Joe was a 54-year-old married man who developed depressed mood in response to some work stress. He was a middle manager who had a new boss who, in Joe’s opinion, knew less than Joe and who relied on Joe to cover for him. Joe became increasingly resentful of this situation. One day, as he was driving to work, he had a panic attack. He became suddenly short of breath and felt as if he was choking; his heart was pounding and he felt intensely frightened. He pulled over to the side of the road until the attack passed, but he went on to have more panic attacks at work, and at home in the morning before leaving for work. He began to dread going to the office, fearing he would have more attacks. As his dread grew, he consulted his family physician.

Treatment gap

Symptoms of a panic attack — which include rapid heart rate, feelings of intense fear, dizziness, hyperventilation, sweating, abdominal pain — are a common cause of visits to primary care physicians. Psychiatrists diagnose Panic Disorder (DSM IV) when a patient has recurrent, unexpected panic attacks accompanied by at least a month of persistent concern either about having more attacks or about the meaning of the attacks (“I’m sure there’s something wrong with my heart”). People often develop avoidance of places and circumstances that they associate with a greater chance of having an attack. Agoraphobia is diagnosed when this avoidance becomes generalized to going outside of the safety of home.

There’s evidence supporting the use of antidepressants and cognitive behavioural therapy to treat panic disorder (benzodiazepines tend not to be effective in the long run). Still, studies indicate that 29-48% of subjects don’t respond to these treatments. Trials of combined treatment with psychotherapy and medication have been disappointingly equivocal. Thus, a significant group of patients with panic disorder have remained beyond the reach of current therapies.

Latterly, research has shown that Panic-Focused Psychodynamic Psychotherapy (PFPP) can be an effective treatment (Am J Psychiatry 2007;164:265–72). The research on PFPP is a randomized clinical trial that found that working with a psychodynamic understanding of panic symptoms can be an effective treatment. This therapy is a “manualized psychotherapy” based on the psychodynamic understanding that meaningful stressors often precede the onset of panic symptoms. The loss of a significant attachment figure or a change in job expectations often precedes the onset of panic symptoms. Some researchers feel that panic symptoms arising after the loss of a significant person may represent a complicated form of bereavement.

Blame the parents

Certain themes have been found in the emotional lives and histories of patients with panic disorder. They often described their parents as critical, demanding, temperamental, and controlling; they frequently reported difficulty acknowledging and expressing angry feelings. Negative feelings were sometimes experienced as being threatening to a connection with important attachment figures in the patient’s life. People with panic disorder regularly had vulnerable self-esteem and felt humiliated by their symptom. They commonly showed ambivalence around issues of autonomy and dependency, many times related to childhood fears of disrupting relationships with parents through the expression of anger.

PFPP was given over 24 twice-weekly sessions. The therapist was allowed to work in an open way, but tried to keep a focus on the panic symptoms and the deepening understanding of their context and meaning. The therapy had 3 phases: an initial phase of exploration of the symptoms and the circumstances in which they occurred; then a phase of consolidating the specific dynamics of the panic episodes; and finally a period focusing on the reaction to termination. One common dynamic in these patients is a reluctance to express any negative emotion, especially anger. Or, if anger is acknowledged, it’s often immediately buried — for example, “I’m angry at my wife” is immediately undone by the comment “but I really love her.” Part of the treatment would be to help the patient articulate and tolerate such feelings.

Back to Joe

Joe’s history had several of the common themes found in panic disorder patients. He was the son of immigrant parents who had relied heavily on him to help them deal with life in Canada. His father had been domineering and he’d had a volatile temper. Joe grew up resenting yet needing his parents. When his boss began to use him to cover up his own deficiencies, old and unacceptable feelings of rage and resentment were triggered in him that manifested as panic symptoms.