Lessons from the Pandemic: Panic Attacks Are Not Random

Enrico Gnaulati, PhD
15
1722

At the height of the Covid-19 pandemic, Google search trends revealed an astronomical rise in searches related to panic attacks and their treatment. At one level this is hardly surprising, given the pre-vaccination hospitalization and death rates due to Covid, the widespread quarantining, downturn in the economy, and uncertain employment prospects affecting most Americans. People had reason to panic.

Yet, when we look at the psychiatric definition of what constitutes a panic attack, reason does not enter into it. Panic attacks, by their very definition, are categorized as random psychophysiological events—pounding heart rate, chest pains, constricted breathing, dizziness, sweating, chills, fear of losing control or dying—that are unpredictable and seem to occur out of the blue, with no ostensible explanation based on surrounding circumstances.

Thea Gallagher, director of the outpatient clinic at the University of Pennsylvania’s Center for the Treatment and Study of Anxiety, captures the seemingly random nature of panic attacks: “What’s happening to me? I feel like I’m dying or going crazy and I’m just sitting in my house.”

Consistent with this, the scientifically endorsed treatment of panic stops short at managing symptoms: slow, deep breathing exercises; “talking back to” catastrophic thoughts; use of mindfulness techniques; possible use of benzodiazepines. Experts also prescribe things like exercise, meditation, and even smelling lavender to sooth one’s senses.

What often gets lost is a viewpoint where panic signifies a deeper psychological struggle requiring treatment that both manages and understands symptoms. Many clients who get flooded and overwhelmed by anxiety are unaware of the real sources of their distress, the knowledge of which would better inform them how to more effectively and productively turn their lives around. This has implications for how we best treat panic in clients during the Covid pandemic. If we stop short at just helping clients manage their panic, we run the risk of foreclosing deeper conversations about the underlying sources of their dread and side-stepping more on-target ways of dealing with it.

For example, during these harrowing times, what some clients assume is a panic attack is really a form of death anxiety—the dreaded awareness that their, or a loved one’s, life could be cut short suddenly and tragically. From an existential-humanistic perspective, there are psychological rewards to facing and accepting one’s mortality, and that of loved ones. It creates true impetus to live more fully, intentionally, and appreciatively in the present. It helps us step around and laugh off all the everyday annoyances that ordinarily vex us, because, after all, we only have one life to live and the clock is ticking. It throws life into perspective, potentially compelling us to prioritize pursuits that give us the most meaning and purpose in life. It is a nagging reminder not to spoil the ever-diminishing time we have lefty on this planet by sweating the small stuff.

Two other types of anxiety that often get confounded with panic are engulfment and separation anxiety. As for the latter, during quarantine, many people forced to live in close quarters with minimal privacy and alone time, intrusively impinged upon by others, their freedom of movement restricted and needs for autonomy undermined, have been prone to engulfment anxiety. Their irritation and crankiness can be thought of a desperate, indirect way of pushing others away to create needed emotional distance.

Effective therapy would seem to entail engendering an awareness and verbal processing of the engulfment anxiety at play, family-of-origin experiences that perhaps potentiated it, and the acquisition of more assertive, proactive, less off-putting ways of asserting autonomy and needs for aloneness.

The pandemic has also separated people suddenly and indefinitely from friends and loved ones, engendering hardship and distress—separation anxiety. Glossing over possible separation anxiety issues in the act of helping clients simply manage symptoms of panic limits what we have to offer as therapists.

In my experience, there are two other clinical phenomena that often get mischaracterized and ignored in the rush to accept at face value a client’s self-report of panic. The first is what I would call a “suppressed rage attack.” The conditions which often govern defenseless flight reactions—panic—also have implications for defensive fight reactions—rage.

Along these lines, several years ago I was conducting a parenting intervention with a divorcing couple. The soon-to-be ex-wife launched into a verbal diatribe of how stingy her husband was with money and insisted she would be hiring top-gun attorneys during the divorce proceedings. In that context, the husband had what appeared to be a full-blown panic attack. I called the paramedics since my immediate concern was the risk of the husband possibly suffering a heart attack.

Days later when I followed up with the husband, he reassured me that the ER had medically cleared him. He confessed that during our session he was doing everything in his power to hold back from showing his fury at his wife, since in his opinion he had always been generous in financially supporting her and had made it known he would continue to be fair and reasonable in his financial dealings with her after the divorce.

