Panic attack

It is experienced suddenly and makes you feel helpless to do anything. The person consciously “knows” they will not die, but at the same time loses the ability to control their fear and begins to believe they will die.

A panic attack can also be directed toward others — worrying that a loved one will be hurt or experience a disaster.

A panic attack may occur only once or twice in a lifetime but can become more frequent and develop into panic disorder.

Epidemiology

According to statistics, 2.7% of the world population experience some form of panic attack within a year, while 4.7% have experienced at least one panic attack in their lifetime.

Panic attacks generally begin during or after puberty, with the highest risk between ages 15 and 19.

Anatomy of a Panic Attack

A panic attack lasts relatively briefly, up to 10 minutes (subjectively it feels longer), and tends to recur.

Italian psychiatrist Franco de Masi identifies several mechanisms underlying the onset of panic attacks:

Preparation

Although it seems sudden, a panic attack has a slow buildup process.

During mild or severe distress caused by stress, a person begins to closely monitor their body, as one would listen to the earth after an earthquake. The mind registers that something is happening in the body, and imagination exaggerates bodily symptoms, inventing danger that triggers overwhelming fear.

The stronger the physical symptoms (dizziness, rapid heartbeat, shortness of breath, sweating...), the more the person believes death is near. The expectation of disaster is so strong that it causes a state of micro-psychosis. Neurovegetative pathways connecting consciousness are highly stimulated, and the person loses the ability for rational control.

The body begins to express its agony, which the person experiences as a panic attack.

Imagination

Imagination plays a significant role in triggering panic. One reason for the repetition and worsening of panic is the link between the stimulus (stressor) — imagination — emotional response.

If unchecked, imagination leads to the development of bodily fear that turns into a panic attack.

The emotional response is a product of imagination. Those experiencing panic attacks believe what they imagine will happen. Fantasy becomes reality.

Traumatic Fear

Once it occurs, a panic attack imprints as a traumatic event. A typical example is a person bitten by a dog who then fears and dreads all dogs.

From then on, everything reminiscent of the panic attack becomes associatively linked and develops fear toward those objects, situations, people... Associations unconsciously spread and increasingly limit autonomy.

Although the person “survived” the panic attack, they fear the next potential attack (because the experience is so unpleasant they never want to feel it again). This creates a vicious cycle that causes an automatic response to any distress, which may escalate into another panic attack.

Recurrence

After the first panic attack, it tends to recur. Even though someone survived a panic attack, it is very difficult to convince them they will survive the next one.

As a result, the person starts over-monitoring their body, so even slight anxiety becomes a sign something is wrong. Consequently, the intensity of fear increases, and the panic attack tends to repeat.

Clinical Picture

A panic attack is a particularly emotional experience that differs from other experiences of fear. It is a true outburst of terror that comes “like a bolt from the blue,” “out of nowhere,” accompanied by thoughts: I will die, I will faint, I’m choking, this is a sign I’m going crazy, I must run away, I must stop this, I can’t bear it...

The most common physical symptoms are: rapid heartbeat, feeling of losing consciousness, difficulty breathing and shortness of breath, dizziness, chest pain and pressure, trembling, legs like rubber, sweating, hot and cold waves over the body, decreased or increased sensitivity to touch, sound, temperature.

A specific feature of a panic attack is the psyche’s failure to contain the fear, which is “released” into the body. When the psyche cannot perform this task, the dread that turns into physical symptoms becomes panic. The person may think, “No, I’m not anxious, I’m dying!” In other words, the same constellation of factors is experienced as in real death.

Besides frightening depersonalization and derealization phenomena, the fear of death is the most common and distressing mental content. It is an experience of life threat that seems imminent or about to occur at any moment. Fear of loss of control is the central content. The person experiences that they will go crazy, run, shout nonsense, or be aggressive toward others.

Behavior During a Panic Attack

Specific behaviors accompany a panic attack:

• Psychomotor agitation — the person feels tension, restlessness, can’t sit still, is constantly moving, ready to flee from the threatening place.
• Appeal behavior — in a state of agitation, the sufferer seeks immediate help and ways to calm down or wants others to calm them. They often call emergency services or personally go to medical institutions demanding urgent intervention.
• Seeking and isolation — less common in clinical practice. The person withdraws from daily events and clings to important people who provide security and protection, often spouse, partner, parent, or children.

The impact of a panic attack is not limited to its peak symptoms and reactions. It can also lead to negative emotions after the attack — feeling ashamed, embarrassed, or inadequate when recalling one’s behavior and words during the panic attack: “What do they think of me now that I lose control like this?”

