Panic attack or panic about the attack

Phobias, panic attacks, agoraphobia, social phobia, among others, belong to the disorders known as anxiety disorders and which, in everyday language, belong to the universe of fears. In all these disorders, starting from the initial fear, whether or not it is focused on a specific object, a devastating and irresistible chain of physical and organic symptoms is set off, ending in the incapacity and devaluation of the person, to the point of plunging them into the most complete ostracism.

However, at the first link in the symptomatic chain, it is not fear itself that presents, but the fear of feeling the attack of fear, which brings about the fulfilment of the self-fulfilling prophecy: the fear of feeling fear builds and sets off the domino effect that will end in panic.

These symptoms, chained together and potentiated, provoke various ineffective responses, such as fleeing the feared situation, dependence on affective companions who provide security, the total cessation of usual activities, leading to isolation and seclusion as ways of protecting oneself in the face of such a distressing situation, among others.

The physical symptoms can range from the classic lump in the throat and stomach pain (areas where anxiety frequently lodges) to tachycardia, stabbing pains in the chest or stomach, sweating of the hands and body, trembling, headaches, nausea, the urge to vomit, hot flushes, drops in blood pressure, weakness in the lower limbs, blurred vision, etc., symptoms behind which lie fantasies of loss of control, of madness and, fundamentally, of death. It will be enough for a few of these symptoms to appear in the face of a given situation for the domino effect to set off all the others.

The therapist must know this whole process perfectly, in order to position himself as an expert, to increase the patient’s faith in the treatment and to carry out a correct exploration of the focus of the problem, seeking to consolidate the therapeutic bond and to obtain as much information as possible.

In general, fear begins as a difficulty in overcoming a certain type of situation but, progressively, it acquires the status of a problem insofar as it cannot be resolved. The symptom is something like a monster that gets inside the patient’s body. A violator who does not ask permission to invade the person’s intimate space. One manoeuvre of externalising the symptom consists in embodying it in the figure of a monster in order, strategically, to give a body to the ghost of the symptoms and to engage in battle against an earthly enemy.

Once what sets off the whole fear syndrome has been clearly identified (when its object can be specified), or once its non-specific character has been identified, it is necessary to explore what attempts have been made to resolve it, understanding that it is these attempts that sustain and reinforce the construction of the problem.

The attempted solutions that maintain the problem

In the case of phobic disorders, in general, it is the proximity of the object that constructs the unfolding of the picture. At first, the person tries to face it, telling themselves that they can overcome it, that nothing is going to happen to them, that they are capable of it and that nothing can happen to them. But the more they repeat this to themselves, the more the opposite effect occurs.

They find it hard to understand what is happening to them and they fill up with questions that heighten their uncertainty. These many attempts have as their corollary the increase in symptomatology, potentiating the initial anxiety and developing an increase in incapacity, helplessness, devaluation and insecurity, which set off even more anxiety. In this way, the vicious circle opens up again.

But the attempted solutions are not limited to personal initiatives. The person, at this stage of the process, has become more dependent on those around them and has begun to turn to them insistently, in search of answers that would bring them closer to improvement. Their close affective circle therefore embarks on a wide repertoire of solutions doomed to failure: it is common for relatives and friends not to understand how the person can be in such a state. They see them as well (that is, physically healthy), which is why they do not understand, for example, that the person cannot manage to get on a bus or into a lift, that they suffocate when caught in a traffic jam, or that they are in despair at the approach of a pigeon, a chicken or anything at all with feathers.

In interactions with those around them, the comments that develop are of the kind: You can do it! Come on! / You’ve always been a strong person, go for it! / You have to get out / Look what a lovely day it is, and you stay shut in! All these well-meaning expressions aim to reverse the person’s behaviour but, unfortunately, they achieve the opposite result. The protagonist feels misunderstood and believes that nobody puts themselves in their shoes (and this turns out to be true). They are at the mercy of the symptom’s despotism, vulnerable, and consequently, despite their efforts, they cannot turn the situation around. So, to the original anguish is added the anxiety generated by feeling helpless in the face of the symptomatology, and stupid or incapable for not being able to accomplish what their affective circle, those around them, propose.