Deficits in personal agency can also set clients up for panic attacks. Or, what used to be called “an external locus of control.” This pertains to clients who live their lives as if they are the subject of other’s intentions. Their beliefs about themselves are overly influenced by their perceptions of how others think of them. This can unmoor them from any solid and consistent self-beliefs anchored to the actuality of their lives.

I once treated a teenage boy who panicked over the notion that he might be gay. He was strikingly handsome and frequently caught boys staring at him. He took this as incontrovertible proof he was gay. He would go home and watch gay pornography, hyper-monitoring any arousal he might feel. Any tiny twinges of pleasure would throw him into a panic. This, despite the fact that he was sexually active with his girlfriend, only ever masturbated watching heterosexual pornography, and was sexually disinterested in members of the same sex. The fluidity of his self-boundaries was such that if he believed other boys were attracted to him, he must be gay.

Had I simply viewed his panic as a random psychophysiological event that needed to be managed with breathing and relaxation exercises, rather than a clarion call to trust his thoughts and emotions more resolutely and not cede personal agency so readily, I would have denied him access to the type of personal transformation he needed to lessen his susceptibility to intense anxiety.

The ease and confidence with which many clients assume they are prone to panic attacks reflects larger cultural trends truncating and framing human suffering in medicalized terms. I am not proposing that cognitive-behavioral techniques and medications do not have their place in the treatment of panic attacks. What I am proposing is that symptom management ought to be considered a starting point, not an end point, to treatment.

Once the client is sufficiently emotionally collected, deeper, less obvious sources of emotional danger and challenge become the therapy’s new frontier. Otherwise, in the words of University of Denver psychology professor Michael Karson, we “disable the burglar alarm instead of dealing with the burglar.”

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

15 COMMENTS

  1. “What I am proposing is that symptom management ought to be considered a starting point, not an end point, to treatment.”

    So true, and the same can be said for all the DSM disorders, including the ones where therapists force people onto the psych drugs, that create the symptoms of their “serious DSM disorders.”

    https://www.alternet.org/2010/04/are_prozac_and_other_psychiatric_drugs_causing_the_astonishing_rise_of_mental_illness_in_america/
    https://en.wikipedia.org/wiki/Toxidrome
    https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome

    I will agree, the “mental health” workers’ desire to “manage symptoms” – while ignoring, dismissing, and actually calling “fictional,” the real life concerns of their clients’ – is one of the biggest problems with both the psychological and psychiatric industries.

    And ultimately, such ungodly disrespectful maltreatment, rendered almost all “mental health” workers – except those who speak out honestly against the system – too stupid for me, personally, to deal with, or respect.

    • I agree Someone Else,
      Psychiatry seems to prolong the problem and make it a lot lot worse. Whereas what’s needed are decent solutions, and there are decent solutions available.

      As far as Prozac goes:- The UK Health System is now pulling away from “antidepressants” due to what you describe above.

  2. I don’t know what anyone elses experience is. But if I was to follow my automatic instincts when in distress my thinking would reinforce my anxiety and create “endless” circular anxiety

    If I don’t engage my circular thinking my anxiety eventually runs out of steam – and then there is no anxiety. My mind comes into acceptance mode and I can look at the same problems, without distress and see what I can do about them.

    So far this has worked for me.

    I didn’t suffer a lot of Anxiety around Covid 19 – but I did (historically) suffer from “Tremendous Anxiety” when withdrawing from long term “Antipsychotic” Injections “suitable” for “Schizophrenia”- and this was when I found my relief.

    We do have to deal with the burglars as well!

  3. I think people are perfectly able to understand and pinpoint what is causing their emotional distress but “treatment” providers routinely dismiss causes as merely “triggers” of inevitable “mental illness”. They also feel no responsibility to help emeliorate the social/environmental causes because that doesn’t sell pills or keep patients returning for more. “Not my problem” the doctor says to himself as he scribbles off another script and creates a new recurring source of income.

    I was physically assaulted, sexually assaulted and experienced a break-in in 2020. The police responses to these events was to target me for potential psych treatment. COVID was the least of my worries. Despite all these insane stressors, I remain prescription free and even bought my first home at the end of the year. I knew that professional “help” would be worse than useless and I muddled by with a little help from my friends. I know damn well where the source of my panic arises and I strongly suspect, having known hundreds of other “patients” over the years that they do too.

    Please don’t infantilized us and act like people don’t know what’s bothering them or that the majority of people living hand to mouth are too stupid or inept to tell you what’s causing their distress.

