Strategies for a brief psychotherapy of panic attack and panic disorder

PHOBOS GROUP: Dr. Alejandro Napolitano, Lic. Fernando Bianchi, Lic. Teresa Cleris y Lic. María Elena Revuelta.

We are introducing to a scheme of brief treatment destined to overcome the paralyzing and catastrophic situation of panic attack and panic disorder, appearing or not together with phobic symptoms.  The treatment  combines both gestaltic psychotherapy and a psychopharmacological help, and it lasts approximately from 12 to 16 weeks.

Panic attacks are a kind of anxiety disorder, each day more frequent, characterized by symptoms that block the normal behavior of the person. Its intense body symptoms may be : fastening of the heartbeat, dizziness, heavy sweating, trembling, a sensation of thoracic pressure, breathlessness and cognitive symptoms that give catastrophic meaning to all that sensations. This idea of passing through a catastrophic situation , for the patient is supposed to be a menace that could harm him or her severely, be it a harm to the body (fear of suffering a heart attack, fear of dying), a psychic menace (fear of going mad) or social menace (feeling ashamed if people notice what happens to him).

The treatment we developed has four stages clearly marked:

1)      Diagnosis;

2)      Psychopharmacological Evaluation

3)      First Psychotherapeutic Stage

4) Second Psychotherapeutic Stage

1)      Diagnosis:

Through the first or second interview, we evaluate carefully the actual situation of the patient, to define it apart from what could be personality disorders, depression, hypochondria, phobia, obsessive compulsive disorder, general anxiety disorder, separation anxiety, stress and vital crisis.

It is of psychosemiologic importance to detect the presence of sensibility to anxiety (fear of fear) as a psychopathological base of the situation.

2) Psychofarmacological Evaluation:

In a group interview between patient, therapist and psychiatrist, it is decided whether it could be convenient or not for the patient to take pharmacological drugs. In case they would be used, the medication will be part of the therapeutic approach, in the sense that it will exist a permanent follow up of the results of using them that will concern not only the psychiatrist. The therapeutic success is attached to the level of acceptance of the patient, the knowledge of the therapist on the effects of the pharmacological approach and also to the capacity of the therapist give answers to the inquiries of the patient without asking the intervention of the psychiatrist.

The therapist´s role is to be the leader of the team, and the psychiatrist works as an auxiliary help. Therefore, a previous arrangement of the relationship therapist - psychiatrist is needed .

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3) First Psychotherapeutic Stage:

This stage of the treatment aims to modify the relation of struggle and desperation to control the symptoms of Primary Anxiety ( body symptoms), looking forward to reach a greater acceptation of them, and - at the same time- working on Secondary Anxiety (reactions in front of the body symptoms). The main objective on this stage is to watch closely what happens during the sudden appearance of the automatic idea of catastrophic situation.

In this syndrome, the presence of physical symptoms (Primary Anxiety) triggers automatically the cognitive catastrophic symptoms (Secondary Anxiety),  always in absence of an external clearly dreadful situation or any clearly defined phobia generating object .

The own body is taken as an object to be afraid of. That is the nature of the typical "fear of fear" in this kind of situations. The patient who suffers this kind of fear treats ineffectively to be in control over the symptoms trying not to feel what he feels and not to think what he thinks. This adds an extra problem that feeds the anxiety circuit in an endless vicious circle. 

This stage of the treatment will be pointed to break the automatic link between Primary and Secondary Anxiety, letting the patient be aware of alternative significations.  With this purpose, we give the patient several tools indicated to the development of  :  a) body supports, b) self- awareness , and c) emotional expression (of the rage underlying the fear that  appear in this  situations, as it happens very often).

a)      Development of body supports:

The first writings of Perls in "Ego, Hunger and Agression", were very useful for us , regarding that he understands anguish as a blocking of the normal rhythm of breath, and he proposes a series of exercises that allow to be aware of one own´s breathing and to be in contact with the fantasies attached to the act of breathing.

We followed as well the writings of Alexander Lowen, when he says that the most primal fears are the fears of drowning or choking and the fear of falling. These two fears are closely related to the two body parts where energetic cuts are produced- the two narrowest parts of human body: the neck and the waist- giving place to a building up of tension as an expression of the conflict between the impulse and the defense, that turns into anguish.

We use some techniques derived from Bioenergetics principles, to develop this point of support and contact, as "grounding " exercises that help to recover conscience of the use of the lower parts of the  body as legs and genital zones, and let the bioenergetic flow run in a more free way. 

We also use the exercise known as " letting drop"  (Lowen), in order to loosen up the neurotic need of control. It´s a great technique that produces a pleasurable sensation, letting the patient give up the control on power and, at the same time, showing him that surrendering to the forces of Nature (force of gravity) is harmless,  and that nothing terrible happens if he does it so.

b)     Self Observation Techniques:

The main goal of these techniques is to develop the capacity of self-observation, to increase the resourcefulness of the patient to find alternative significant relations between Primary and Secondary anxiety, turning to conscious the preconscious processes that determine the automatic reactions of the patient.

