Panic Disorder, and Honoring Fear
Rees Chapman, Ph.D.
December 2011

When I begin therapy with clients with panic disorder, I am generally quick to offer an interpretation of their symptoms which they have yet to encounter.  After obtaining a detailed history and empathizing with the often catastrophic effects of panic episodes, I ask them to tell me about fear.  Is it a sign of weakness?  Is it normal?  Is it ever beneficial?   Most clients give lip-service to understanding that fear is a natural consequence of threatening circumstances, but make it clear that they often have no awareness of their apprehension or fright until they begin to experience the bodily signs of panic: palpitations, accelerated heart rate, sweating, trembling or shaking, shortness of breath, smothering, choking, nausea or abdominal distress, chills or hot flushes, numbness or tingling sensations, feeling dizzy, unsteady, lightheaded, or faint.  At that point, I typically suggest that the problem may be that they are numb to their fears, even as they are intensifying, until they reach a threshold that is overwhelming.  They become suddenly acutely anxious, and this compels a vicious cycle in which they become increasingly terrified of their own fear (which further exacerbates their terror).

So, from this perspective, the key is for clients to be more aware of their fears much earlier as they develop, to understand them as normal but manageable, and to be more proficient at avoiding potentially adverse consequences while comforting themselves.  Often, this includes challenging their assumptions, mislearned in childhood, that fear is bad and a sign of weakness.  The normalcy of the fight-or-flight response is stressed.  Fear is described as an alarm, which goes off to awaken the sleeping person, and which must be turned off as the person arises; remaining asleep while leaving the alarm on (and growing louder) means that the person will be jolted from his/her bed with a cacophonous roar (which can ruin the person's whole day).  Fear is promoted as an important source of intuitive information, that benefits the person organismically.  Relaxation skills are taught, coping skills are enhanced, and problem-solving strategies are explored.  Often, the most beneficial component of the therapy is for the client to be able to tell those about him/her "I'm scared."

In one remarkable case, a client who was a big-city attorney came to me with panic episodes which were disrupting his otherwise lucrative practice.  He would be articulate, bold and skillful in the early phases of a court case, but at some point, he would have to escape to the bathroom, where he would cower and quake in a toilet stall, often for up to an hour.  Medications reduced the frequency and intensity of these panic episodes, but also diminished his "edge," such that he felt tranquilized.  At first, he argued that part of his job as a lawyer was to be unmoved by fear, and I agreed, but I insisted that was not the same as being unaware of and numb to them.  I had him list as many of his apprehensions and anxieties about a particular case as he could realize, and to communicate these to his assistant prior to appearing in court.  At certain points during a trial - before he felt overly scared - he would deliberately step outside, take deep breaths and relax his body, then return to the courtroom (ready to wreak havoc).

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