  4. Thank you for the great article. “Reason does not enter into it” – I especially like this! Indeed, if one applies PANSS rating scales to “the psychiatric definition of what constitutes a panic attack” and to other such definitions, their authors, according to their own criteria, should get a psychiatric diagnosis. One PANSS item is “stereotyped thinking … as evidenced in rigid, repetitious or barren thought content.” Right on target – you cannot get more stereotyped and less barren thought content than displayed by such definitions

  5. This is an interesting commentary. It seems to say that people (patients?) are self-diagnosing a panic attack when something else is really going on. Or clinicians might be doing this, too?

    To me, this just continues to betray the enormous lack of knowledge about people and the human mind displayed by most clinicians, and of course, most people who are being informed by these clinicians, or other “mental experts.” How long does this have to continue before someone inside the subject begins to get the idea that they need to figure this out?

    When someone behaves in a way that seems irrational or inappropriate to the situation, we have to realize that the information, instructions or commands that caused that behavior must have come from somewhere. We normally call that place “the mind.” There are two main pathways for information to enter the mind. One is an analytical, rational and conscious pathway. The other is a non-analytical, irrational, and unconscious pathway. The main goal of therapy is to put the being in a position where they no longer need to rely on any of the mental information acquired via the unconscious pathway. That puts them back in full control of their behavior, which is where they ought to be. The apparent fact that most therapists have little or no idea how to accomplish this is a huge condemnation of the subject. They have had ample time to figure this out, and they have failed. We must assume that figuring this out, and thereby really helping people, was not their major purpose in getting into the field of psychology. What, then, was?

    • I_e_

      “…The apparent fact that most therapists have little or no idea how to accomplish this is a huge condemnation of the subject….” – Most therapists would have LITTLE OR NO IDEA of what you are just after explaining.

      “…We must assume that figuring this out, and thereby really helping people, was not their major purpose in getting into the field of psychology. What, then, was?..” – Wasting Time, and getting paid for Wasting Time.

      • A big part of the problem is that there is no actual standard on what “helping people” actually means. Of course, it can be vastly different for each person from their own perspective -forr one it’s getting married, another it’s getting out of a dead-end job, another it’s recovering from childhood abuse, another is working on serious health issues – naturally, when you lump together people who have little to nothing in common, it’s going to be hard to define any kind of “improvement.” The only thing that makes sense to me as a standard is that the person in front of you becomes more capable of handling his/her life in as self-determined a way as possible. Nothing else really can make sense for everyone at one time. Not very “measurable,” but I’d say the client/helpee will know if they are feeling more in control of their lives!

        • “Help” will always be an entirely subjective proposition, won’t it?
          While I can imagine what might be most helpful to a person in emotional or mental distress, and might base my attempt to help on my idea, I won’t know if the person has been helped unless I ask them.

          There is, perhaps, a strata in society that is so lacking in self-awareness that they would be unable to tell you if they had been helped or not. And there are others who just wish someone would help them to die. But the great majority have some general concept of what helping and being helped really means.

          So your “measure” in the field of mental health should be: Does the person feel helped? Shouldn’t it be? I suppose a person could become so deluded that he confuses harm for help. But most people should be able to give you a straight answer to this question, and why would we settle for any other measure?

          • “Helping” is what I do when I set the table or wash the dishes when I am asked to dinner at someone’s home. Despite the fact that professions in the “mental illness industry” are sometimes classified as “helping professions” there is what we call now a big disconnect. What the psychiatrists and their buddies do is not “help.” It is nothing but interference in another person’s life. True Helping is practical and kind. psychiatry is neither practical nor kind. Drugging and psychotherapy and their other hair-brained treatments are not practical and kind, but damaging, dangerous, and life threatening. We need the kind of help as I described at the beginning of this post. It is natural and humane. It shows consideration, respect, decency, kindness and understanding. I wish I could say the same for psychiatry, etc. Sometimes, they seem to try; but, it is phony and false. And, even more terror is added onto to this when you receive the bill or pay for those drugs. Psychiatry doesn’t help. It hurts. It hurts so bad, I would rather fall down and skin my knees. Thank you.

  6. Perhaps, the standard could be that without drugs or other false treatments or therapies, the individual is not as afraid of the storms. The other standard is that without drugs or other false treatments or therapies, the person is more aware of the strengths and weakness in which he or she was gifted from God and can not utilize these in service to God and others. All this involves a special word that seems to be the definite enemy of psychiatry, etc.—-LOVE. Thank you.

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