Panic disorder is a type of anxiety disorder characterized by recurrent and unexpected panic attacks, Barlow, DH (2002). Panic attacks have been documented throughout history, but their meaning and connection to anxiety disorders have not been fully understood.
The History of Panic Disorder
Ancient Greek and Roman medical texts mention symptoms similar to panic attacks, but no distinct disorder was recognized, Goisman, RM, & Warshaw, MG (1995). French physician Jean-Martin Charcot observed a condition he called "Great Hysteria", which included symptoms resembling panic attacks. Sigmund Freud also studied similar symptoms and classified them as "anxiety neurosis" or "anxiety hysteria." In the early 20th century, psychologists and psychiatrists continued to study anxiety disorders and the manifestations of panic attacks, Barlow, DH (2002). A German psychiatrist, Emil Kraepelin, described a condition called "phobic anxiety" which encompasses panic-like symptoms. However, the exact classification and understanding of panic disorder was still evolving, and around the mid-20th century, researchers such as Donald Klein and others began to focus on panic attacks as a distinct phenomenon in their own right. They recognized that panic attacks could occur without an external trigger and were not necessarily associated with other psychiatric disorders Grossman, RM, & Warshaw, MG (1995). The third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III) officially recognized panic disorder as a distinct diagnosis. She also classified panic disorder as an anxiety disorder characterized by recurrent, unexpected panic attacks and subsequent anxiety related to the possibility of experiencing further attacks. Since its official recognition, considerable research has been conducted to better understand panic disorder. The role of neurotransmitters, particularly serotonin, in the development of panic disorder has been studied extensively, although much criticism remains on this subject, Klein, D. F. (1964). Medications, such as selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines, have been developed and studied, in randomized clinical trials, as effective treatments for panic disorder. Additionally, cognitive behavioral therapy (CBT) and other psychotherapeutic approaches have been shown to be beneficial in the management of panic disorder, Nardi, AE, & Freire, RC (2010) as well. Contemporary research and understanding of panic disorder continues to explore the causes, risk factors, and treatment options for panic disorder, including the role of genetics, environmental factors, and the interaction of different neurotransmitters, Craske, MG, & Barlow, DH (2006), but there have been few significant developments. It is important to note that the understanding and recognition of panic disorder has evolved and treatment options are available for patients.
Diagnosing panic and agoraphobia
Not everyone who has panic attacks has a panic disorder. For a traditional diagnosis of panic disorder, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, lists the following criteria.
- You must have frequent and unexpected panic attacks
- At least one of your attacks was followed by a month or more of constant worry about having another attack; continued fear of the consequences of an attack, such as losing control, having a heart attack, or "going crazy"; or significant changes in your behavior, such as avoiding situations that you think could trigger a panic attack.
- Your panic attacks are not due to drug or substance use, a medical condition, or another mental health condition, such as social phobia or obsessive-compulsive disorder.
Strategic etiology
The World Health Organization defines panic disorder as a significant condition that affects up to 20% of the world's population, with women being twice as likely to be affected as men. Panic disorder evolves through progressive attempts to control our natural and spontaneous reactions to a perceived threat. This attempt at control usually seems to work for a while, until the person experiences their first total loss of control, Nardi, AE, & Freire, RC (2010). This overwhelming feeling of panic and psychophysiological excitement that exceeds the normal limit is perceived as a truly frightening and often life-threatening episode. Failed attempts to eradicate fear create a spiraling problem that becomes a vicious cycle of responses and perceptions, which becomes even more rigid with the repetition of useless solutions. The person's constant hyper-vigilance of themselves, their breathing, their heart rate, their balance, etc., as well as their desire to control any alterations in their physiology, precipitate fear. even that the patient seeks to control. At this point we can say that the genie is out of the bottle and the body's natural arousal system is triggered. The greater the level of control one seeks to impose on one's bodily reactions, the more these become worse, leading to panic disorder. The patient's solution became his problem, and his problem became his solution. It is trapped and any attempt to solve it through control is doomed to failure. This fear of panic and, later, the fear that it occurs when the patient is alone and outside, induces agoraphobia, even claustrophobia accompanied by panic attacks.