We use a notebook with pages with four columns (moment-situation-emotion-ideas), to be used by the patient who will be asked to write down - each time he feels a state of intensified anguish- the date and time on the first column, completely detailed description of the situation in the second column, emotions and body sensations in the third column and the ideas that come to his mind in that very moment.

This notebook works as a registry that makes evident the frequency, sequence and characteristics of each episode.

c)      Exercising of the continuum of conscience: 

This practical exercise of gestaltic therapy allows us to explore and operate on the panic disorder.

In this first psychotherapy moment, once the constant struggles to control symptoms has receded, it begins the stage that we could call as " introvision"  ( internal sight) , in the sense of looking inside of oneself, aiming to get in touch with the introjections that take part of this situation.

In this moment of a deeper contact, we use another gestaltic approach: the guided fantasies.

We know that the guided fantasies are very similar to dreams and to the piece of works of artists, because they induce the person to a state of a higher perception of body sensations with makes it easy to weaken the rational control.

We are in search of the expression and showing of what is feared. We consider that what is feared is something very deeply rooted, many times attached to situations of the childhood.

Besides, we know that panic attacks move situations that are classic archetypes, treated by mythology and by scary movies whose subjects we try to use in therapy.

In these situations, the person puts becomes conscious of beliefs that were hidden in the bottom - and that are the basis of the vulnerability experience- or beliefs that erase the capacity of putting up with something, to confront a  situation.

What the patient feels in during an attack is:  "I´m here alone, all by myself, sure that the worst will happen to me and I don´t have any way or any mood to save myself" .

This cognitive compound is processed at a preconscious level, the same level in which the directed fantasy acts. We make up a guided fantasy, beginning from the most feared scene.

This fantasy is unique and personal. The work of the therapist is to walk along the patient step by step towards the awareness, in order to help him to show the internal situations he fears.

4) Second Psychotherapeutic Stage:

This second psychotherapeutic stage works on the experience of vulnerability. It begins when the patient enters a therapeutic relation in which he can trust completely.

In case medication is needed, it has to be tolerated and accepted .The patient enters a stage in which he had given up the desperate and constant struggling to have control over the symptoms, in the Primary Anxiety. We could compare the panic disorders with fever. Fever is a symptom that gives us the clue that the body in undergoing and infectious process. In this case, the whole set of symptoms (heavy trembling or sweating, fast heartbeat, fear of dying, fear of getting mad ) act like fever. What is shown on the outside give us a clue that a general process is taking place.

In this moment of the treatment, we will ask the patient how does he experience his fear. We ´ll base our approach in the researchs done by Dr Norberto Levy.

We try to know what is the bottom line of the situation, or the infectious focus ( a cause- effect question ,  belonging more to the medical paradigm, than to gestaltic idea of configuration)

What is fear?

Fear is an emotion that appears in case of perception of a menace or a danger. It doesn't have to be a direct menace, but a signal of menace. It also isn't an abstract menace, but a menace "to somebody".

Everything may turn into a menace,  depending on the resources the patient has to confront it. Therefore, for example, I´ll be scared and I ´ll be afraid each time that I notice a disproportion between the menace and the  resources I have to fight against it .

The snowy slopes of a mountain could be felt as a terrible menace for someone, but an expert skier doesn´t see it like that. Therefore, there isn´t a justified or unjustified menace, but " a menace to somebody" and so, " a feared thing to someone".

 We human beings not only produce an emotion - as fear, for example- but also a  second reactive emotion in front of this emotion. We feel scaed , and also we may feel ashamed , humiliated or furious of being scared.

Depending on what kind of reaction  I have, fear will get weaker and it will get into being functional fear ( a search of resources to  confront the menace) . But if in front of the fear, if my reaction is autoagression, auto- censorship or I begin to feel fool and to critize myself, my fear will get bigger and bigger, and it will grow into a dysfunctional fear that will leave me helpless, without any possibility to defend myself or to look for tools to overcome fear .

Menace will not only be external, but also internal. I may constitute my own menace and my fear will get stronger and deeper, turning into phobia., beginning a snowball of fear that leads to panic situations. Disfunctional fear ceades to be  a sign of alert that gives me protection , and becomes a menace in itself, a source of terror, rage, fury, helpnessless, disorganization .

When a person watches his fearfull aspect and to change it, they reject it, he goes through a process where it is very difficult to find a way out.

 This inadequately violent attitude of sudden change doesn´t legitimate nor recognize the existence of the fearful aspects. It only helps to go on with the idea os suffering a menace, forcing the person to produce reactions as fury, terror, shame or resentment.

In a self - support strategy it is very useful to develop an interior assistant capable of listening and accepting the search of the fearful aspect.,This aspect , finally, has all the clues  to the healing.

That is the work developed in this moment of the treatment. When it is finished , we  consider the process of brief psychotherapy  centered on the symptoms , has  concluded.

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