Panic attacks linked to a specific situation may be underestimated precisely because the circumstance in which they occurred is interpreted as the triggering factor, or the cause. The person therefore does not fear that the attack will recur outside that particular circumstance.
“Unexpected” attacks, which are the typical form, instead immediately or subsequently create a state of alarm without a specific cause or identifiable trigger, and therefore an alarm that remains constantly “lying in wait.”
Similarly, if, after an initial attack linked to a specific circumstance, subsequent attacks occur in different circumstances, the number of possible triggers multiplies. The person becomes convinced that an attack can occur in a whole range of different circumstances and, essentially, without a single specific reason.
In situations in which the person believes that an attack might “start,” or believes that one is already beginning based on certain “warning” symptoms, they develop what is known as an anticipatory anxiety response.
This is essentially a preparation for a possible attack: an anxious state of readiness in which being prepared does not improve the person’s ability to manage the situation if an attack occurs, but instead makes it worse.
Two dynamics take place in this mental state. One involves interpreting the circumstances of the moment as factors “for” or “against” panic.
On the one hand, the person becomes attached to elements they believe will help prevent the attack or keep it under control. On the other hand, they flee from elements they believe might trigger panic or make it impossible to manage—for example, crowds, enclosed spaces, being far from home or from a familiar place, and so on.
The two guiding thoughts become:
- How can I avoid the attack?
- How can I escape to safety if an attack occurs?
The person tends to convince themselves that anticipatory anxiety itself must be avoided because otherwise it will bring on the attack—that is, they may become so suggestible that they actually trigger a panic attack simply because they are afraid of having one.
Attention and countermeasures therefore tend to focus not on the panic attack itself, which is already difficult to manage regardless and may vary in intensity and duration, but on anticipatory anxiety, which becomes the “ambassador” of the panic attack.
By focusing on anticipatory anxiety, the person loses a rational understanding of the panic attack and shifts toward a “phobic” way of viewing it.
In other words, after ten panic attacks, the person should ideally come to understand that the attack does not develop into anything particularly dangerous, that it is a known phenomenon, that other health problems have been ruled out, and that the attack passes on its own.
Instead, as the disorder progresses, the person becomes increasingly concerned with avoiding the attack, fearing that it might have irreversible consequences, that they might go crazy, lose control, have something seriously wrong with them, or suffer some kind of harm precisely because an attack was not stopped in time.
The person therefore does not behave in a way that allows them to manage possible attacks while preserving their freedom of movement and action.
Instead, they sacrifice their freedom of movement and action in an attempt to prevent a possible attack, while “raising the antennas” of anticipatory anxiety and convincing themselves that a multitude of signals or situations must be treated as indicators of risk for possible attacks.
The person with panic therefore ends up becoming dependent on anticipatory anxiety. During an actual attack, they would nevertheless have a tendency toward escape and avoidance, but not necessarily and not in advance.
For this reason, in terms of behavioral limitations, anticipatory anxiety is often more disruptive than the attacks themselves.
Inevitably, over time, all of this results in increasing restrictions on a range of behaviors, situations, and distances.
Furthermore, the person—especially if male—may regret this apparently “fearful” behavior, regarding it not only as impractical but also as undignified, and perhaps attributing it to a form of moral weakness.
Symptoms of Panic
The symptoms of panic are diverse and variable.
They range from the classic and most frequent “chest” symptoms to fairly common intestinal and balance-related symptoms, such as a feeling of faintness, instability, or mental confusion, as well as internal and external sensations such as heat, prickling or stabbing sensations, pain, burning sensations, and so on.
The attitude of the “panicked” brain is to treat every symptom as a separate element, initially in an attempt to determine which symptom is important and what it means.
Eventually, however, confusion develops: each attack involving a different symptom renews the person’s fear.
People may even describe attacks as different from one another when, from the doctor’s perspective, they appear to be virtually identical.
During the early stages of treatment, side effects or panic symptoms “filtered through” the medication may also be experienced with fear because they are classified as “different” attacks.
A person who may have become reassured about the harmlessness of their “usual” attacks can become alarmed again if an attack changes in terms of its symptoms.
Ultimately, the picture of panic disorder, as it is described by the person or observed after some time, consists of:
- major attacks;
- minor attacks, or “shadow” attacks;
- anticipatory anxiety (fear of panic);
- avoidance;
- dependence on factors perceived as protective.
Protective Factors and Reassurance
Regarding the last point, there are “benign” factors that people may become dependent on, such as being accompanied by another person or knowing that they are in contact with someone, as well as other factors that can be harmful or toxic.
Sometimes the relationship with the doctor becomes complicated—especially at the beginning, during the early stages of treatment—because the person sees the doctor as a reassuring figure, particularly if they consider the doctor competent, but also as someone who is reassuring simply because they are a doctor.
In this respect, being a doctor, and therefore a professional with expertise in the subject, may be confused with something else: being the person who, more than anyone else, can provide reassurance and manage acute anxiety.
Not only is this impractical, but it is also not a useful solution for panic.
The doctor may be perceived as reassuring or not, often depending on how easily they can be reached or how willing they are to provide reassurance.
This function, however, is not a therapeutic function. It is simply a function induced by the state of panic—that is, something to which the person with panic attaches importance.
Before treatment has had time to take effect, the relationship with the doctor may therefore become complicated when the patient begins to rely on the doctor’s presence as a new and effective way of controlling anxiety.
This can lead to distress and even irritation when the patient cannot find the doctor, cannot speak to them, or does not receive what they consider sufficient reassurance during a period of anticipatory anxiety.
Some people eventually become “dependent” on reassurance from their doctor, while at the same time becoming disappointed when they feel that the doctor does not attach enough importance to their need for reassurance.
This situation is not therapeutic and, in fact, often interferes with the patient’s ability to concentrate on and engage with the actual treatment process for panic.
Course
After treatment is discontinued, up to half of people experience a return of symptoms within six months, and this type of recurrence is not merely temporary.
After several years, however, approximately half of people have residual or less severe symptoms, while about one in four continues to experience the disorder in a persistent and full form.
Treatment for panic should therefore be long enough in duration and should continue even after complete remission of the behaviors and thoughts characteristic of panic, as well as after the attacks themselves have disappeared.
Once results have been achieved, treatment should not be discontinued or reduced to “the minimum,” but maintained within the range necessary to preserve its effectiveness.
This applies both to pharmacological and non-pharmacological treatments.