Anxiety and panic attacks: understand, manage and treat

01Normal anxiety vs pathological: where does the line cross#

Anxiety is an integral part of human functioning. It corresponds to an anticipatory reaction to a real or perceived threat, with a physiological component (cardiac acceleration, increased vigilance, adrenaline release) and psychological (worry, alertness). This reaction is not only normal, it is useful: it pushes us to prepare for an exam, review an important file, avoid a dangerous situation. Without anxiety, humans probably would not have survived the ancestral threats that shaped their brain.

Anxiety becomes pathological when it crosses three thresholds simultaneously. First, it is disproportionate to the real situation: we worry for weeks about a banal business trip, we constantly fear an improbable event. Second, it is persistent: while normal anxiety extinguishes once the situation passes, pathological anxiety extends beyond six months in absence of concrete threat. Third, it is disabling: it disrupts sleep, work, social relations, marital life, the ability to enjoy daily life. When these three criteria are met, this is called an anxiety disorder and medical consultation is required.

In Morocco, the National Mental Health Survey (NMHS) conducted by the Ministry of Health in collaboration with WHO reveals that 24% of Moroccan adults present significant anxiety symptoms in their lifetime, of which approximately 9% meet the criteria for characterised generalised anxiety disorder. Women are nearly twice as affected as men, corresponding to international averages and explained by a combination of hormonal factors (menstrual cycle, pregnancy, menopause), socio-cultural factors (mental load, exposure to violence, economic precariousness) and possibly linked to under-diagnosis in men for stigmatisation reasons. Prevalence has clearly increased after the Covid-19 pandemic, several recent Moroccan studies (Faculty of Medicine of Rabat, 2022) showing a near-doubling of consultations for anxiety disorders between 2019 and 2022.

02The main anxiety disorders#

Pathological anxiety does not form a homogeneous block. The DSM-5 and ICD-11, used in clinical practice in Morocco, distinguish several well-defined clinical entities, each with its own pathophysiology, treatment and prognosis.

Generalised anxiety disorder (GAD) is probably the most frequent, affecting 5 to 7% of the Moroccan population. It is characterised by excessive and permanent worry covering multiple subjects of daily life — health, finances, work, children, upcoming events — without any one really dominating. The patient often describes that they "cannot stop thinking", that their mind constantly anticipates the worst scenario. On the bodily level, GAD is accompanied by chronic muscle tensions (cervical, lumbar), sleep disturbances with bedtime ruminations, increased irritability and fatiguability.

Panic disorder, which affects 2 to 3% of the population, is dominated by the recurrence of acute panic attacks often occurring unpredictably, outside any identified trigger. The fear of having another attack (anticipatory anxiety) itself becomes disabling and progressively leads to avoidance of certain situations — public transport, crowds, closed spaces — which can evolve into secondary agoraphobia, that is, fear of being in a place from which one could not easily escape.

Social phobia, which concerns 7 to 12% of adults according to studies, is an intense fear of being judged, observed or humiliated in social or performance situations — public speaking, meeting new people, eating in front of others, being the centre of attention. It typically begins in adolescence and remains frequently unrecognised as patients develop avoidance strategies that mask real suffering.

Specific phobias (intense fear of a specific object, animal or situation: airplane, heights, blood, spiders) affect about 10% of the population. Obsessive-compulsive disorder (OCD), now classified separately from anxiety disorders in DSM-5 but clinically very close, concerns about 2% of Moroccans. Finally, post-traumatic stress disorder (PTSD) occurs following traumatic events (accidents, violence, attacks, disasters) and manifests as re-experiences, nightmares, avoidance behaviours and a state of permanent hypervigilance. Its prevalence is 3 to 4% in the general population, much higher in survivors of the 2023 Al Haouz earthquake.

03Recognising and managing a panic attack#

The panic attack — or panic attack in medical terminology — is a particularly trying experience that occurs suddenly, reaches its peak intensity in less than ten minutes and generally resolves in less than thirty minutes. Symptomatology is typically spectacular: palpitations or tachycardia, profuse sweating, tremors, sensation of breathlessness or suffocation, chest pain sometimes pseudo-coronary, nausea, light-headedness, depersonalisation ("I am no longer myself"), fear of losing control, fear of dying, fear of going crazy. Many patients consult for the first attack at emergency convinced they are having a heart attack, and it is indeed essential to rule out this hypothesis, especially after age 50 or in presence of cardiovascular risk factors.

