-surveillance in fact translates into behaviors such as sleeping with the lights on or repeatedly making sure that doors and windows are closed before going to bed.

A curious fact is that those who suffer from nocturnal panic attacks are more sensitive to anxiety, but not with respect to bodily sensations as hypothesized, but with respect to the social component. That is, those who have nocturnal panic attacks seem to worry more about the judgment or rejection of others. This could mean that those with nighttime panic attacks fear that a person they sleep with may notice and judge negatively their sleep difficulties. Another possibility, which should be further studied, is that those who experience nocturnal panic attacks also have social anxiety problems.

In addition to supporting the theory of loss of alertness, the results of this study also contribute to the development of treatments to intervene in nighttime panic attacks. For example, working on the fear of being unable to react in unexpected threat situations could be an important help in countering the onset of nighttime panic attacks.