Another of the failed attempts to resolve the problem is the figure of the anti-panic or counterphobic companion. In these cases, there is always a relative (mother, spouse, brother, friend, etc.) who takes charge of the situation and is over-involved in it. They accompany the affected person everywhere the feared situation might arise, like a drip for a dying man, adding the security the person does not possess. Generally, this companion is totally absorbed by the problem, appearing more worried and fearful than the patient himself, adhering to all the protagonist’s actions, thus stimulating dependence and fostering insecurity, sensations contrary to those desired.

Having reached this point in the process, the person has acquired the status of sick.

Moreover, the patient may have tried the suggestions of neighbours, of general practitioners who prescribed vitamins to fortify the nervous system, or of psychiatrists who recommended some psychotropic drug that relieved the symptom insignificantly, prescriptions that pushed them towards a new dependence. When it was not a relative who took them to a parapsychologist, a clairvoyant, a sorcerer or some such character, who assured them that a spell had been cast on them to do them harm and that they had to light a certain number of candles of different colours and clean the house with white vinegar, a dormitive explanation that raises expectations, with failure as the result. If the therapist does not exhaustively analyse the attempted solutions, he may become one more frustrated attempt among all the others, and constitute himself as an additional character in the story of the panic sufferer who will have succeeded in stimulating symptomatic production.

Paradoxical prescriptions

One of the effective interventions used as a therapeutic resource is the paradoxical prescription, a prescription that turns the actions suggested up to that point by 180°. This possibility constitutes a break with more of the same. That is, ceasing to do what has been done until now, given its ineffectiveness.

Besides prescribing the opposite action, it will be necessary at the same time to teach the patient to set appropriate limits to the imperative suggestions of those around them, who press for change and end up increasing the symptom. The type of messages they will be told to use to deal with these suggestions will be of the kind:

It must be borne in mind that resistance to change is due, mainly, to the persistence of the symptom in the system, which is why a particular ecology has been created around it. Consequently, the modification of this status quo is fought not only by the protagonist, but also by all the members who, to varying degrees, derive benefit from both the sacrifices and the advantages that the symptomatology entails. This is why it is necessary to intervene, as in this case, through the prescription addressed to the patient and through direct interventions directed at the close affective circle.

As regards the indication of a prescription, it is not only a matter of the content one is trying to convey, but of the way in which it is presented. Using Ericksonian hypnotic techniques, the therapist will “sell” a prescription that is very hard to “buy”: to do exactly the opposite of what rational logic dictates, that is, to propose producing the symptom one is trying to suppress. If the patient has tried to assert to themselves: Nothing is going to happen to me (and this has succeeded in increasing the symptom), the attempt will now be to provoke one or two of the first stages of the attack in the face of the feared situation, for example the anguish in the throat and stomach, and the tachycardia.

Faced with the patient’s stunned expression, and firmly, the therapist, as an expert in this type of work (we repeat: he will always present himself as such, in order to strengthen trust and to bring about the carrying out of the task), meticulously suggests the prescription, recreating the images in advance and entering through the channels most developed in this patient (visual, auditory, tactile, olfactory). He will look for approval in the patient’s gestures, speaking their own language and perhaps resorting to analogies, tales or metaphors, for example:

In general, the introduction of prescriptions can produce several types of result. For example, when the patient has not carried out the prescription, it is a failed effect that shows the difficulties of change (or the possibility that the therapist prescribed inadequately). In general, many pretexts are put forward, the most frequent being: that they wanted to do the task but could not, that they did not have time… This appears even more clearly when they claim to have forgotten to do it and only remember when the professional mentions it at the next session. On other occasions, they remembered that they had a task, but it remained recorded only at the level of an idea and they did not put it into concrete action.

Another frustrated effect occurs when the patient claims to have carried out the prescription but, when the therapist asks for details of the process, argues that they did not need to summon the symptom voluntarily, since it appeared spontaneously. A small stratagem that evades the possibility of mastering it and keeps the symptom in place.

Three results can be considered favourable: …