Agoraphobia
In the case of agoraphobia, a relational dynamic is introduced and the patient generally seeks help and turns to anyone who can help him by accompanying him in the social situations he may face. As stated earlier, all human behavior is a form of communication, and every time a person seeks help and gets it, they lock themselves into a double bind, Watzlawick et al. (1967). Whenever someone accompanies her, "she confirms that she is safe because she has help, but she also confirms that she is unable because she needs help" and therefore his solution fuels his problem, pushing his phobia to new extremes, Gibson, 2021; Barlow, DH (2002). Some people with panic disorder have a clear and distinct place or situation that triggers the fear, and others seem to live in constant dread of that ghost that frightens them at all times, living their lives like a soldier on a field of mines that are perpetually anticipating a loss of control. An effective treatment allows us to act on the mechanisms described above, quickly block the problem and resolve the disorder, often in 7 to 10 sessions. Panic is often misdiagnosed as generalized anxiety disorder, when in reality there is no complete loss of control typical of panic in generalized anxiety disorder. In generalized anxiety disorder, the state of arousal is constant, but there is rarely, if ever, a tipping point in fear. Panic as we have defined it is characterized by an extreme form of arousal of fear, which becomes pathological and therefore requires professional help when the person is stuck with the problem - despite their constant personal attempts to resolve it. , Klein, DF (1993). In our strategic diagnosis, we focus our attention, not on describing the problem, but on intervening in how it works and how we can intervene in the patient's attempts to solve it.
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Failed attempts to resolve panic disorder
- The attempt to avoid situations of fear makes us less able to face this monster that consumes our thinking and our behavior and increases our fear of avoided situations.
- The search for help and protection, which at the same time provokes the feeling of security, but which then feeds the perception of fear. By delegating our fears to others, we become completely unable to face these situations alone and thus we feed our feeling of dependence and incapacity.
- The permanent and continuous attempt to control one's physiological reactions to fear paradoxically leads to a total loss of control of one's natural reactions.
Strategic Solutions
Avoid-Avoid
Resolution involves the therapist acting on the avoidance behavior as we have described it. To do this, we use a series of suggestive interventions capable of distracting the person during the feared situations, which leads the patient to adopt counter-avoidance measures. Finally, we interrupt their attempt to intentionally suppress their spontaneous reactions. We also use the diary intervention (see below) (Gibson, 2019, Nardone, 2002, 2003, 2007, Portelli & Nardone, 2007). This intervention has been designed in such a way that with minimal effort we can produce an emotional detachment from the situation and create a new capacity on the part of the patient to better manage his situation.
The worst of fantasies
At the heart of panic attacks is the attempt to control, which leads to loss of control. It is therefore necessary to introduce a technique capable of successfully intervening in panic attacks in the absence of a real source of threat. This is especially true in cases where the frightening threat does not come from outside but emanates from the fear of fear that triggers the paradoxical escalation of panic. The "worst fantasy" technique is the fruit of our continuous research in the clinical setting and is based on the real and concrete effects of paradoxical interventions. These are interventions that seem to go against the objective that we are trying to achieve. We ask the patient to actively produce their symptoms as part of a daily ritual. The "worst fantasy" is for the patient to take 30 minutes a day to induce a panic attack. It's about gaining control or losing control to regain it. In general, this has two possible effects. Either the person can produce the fear which subsides over time, thus eliminating his fear through habituation, or he experiences the paradoxical effect of not being able to produce the fear. In this case, the patient finds that he is better able to cope with situations he previously feared.
Anxiety diary
This intervention is most effective for people who become overly aware and anticipatory, avoiding their fears that can trigger panic. As part of this intervention, the therapist asks the patient to continue his daily life as usual, but to take with him the logbook which will help us to follow and therefore understand what is happening to him in these critical moments. Each time he feels a fear, he must quickly take out the diary and fill in the following table: date and time, place and person(s), situation and thoughts, symptoms, reactions. The real intention of this task is to shift their attention from their fear to the task, allowing them to better handle this difficult time, on their own. This intervention leads to a corrective emotional experience between sessions in everyday life. What we usually find is that not only does the person come back to the next session with the task done, but more often than not their panic episodes have reduced considerably (it is not uncommon for them to be reduced to zero ) and that she feels different about her situation. This emotional change is very important for our work, because only after the person has felt a sense of change can we start introducing other situations in which they can challenge themselves, but they start anyway to do it spontaneously.
fear of help
Research and strategic intervention in phobic and obsessive disorders (Gibson, 2022, Portelli and Nardone 2007, Nardone, 1996) have shown that when a person asks for help and receives it, this solution confirms and nurtures their issue. To quickly break this vicious cycle, we have proven a strategic reframing of their seemingly helpful solution:
“Well, first of all, there's something I want you to think about over the coming week. I want you to think that every time you ask for help and receive it, you receive two messages simultaneously. The first message, obvious, is "I love you, I help you and I protect you". The second message, less obvious but stronger and more subtle, is "I'm helping you because you can't get by on your own and you'll be sick if you stay alone". Please note that I am not asking you to stop asking for help because I know that right now you are not capable of not asking for help. I only ask you to remember that each time you ask for help and receive it, you are helping to maintain and aggravate your problems. But please don't make an effort to avoid asking for help, because you are not yet capable of not asking for help. The only thing is, every time you ask for help and receive it, you make things worse."
