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.”
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.