Panic Attack on a Plane: How to Get Through It in Your Seat

Why a plane cabin can set off panic

Once the doors close, you cannot leave until the plane lands. The NHS describes agoraphobia, which can develop as a complication of panic disorder, as a fear of situations where escape might be difficult or help would not be available if things go wrong. For some people, a flight can feel like that kind of situation. A panic attack can also arrive with no obvious reason at all: the NHS notes that attacks can come on very quickly and for no apparent reason, so you do not have to be afraid of flying to have one in the air.

One panic attack on a plane does not mean you have panic disorder. The NHS describes panic disorder as regular and unexpected panic attacks, followed by at least a month of continuous worry about having more.

Researchers describe fear of flying as a mixed picture rather than one fear. A 2010 review in Travel Medicine and Infectious Disease concluded that it is acquired through a complex mix of psychological, social and physiological factors that differ from person to person, and that treatment should therefore start from an assessment of the individual rather than a standard script.

Body sensations matter too. In a small 2011 experiment, people with fear of flying were more accurate than other people at detecting slight resistance added to their breathing, and the better they detected it, the more bodily symptoms they reported. The authors suggest that treatment for fear of flying should also work on these internal sensations, not only on the plane itself. In the moment, it can help to remember that noticing every small change in your breathing is part of how this fear works.

A seat-friendly routine for the peak of an attack

You cannot walk it off on a plane, so every step here works from your seat with the belt fastened. The breathing step follows the NHS breathing exercise; the rest are practical coping tips rather than tested treatments, so keep the ones that help you.

• Settle your body: both feet flat on the floor, back against the seat, hands resting on your thighs rather than gripping the armrests.
• Breathe without forcing it. The NHS breathing exercise suggests breathing in through your nose and out through your mouth, counting steadily from 1 to 5 if that helps, and keeping it up for at least 5 minutes.
• Unclench one place at a time: your jaw, then your shoulders, then your hands.
• Give your eyes a job: read the safety card line by line, describe the seat pattern in front of you, or name five things you can see and four you can hear.
• Use what you brought: a film, a podcast or music can hold your attention while the sensations rise and fall.
• Name it in one sentence: "This is a panic attack. It is very unpleasant, and it will pass."

Turbulence and the seat belt sign

If bumps frighten you, it helps to know what the Federal Aviation Administration actually says. It describes turbulence as air movement that normally cannot be seen, often occurs unexpectedly and can happen even when the sky looks clear. It says turbulence is normal and happens often, but that it can be dangerous, because the bumpy ride can throw passengers who are not wearing their seat belts from their seats without warning.

That gives you one clear, useful thing to do when the plane shakes: keep your belt fastened whenever you are seated, as the FAA advises. FAA rules require passengers to be seated with belts fastened when the plane leaves the gate and climbs after takeoff, during landing and taxi, and whenever the seat belt sign is on. Listen to the pilots and flight attendants. During a bumpy patch, avoid getting up to "escape" the feeling; stay seated, belt on, and let the breathing routine carry you through.

What to say to the cabin crew

You do not need to hide a panic attack from the crew. Press the call button or catch a flight attendant as they pass, and say it plainly. Short phrases are easiest when you are short of breath:

• "I am having a panic attack. I get them sometimes, and it should pass."
• "Could I have a cup of water, please?"
• "Could you check on me again in a few minutes?"
• "I have chest pain and I am not sure it is panic." Always say this if it is true, so the crew can decide how to help.

Benzodiazepines and alcohol before take-off

It can be tempting to reach for a pill or a drink before boarding. One controlled study suggests this can backfire. In a 1997 trial, 28 women with flying phobia flew twice, a week apart. Before the first flight, half took 1 mg of alprazolam (a benzodiazepine) and half took a placebo, without knowing which. On the first flight the alprazolam group reported less anxiety, but their heart rate and breathing rate were higher than in the placebo group. On the second flight they reported more anxiety than the placebo group, and the share of the alprazolam group having panic attacks rose from 7% on the first flight to 71% on the second. The authors concluded that the drug hindered the benefit of facing the flight.

This was one small study of one drug, so it is not a reason to stop or change a medicine you have been prescribed. The NHS advises keeping to prescribed treatment and only stopping when your GP advises it. If you are thinking about medication for a flight, talk it through with your doctor, including what the evidence says. NICE guidance also says benzodiazepines should not be prescribed to treat panic disorder, because they are associated with poorer long-term outcomes.

Alcohol is no better a crutch. The NHS lists alcohol, caffeine, sugary food and drinks and smoking among things that can make panic attacks worse.

When symptoms on a flight need medical attention

The NHS notes that most panic symptoms can also be caused by other conditions. Tell a flight attendant straight away, and say you think it may be your heart or your breathing, if you have:

• Chest pain that feels tight or like squeezing, or chest pain that spreads to your arms, neck or jaw.
• Severe difficulty breathing: gasping, choking or being unable to get words out.
• Lips or skin that look pale, blue or grey.
• Symptoms that feel different from your usual panic attacks, or that do not ease as an attack normally would.

Preparing for your next flight

Practise on the ground. Slow breathing and grounding are much easier to use mid-flight if you have rehearsed them on calm days, so they feel familiar rather than like one more thing to get right under pressure.

Try not to let one bad flight decide the next. The NIMH lists avoiding places where panic attacks have happened among the signs of panic disorder, and the NHS describes how avoidance creates a cycle of living "in fear of fear". Habits you lean on to feel safe, such as gripping the armrests for the whole flight, are called safety behaviours. In one small experiment with people who had panic disorder and agoraphobia, those told to drop their safety behaviours during a 15-minute exposure session had a greater fall in anxiety and in catastrophic beliefs than those told to keep them. That study was not about flying, so treat it as a reason to work on these habits gradually, ideally with a therapist, rather than to drop them all on your next flight.

Fear of flying responds to treatment. In a randomised trial of 83 people with fear of flying, four sessions of anxiety management followed by exposure, either to a virtual plane or to a real plane at the airport, led 76% of people in each treatment group to fly on a test flight after treatment, against 20% of those on a waiting list. Gains held at 12 months, with more than 70% of respondents still flying. For panic disorder, NICE recommends cognitive behavioural therapy, and in England you can refer yourself to an NHS talking therapies service.