Dr. Matthew Paldy

On the Dynamics of Panic Attacks

According to Franco DeMasi, "A panic attack is characterised by the sudden emergence of entirely unpredictable and unstoppable episodes of intense anxiety. Its intensity is such that it leaves behind a sense of utter exhaustion. Usually the panic attack is accompanied by strong neurovegetative manifestations, such as palpitations, tachycardia, vertigo, body tremors, diarrhoea or excessive sweating and, most importantly, a sense of suffocation. (The symptom of suffocation convinced some biologically oriented researchers that the panic attack might be due to the onset of the choking reflex, normally activated by a lack of oxygen or by an excessive amount of carbon dioxide. One of the therapies consists, therefore, in supplying oxygen as a means of preventing the attack.) The panic attack always manifests itself psychosomatically, being a pathology that primarily affects the body.

A specific characteristic of panic attacks is the failure in the mental function that should contain anxiety. The subjective drama experienced during a crisis is equivalent to the nameless dread that is such because the mind, unable as it is to contain fear, pours it then into the body. In so far as the mind can contain anxiety, this can be recognised and treated for what it is. One can say, ‘I feel anxious or anguished for this or that reason’. When, however, the mind fails to perform this task, anxiety pours into the body and becomes deadly panic. One will then think, ‘No, I am not anxious, I am dying’. In other words, what we can observe here is the same constellation that belongs to the experience of terror during real death.

In the course of a panic crisis, a backache, diarrhea, a praecordial pain become unthinkable elements followed by the collapse of the capacity for mental containment and by the anxiety's flooding of the body. The defence mechanisms, including the oblivion of anxiety, that would normally protect our existence, seem not to exist for such patients. They are without a ‘psychic skin’. The skin tears open, the boundary between inside and outside is lost and anxiety spreads into the body. (A sense of confusion in one's bodily integrity, which is at the root of the panic attack, also manifests itself in the body's problematic relationship to space. Claustrophobia, as the anxiety of being invaded, or agoraphobia, as the fear of vanishing into open spaces and loneliness, continually threaten those individuals who have a poorly structured self and who suffer from occasional panic attacks.)

In order to emerge from a panic attack, the patient needs an interlocutor who can function as a container of anxiety: if by any chance he is on his own, it is important that a telephone is within easy reach. Fear requires a prompt reception by a calm and thoughtful listener. When the patient dreads that a panic attack may get close, he becomes just like a young child looking into his mother's face in the hope of getting information about the dangerousness or otherwise of a disturbing element that has caught his attention or threatened his body. If the listener is detached or irritated, or trivialises the catastrophe, fear will grow to the point of becoming nameless dread. Even the slightest emotional resonance, anxiety or doubt may sound suspicious and a confirmation of the potentially somatic nature of the problem, making the patient's anxiety an even more concrete experience.

-- from The Psychodynamic of Panic Attacks: A Useful Integration of Psychoanalysis and Neuroscience. By Franco De Masi.