Recent research indicates that panic disorder can be differentiated from other disorders of the anxiety spectrum on psychological and biological dimensions. Traditional theories of psychopathology are unable to account for these data. A framework in which to conceptualize the unique and distinctive characteristics of panic disorder is discussed. The various modalities that have demonstrated efficacy in the treatment of this condition are reviewed and an integrated and comprehensive treatment approach is presented.
The Phenomenology of Panic Disorder Prodromal Period
Research has shown that individuals who later develop panic disorder have gross prodromal signs and symptoms in their childhood and adolescence.25"6 Furthermore, in my experience, careful anamnesis often reveals even more frequent but subtle signs of a developing endogenous disorder. Early prodromal signs of autonomic-nervous-system dysfunction such as easy blushing, cold or wet hands, faintness, palpitations are often found. Subclinical indications of hypochondrias is, heightened self-consciousness, separation anxiety, and abnormal trait anxiety are common. In most instances these prodromal signs, while bothersome, are not overwhelming and may be ignored or hidden. However, they can retard the healthy development of personality in multiple ways. The resulting greater than normal need for security and safety may inhibit and distort the formation of interpersonal relationships. Habits of avoidance, the tendency to make excuses, passivity, withdrawal, dislike of competition, etc., may surface and become established traits. There is often a concomitant loss of confidence and self-esteem as the individuals become aware of their emotional handicaps and limitations.
Overt Manifestation of the Disorder
At some point in the sequence of prodromal signs, often following a period of nonspecific stress, the first moments of panic occur, soon escalating into rapid volleys of autonomic discharge combined with intense fearfulness and forebodings of doom—the full-blown panic attack. The individuals are overwhelmed by the horrible experience and their initial attempts to understand what has happened lead to the conclusion that they are either going insane or have some terrible physical disease. The latter comes easily to mind because of the intensity of the physical manifestations of the panic attack, e.g., tachycardia, palpitations, dyspnea, etc. The course of events following this initial manifestation is now well documented.2 The patients form an intense fear of further panic and anticipatory anxiety develops. It must be remembered that the panic experience itself is so severely frightening that such a reaction is to be expected. Anticipatory anxiety and the increased likelihood of panic develops for those situations where the individual would be unable to escape or receive help or would be forced to suffer the ignominy of others knowing his or her problems, should a panic attack occur.
Such events as crossing long bridges, sitting in the center of a row in a movie theatre, being in a crowded room or alone in the street could, therefore become so feared as to induce further panic. The stimuli associated with these events or locations can in turn produce still further anxiety. The patients soon begin to avoid such situations. Thus, the initial spontaneous panic often leads to the formation of phobias perhaps hastened by any habits of avoidance developed in the prodromal period.
Two subtypes of phobic conditions secondary to panic disorder have been identified:"7 (1) mixed phobia wherein relatively limited fears develop such as phobias of flying, social phobias, etc; and (2) agoraphobia where the individual develops a massive fear of public places and traveling and feels relatively safe only at home. Whichever condition develops, the lives of the patients soon become miserable. They can become so oversensitized that chronic anxiety is experienced between panic episodes thereby further increasing the likelihood of such episodes. Only rarely are the patients hospitalized. They attempt to cope with their disorder by narrowing their field of functioning. Over time, however, secondary reactions occur and become established.
It is important for the treating clinician to realize the extent of these dysfunctional personality changes. It is easy to interpret these secondary reactions as psychodynamically caused ego defects or "neurosis," but I propose that they are the direct result of the anxiety condition itself. These secondary reactions are extensive. Self-esteem and self-confidence plummet to painfully low levels, a consequence of the patients’ awareness of their handicaps and the resultant shame and sense of inferiority. The patients know they are unable to do many of the normal activities, e.g., sit comfortably in movie theaters, travel to the supermarket, fly on airplanes, speak in front of groups, etc. They feel like cowards, always looking for exits and ways to avoid fearful situations.
Their autonomic dysfunctions contribute to this ego-deflation in ways that can be easily overlooked. For example, a man developed a condition where his hands were always wet and cold. As a result he felt intense embarrassment and dreaded situations when he had to shake hands with others—an indication to him of his lack of masculinity. He spent much time developing ways to avoid this common act. At the same time, he experienced a great dilemma when it came to sexual relationships. He feared the ridicule of potential female sexual partners if he were to touch them with his clammy hands and refrained from such relationships which he actually very much desired. He subsequently began to deny his interest in women, a secondary reaction far removed from his original problem. Many patients experience similar conflicts which, though greatly affecting their lives, are kept hidden.
Another common secondary consequence of the disorder is a heightened sensitivity to pain. Mersky3 states, "anxiety and apprehension, plus personal experience, cultural conditioning and fear of illness all make pain worse." Panic disorder patients become more sensitive to physical pain. Slight changes in their physical condition, as might be associated with exercise fatigue or common illnesses and injuries, may be experienced with an exaggerated sense of pain and worry.
Because of the autonomic hyperactivity that is characteristic of panic disorder patients, the somatic component involved in their experience of emotion is abnormally intense. Typical events that arouse negative emotions in all people, e.g., rejection, criticism, disappointment, are felt much more strongly, thus producing greater psychic pain. Even positive events such as success, because of the patient’s unusual sensitivity, can become associated with discomfort. When combined with poor self-esteem even minor stresses can trigger severe internal turmoil. A Frequently adopted defensive posture involves an exaggerated effort to maintain control over emotions. Rather than help, however, this usually leads to still greater fear. Hence, many afflicted individuals begin to intensely worry about losing self-control, e.g., fearing that they will get so angry that they will seriously hurt others.