An even stronger and more unpleasant emotion than shame can be fear of the next panic attack, which partly guarantees that the next attack will occur again. In such cases, the next attack may be much more intense, leading to feelings of helplessness, hopelessness, and dysfunction.

Causes of Panic Attacks

Panic attacks do not occur without reason, contrary to what those experiencing them for the first time might think.

They are usually preceded by a series of adverse events that cause the person to feel distressed: chronic stress, intense anger, loss of loved ones, prolonged psychological pressure, insomnia, separation from (home, family, partner), job loss, but also use of psychoactive and psychotropic substances.

Besides psychological, neurobiological, and physiological factors such as inherited temperament traits, sensitivity to stress and fear, hypersensitivity — panic attacks have roots in childhood.

Research has shown that parental behavior plays an important role. Many sufferers report that their parents were overprotective or neglectful, expressed anger and hostility, frightened them, or were controlling and critical. One parent may have been passive and withdrawn, the other dominant. They were emotionally unavailable and could not form quality emotional bonds.

On the other hand, parents themselves may have often been distressed and did not know how to calm themselves.

The most common conflict zone in panic attacks built between children and parents is dependence-independence. Parents who encourage dependence often create an image of themselves as someone without whom the child could not cope. This attitude firmly binds the child, creating feelings of helplessness, emotional dependence, and low self-confidence.

Psychodynamics of Panic Attacks (skip if uninterested)

According to Freud, a panic attack is a “neurotic manifestation of condensed anxiety” consisting of:

1. Inability to properly use signal anxiety, experienced as disintegrative
2. Inability to resolve the Oedipal situation
3. Inability to modulate aggressive impulses, experienced as fear of death or madness
4. Lack of mental container — a second person needed to process emotions

Signal and Automatic Anxiety

Freud distinguished Signal Anxiety (potential danger) from Automatic Anxiety (real danger).

Signal anxiety warns us of impending danger and prepares us to face it. In these situations, since the Ego is hypersensitive and poorly developed, it cannot distinguish signal from automatic anxiety and transforms potential danger into real.

The mind ‘contains’ the anxiety without being overwhelmed. The subjective drama experienced during the crisis is equivalent to ‘nameless terror’ or ‘disintegrative anxiety,’ and since the mind cannot process it, it flows into the body. So instead of feeling anxious, the person feels like they are dying.

Unresolved Oedipal Conflict

Within the psyche, incestuous and aggressive impulses prevail. Since they are undernourished in the Id, they demand discharge from the Ego. Meanwhile, the strict Superego does not allow their expression. Thus, enormous pressure is applied on the Ego from both sides.

Because the Ego is weakened or underdeveloped, its defenses are not strong enough to resist the demands of the Id and Superego, and the Ego perceives them as terribly dangerous and uncontrollable.

In this state, unconsciously, the subject perceives themselves as a dangerous and aggressive opponent and evokes danger of hurting libidinally cathected objects. Therefore, a defensive regressive process is activated, leading to a dependent and helpless state. Then feelings of unconscious guilt are activated by aggressive impulses.

This leads to the attack state.

It is called traumatic anxiety because during the attack, the Ego unconsciously replays trauma in physical ways. Extreme bodily vulnerability as fear of castration deepens separation anxiety.

Panic sufferers often want to escape from their ‘fragile’ parts of self, using counterphobic processes. Sometimes fantasies of complete independence occur, in conflict with the desire for dependence.

Loss of Mental Container

Why container? Since the panic sufferer cannot calm themselves, they need a ‘container’—someone externally available to process emotions for them. During a panic attack, the person regresses to a childlike state seeking a mother figure to help understand where the ‘inner terror’ comes from.

In the absence of a mental container and inability to symbolize, the individual undergoes actual trauma (images, sounds, bodily symptoms indicating that the fear is experienced as trauma).

Greenacre speaks of a deficit theory of panic attacks—people who experienced prolonged unresolved tensions in childhood did not develop the Ego’s capacity for defense and frustration tolerance.

Treatment of Panic Attacks

The good news is that the prevalence of panic attacks is very treatable.

In most cases, a short-term psychotherapy treatment lasting a few sessions is sufficient. In severe cases, where panic attacks last years or are accompanied by other mental disorders, medication is needed alongside psychotherapy.

It is important to emphasize that psychological treatment is tailored individually. We are all different and cope with problems differently. Everyone has their own pace of dealing with difficulties, so if panic attacks persist after several sessions, it doesn’t mean the person is severely disordered.

Sometimes symptoms can return after successful treatment, requiring additional consultation with a therapist.

Nemanja Kurlagić – psychotherapist trained in the O.L.I. method