When an attack occurs, several techniques can reduce its duration and intensity. The first is to take shelter in a quiet place, ideally seated or lying down, loosening tight clothing. The 4-7-8 breathing — inhale for 4 seconds, hold air 7 seconds, exhale slowly 8 seconds — is a validated technique that slows heart rate and activates the parasympathetic nervous system. The simple fact of prolonging exhalation more than inhalation suffices to calm the autonomic nervous system.

The 5-4-3-2-1 grounding technique is particularly effective for stopping the anxious spiral: one consciously identifies 5 things one sees, 4 one touches, 3 one hears, 2 one smells and 1 one tastes. This exercise brings attention back to the present moment and to the body, where anxiety functions through anticipation and catastrophisation. Finally, it is precious to internally remind oneself that what one is going through is a panic attack, that it will pass in less than thirty minutes, that it will not provoke heart attack or insanity or loss of control. This meta-cognition, learned in therapy, allows defusing the vicious circle by which fear of fear amplifies the attack.

04Self-evaluation by GAD-7#

The GAD-7 (Generalized Anxiety Disorder 7-item Scale) is an internationally validated self-evaluation tool widely used in Morocco, including in public health centres. It comprises seven questions about the frequency of anxiety symptoms during the last two weeks, rated from 0 (never) to 3 (almost every day), for a total score from 0 to 21.

GAD-7 does not replace medical evaluation but provides an objective starting point, particularly useful for patients hesitant to consult or seeking to evaluate the evolution of their symptoms under treatment. Sahha offers a free interactive version of this questionnaire as well as the PHQ-9 (depression) on the /mind/questionnaire page, with totally anonymous mode respecting maximum confidentiality.

05Treatments: CBT first-line, medications when necessary#

Moroccan recommendations, aligned with those of French HAS and British NICE, place cognitive-behavioural therapy (CBT) as first-line for mild to moderate anxiety disorders. CBT is a structured psychotherapy, generally 12 to 20 sessions, combining work on anxiogenic automatic thoughts (cognitive restructuring) and progressive exposure to avoided situations. Its efficacy is demonstrated by dozens of Cochrane meta-analyses, with long-term benefit superior to that of medications alone. In Morocco, several clinical psychologists and psychiatrists trained in CBT practise in Casablanca, Rabat, Marrakech, Tangier and Fes, with an average session cost of 300 to 600 MAD, partially reimbursed by some complementary mutuelles.

Regular physical activity — 150 minutes per week of moderate intensity — is now considered a treatment in its own right for mild to moderate anxiety disorders, with an effect comparable to that of sertraline in several studies. Brisk walking, swimming, yoga and tai-chi are particularly recommended. Relaxation techniques (cardiac coherence, mindfulness meditation, sophrology) are useful complements, especially for anxious patients with marked somatic component.

For severe or CBT-resistant anxiety disorders, or as a complement to it, SSRI antidepressants (selective serotonin reuptake inhibitors) — sertraline, escitalopram, paroxetine — constitute the reference medication treatment. Their efficacy begins after 2 to 4 weeks and treatment must be maintained at least 12 months after remission. Pregabalin is a validated alternative for GAD, and hydroxyzine (Atarax) an anxiolytic antihistamine useful as adjunct treatment without dependence risk.

Benzodiazepines (Lexomil, Xanax, Lysanxia, Témesta) must be reserved for emergency situations or acute crisis periods, on durations less than four weeks according to HAS and ANAM recommendations. Their prolonged use induces tolerance (loss of efficacy), physical dependence and risk of withdrawal syndrome sometimes severe. In Morocco, excessive and chronic prescription of benzodiazepines remains an underestimated public health problem, and one must know how to refuse systematic renewal in favour of a more adapted treatment.

06When to consult urgently#

Certain situations require immediate consultation or call to 141 (Morocco SAMU) without delay. Suicidal ideation or self-harm, even fleeting, must always be taken seriously and lead to urgent psychiatric advice — Ar-Razi hospital in Salé, the psychiatry service of CHU Ibn Rochd in Casablanca and all regional CHUs have 24/7 reception. Atypical chest pain in an anxious patient, especially over 50 or with cardiovascular risk factors, must lead to ruling out coronary syndrome by ECG at emergency before retaining the panic attack diagnosis. The sudden onset of disorientation, language disorders or motor weakness must suggest stroke and not anxiety attack.

For non-medical psychological support, two listening lines operate in Morocco: SOS Amitié Maroc on 141 and ECOUTE on 0801-000-180, free and anonymous. Several associations (Sourire de Reda, Maman du Maroc) also offer specialised accompaniment. And of course, talking to your treating doctor remains the first step to leave isolation and engage in an appropriate care pathway.