Other secondary reactions can occur as well. The chronic discomfort may induce severe fatigue and a sense of exhaustion. The altered state of consciousness involved in continuing panic episodes may lead to a frightening experience of depersonalization. The individuals can become overly self-involved and self-centered which may set up conflict in their close relationships with others. Obsessive rumination, caused by habits created through anticipatory anxiety, often becomes a particularly severe and chronic secondary reaction. Cognition can become affected, especially short-term memory, concentration, and perceptual accuracy.
Many of these secondary reactions interact to produce deviations in mood and personality. The individuals tend to become, to various degrees, withdrawn, introverted, passive, dependent, and less competitive. Any change at all can become a stimulus for a fear reaction. Affect may become blunted and mood depressed.3’ The joy and meaning of life may gradually ebb away. Many of these patients become what Frank32 defines as demoral.
Working with Relatives
Still another source of motivation and help for panic disorder patients are the relatives, i.e., spouses and parents. Work with relatives towards the goals of the approach just described are also very different from the traditional methods of the various schools of family therapy. Family dynamics or family-systems issues are not the focus for involving the relatives. I suggest that relatives of panic disorder patients be accorded the same rights as suspects in criminal trials: innocent until proven guilty. There are no data to support the notion that relatives cause panic disorder. It is probably more accurate to conclude that an endogenous anxiety disorder presents severe problems for relatives who may as a result appear pathological in their reaction. Consider the guilt and sense of failure induced in parents by their offspring’s bewildering and sometimes frightening anxiety problems or the embarrassment, disillusionment, and anger of a spouse living with an agoraphobic mate. Rather than implied accusations to relatives about their role in the creation of the "identified patient’s" problems, it would seem more helpful to utilize the power of the existing family bonds to help the patient overcome fears and avoidances.
Parents of an adolescent or young-adult panic disorder patient can learn to adopt a sympathetic posture while firmly encouraging their child to engage in the feared activities. Parents of one male teenager patient with severe social fears secondary to panic disorder held a surprise birthday party for him and invited all his acquaintances. Faced with the surprise, and unable to escape, the patient was initially quite angry at his parents, but, as the center of attention in a very friendly group, he gradually began to relax and socialize. A female teenager in attendance took the opportunity to express her interest in the patient and a date (his first) was made. The following weekend, as the date was about to take place, the patient balked and was about to call it off until the parents insisted. He had a good time, gained valuable interpersonal experience, and his mood lifted dramatically.
Spouse and patient, with the therapist’s guidance, can plan practice assignments together, with the spouse providing encouragement and aid. One spouse however used a completely different approach. After trying with little success and much conflict to coerce his agoraphobic wife to leave the house to attend social functions, he tried a new tactic. He began to attend social events by himself (rather than stay at home with his wife) and upon returning told her of the wonderful and interesting time that he had had. Soon after, the patient began to show more willingness to accompany her husband to social outings.
Developing Compensatory Abilities
Panic disorder can detrimentally affect abilities needed for effective functioning, especially the development of a clear sense of identity and social skills.
Sense of Identify
Patients may lose a sense of continuity to their lives because of the disruptive forces caused by panic disorder. This contributes to a sense of bewilderment and a loss in the clarity of self-identity. One way the clinician can help is to carefully review patients’ past, including early years of development, with a focus on distinguishing very early prodromal signs of the disorder, e.g., early feelings of discomfort with people, feelings of inferiority, unexplained fearfulness, and so forth. Attention should be focused on what conclusions patients drew about themselves at specific times and what mechanisms they used to ameliorate the discomfort. A clearer picture of what has happened to patients can emerge and how the disorder, even prior to being identified, affected the course of their lives in many ways. A similar procedure can be followed to clarify and integrate the sort of subtle effects the disorder has had on their lives following its overt manifestation.
Judgment and Social Skills
Panic disorder patients often exhibit deficits in the following areas involving judgment and social ability. The clinician can provide instruction and education to help the patient learn ways to compensate.
Naivete: Many patients with panic disorder appear to have a somewhat naive perception of others. This may result from the avoidance of new experiences and the need for insulation from unpleasantness. They have difficulty assessing the underlying motivations of others and sometimes seem oblivious to the politics of power relationships. They can become Walter Mitty-type dreamers apparently having learned little of the Machiavellian aspect of human nature. This puts them at a marked disadvantage in dealing with others more educated in the ways of the world. In order to compensate, patients may sometimes use their disorder to gain the leverage in social relations that they cannot obtain by more appropriate means. Thus the conditions are present for patients to obtain dysfunctional secondary gain from their symptoms.
The clinician can aid in this area by helping to broaden and deepen patients’ social perceptiveness. Instruction in analyzing the hidden power motives of others and in realistically "sizing up others" can be provided. Careful discussion of past misperception of motives and intent of others and the resultant problems for the patients can be facilitating. New ways of thinking about and judging others should be provided.
- Roberts, Randy; An Integrated Approach to the Treatment of Panic Attacks; American Journal of Psychotherapy; July 1984; Vol. 3, p 413-427
Reflection Exercise #4
The preceding section contained information
about an integrated approach to the treatment of panic attacks. Write
three case study examples regarding how you might use the content of this section
in your practice.
What two subtypes of phobic conditions secondary to panic disorder have been identified by Roberts? Record the letter of the correct answer