So, even if their help initially seems to have beneficial effects, it will eventually lead to a worsening of their disorder. The technique used here is that of fear against fear. The fear of increasing the severity of the problem is much worse than the fears that constantly drive the person to seek help. Fear is conquered by fear, as the Latin saying goes: "Ubi major minor cessat".
Some useful questions
When you panic, are you afraid of dying or losing control? (phobia or obsession)
When you panic, do you face the situation or do you tend to avoid it? (attempt to solve)
If you have to confront yourself, do you do it alone or do you include other people? (relational dynamics)
When you run away from a situation, do you tend to talk about it or not? (relational dynamics)
Does panic occur in a specific situation or can it occur anywhere? (general or specific phobia?)
Case study
This case study presents the story of Maria, a 47-year-old woman who was diagnosed with panic disorder. Panic disorder is a type of anxiety disorder characterized by recurrent, unexpected panic attacks and a persistent fear of future attacks. This case study aims to provide an in-depth understanding of Maria's experiences, symptoms and treatment journey.
General informations
Maria is a brilliant marketing manager who leads a demanding professional life. She has a supportive family and a group of close friends. Over the past year, Maria has experienced sudden and intense episodes of fear and unease, accompanied by physical symptoms such as rapid heartbeat, shortness of breath, tremors and dizziness. These episodes, known as panic attacks, began to impact his daily functioning and overall quality of life. Maria's panic attacks usually occur with no apparent trigger and can occur at any time. She describes these episodes as overwhelming and terrifying, with a sense of impending doom. The physical symptoms are so intense that she often fears she is having a heart attack or losing control. As a result, she developed a fear of going out in public, crowded places, or situations where it would be difficult to escape. Maria's panic attacks became increasingly frequent, occurring at least once a week. The fear of having another panic attack caused her to avoid various activities, such as social gatherings, shopping malls, or even highway driving. She also noticed a significant impact on her sleep patterns, often having difficulty falling asleep due to her fears of having panic attacks.
Results
During therapy, Maria notices an improvement in her symptoms and a reduction in the frequency and intensity of her panic attacks. She becomes more confident in managing her anxiety and develops effective coping strategies. Maria is gradually returning to her daily activities, including socializing and participating in situations she previously avoided. With the continued support of her therapist, Maria continues to work on her long-term recovery and relapse prevention.
Impact on life
Maria's case highlights the impact of panic disorder on an individual's daily life and the importance of early intervention and appropriate treatment. Through a combination of psychotherapy, medication and lifestyle modifications, Maria manages to control her panic symptoms and improve her quality of life. This case study demonstrates the effectiveness of a comprehensive and individualized approach in the treatment of panic disorder, giving hope to people facing similar challenges.
Bibliography
1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
2. Barlow, DH (2002). Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic. Gilford Press.
3. Craske, MG, & Barlow, DH (2006). Mastery of Your Anxiety and Panic: Therapist Guide for Anxiety, Panic, and Agoraphobia. Oxford University Press.
4. Gorman, JM (1996). Panic Disorder and Its Treatment. Journal of Clinical Psychiatry, 57(Supplement 10), 39-45.
5. Grossman, RM, & Warshaw, MG (1995). Panic disorder. Harvard Review of Psychiatry, 2(2), 89-101.
6. Kessler, RC, Chiu, WT, Demler, O. and Walters, EE (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617-627.
7. Klein, DF (1964). Delineation of two drug-responsive anxiety syndromes. Psychopharmacology Bulletin, 1(1), 13-19.
8. Klein, DF (1993). False alarms of suffocation, spontaneous panics and related states: An integrative hypothesis. Archives of General Psychiatry, 50(4), 306-317.
9. Nardi, AE and Freire, RC (2010). Panic disorder and social anxiety disorder. The British Journal of Psychiatry, 197(1), 6-7.
10. Nardi, AE, & Stein, DJ (Eds.). (2012). Handbook of Anxiety Disorders. Springer.
11. Watzlawick, P., Jackson, D and Beavin Bavelas, J. (1967). On Human Communication: A Study of Interactional Patterns, Pathologies, and Paradoxes. Norton.
12. Watzlawick, P., Weakland, J. and Fisch, R. (1974). How Real Is Real? : Confusion, Disinformation, Communication. Norton.
13. Watzlawick, P., Weakland, J., and Fisch, R. (1974). Change: Principles of Problem Formation and Problem Resolution. Josey Bass.
14. Watzlawick, (1984). The Invented Reality: How Do We Know What We Believe We Know? Norton.
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