Panic Disorder
Introducing a ‘Conflicting Identity’ model of Panic Disorder which focuses on specific vulnerability factors of core ‘identity beliefs’ that have their origins in childhood (ie the precursor event or circumstances). Working with Child Ego States makes the resolution process straight forward in addressing the two ‘emotional development needs’ from the CAARP-ALIAS model that have been unmet/violated and result in the problematic ‘identity beliefs’. Conventional treatments aim to reduce severity/frequency of panic attacks by medication or psychology (CBT). However, working with this Conflicting Identity model, the target of hypnotherapy is NOT Panic Disorder itself which is merely a manifestation of the underlying issues. To just focus on the Panic Disorder is a band aid solution. By contrast, using hypnotherapy to treat the relevant Child Ego States representing the underlying issues, resolution of the condition can be achieved in a single session, a follow-up session to confirm the results, plus homework to reinforce the therapeutic changes.
Caveat:
No claim is made that this is THE definitive model that applies to all cases of Panic Disorder. What I am presenting here is a model based on treating my clients: what experiences they had in common and a successful treatment outcome.
Anxiety in Society
Our biology is designed for delf reliance in survival in the wild – the main mechanism being fight/flight - aided by our perceptual system which is designed to make an instantaneous assessment of a situation based on minimal or incomplete information. Therefore, fear invoking fight/flight is a natural reaction to a life-threatening situation. However, in the West, humans now live in relatively civilised societies so the situations that trigger fight/flight system are generally non-life-threatening which results in semi-arousal of fight/flight - experienced as ‘anxiety’. The fight/flight mechanism is hijacked by interpersonal or social situations that are a threat to our ego or emotional (or financial) security rather than our personal safety.
Much of our anxiety is learned reactions to these non-life-threatening situations – based on our fears, expectations, imagination. We can all experience some anxiety on occasions, it resolves and we move on. But when anxiety escalates in intensity and frequency or becomes chronic to such an extent that it impacts on a person’s ability to function optimally, that is pathological and people may seek professional help.
All anxiety is not the same and DSM provides different labels to different expressions of anxiety. What they have in common when they manifest as an adult, is a prior existing vulnerability created in the childhood environment – even PTSD (Martin Seligman found war veterans had pre-existing vulnerabilities that resulted in ‘negative attitude’). A one-off panic attack is not of any significance – so anyone experiencing one need not expect that they will inevitably develop Panic Disorder. One attack can be a reaction to a situation that leaves no lasting consequences. Likewise, having a bad day feeling down in the dumps or ruminating on how shitty your life is doesn’t mean you have ‘clinical depression’ or are likely to.
As therapists know, often the ‘presenting problem’ that has manifested as an adult and prompted that person to seek professional help, has an earlier precursor ‘sensitising event’ or circumstances in childhood - which also needs to be addressed in therapy.
In longitudinal research and psychodynamic results for Panic Disorder, the focus seems to be on merely identifying a list of childhood risk factors – job done. There does not appear to be any attempt to explain the link between negative childhood experiences and later psychopathology. Therefore, the co-existence of so-called ‘risk factors’ is not in itself evidence that all these play a causal role. There appears to simply be an acceptance that kids with undesirable childhoods are going to be anxious and fearful anyway, therefore this is sufficient to account for any increase in risk of experiencing any anxiety disorders as adults. However, the link with Panic Disorder is not in the earlier trauma itself simply creating a long standing anxiety. Hence, we need to know not just about childhood factors, but what has happened in the child’s mind, what have they ‘learned’, how has it impacted on their emotional developmental foundations such as ‘self beliefs’ and how they ‘perceived’ they were valued by their parents. As therapists, to provide effective treatments, we need to know the specific risk factors, not just a generalised ‘crappy childhood’. For those factors that are relevant, we need to know why and how they impact the child – we need to know not just what factors are relevant but also what is significant about those risk factors that are responsible for the vulnerability in some kids but not for others.
These important questions are addressed in the explanation of the ‘Conflicting Identity’ Model of Panic Disorder. The answers to these questions also indicate where therapy needs to be targeted for complete resolution.
Panic Disorder:
To clarify what Panic Disorder is, here is a brief description.
Definition: Panic Disorder is an anxiety disorder characterised by recurring unexpected panic attacks.
Symptoms: Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something terrible is going to happen, based on a perceived threat rather than an actual danger.
Defining criteria: ‘Fear of repeated panic attacks’. (A self-fulfilling belief)?
Diagnosis: If the person becomes afraid to leave home in case they have a panic attack, then agoraphobia is added as a qualifier to the diagnosis - Panic Disorder with Agoraphobia or Panic Disorder without Agoraphobia.
Early case Examples:
Case #1.
My client, a young male, started having panic attacks after his fiancé was mugged and robbed at an ATM while he was visiting a distant city on business. She was fine, no aftermath, just grateful she was not really hurt and the mugger was caught. The young man, who was not even present to witness the event, developed Panic Disorder.
Exploring his history: At age 14, his father had died after a lengthy illness. During this time, the father had impressed on his son his future role, as the ‘man of the house’ and he was relying on his son to ‘take care of his mother and sister’. The fourteen-year-old had a deep sense of responsibility to live up to his father’s expectations by taking care of his family (ie gaining his father’s ‘approval’). There were also other issues around him ‘not feeling good enough’ (believing he had not lived up to his father’s prior expectations). As an adult, he was confident that he had carried out this role as ‘man of the house’ and felt a sense of pride in that - until his fiancé was mugged. He felt he had failed to protect her which hit at his belief in his ability to be a ‘strong protector’ - irrational since he was not even there – and more importantly, also failed to live up to his father’s expectations, thereby reaffirming his belief in ‘not being good enough’.
Case #2.
My client was a married woman in her forties. She had been having panic attacks for several years but was unable to identify a specific triggering event or when it had actually started. During the assessment interview, beliefs about sense of self were identified and her childhood explored.
Identity 1) ‘Strong person’.
She felt she had to become ‘an adult when young’, because she had taken on ‘adult responsibilities’ and subsequently missed out on her childhood. When she was eight-years-old and her sister was ten, they were ‘handed a baby sister to take care of’ plus cooking, cleaning, washing, while the parents worked long hours to provide for their family.
Identity 2) ‘Not good enough’.
i) Her parents paid her $50 per week for her work, but she felt she was being ‘bought off’ for not being able to be out playing with her friends, felt she did not ‘deserve to be playing’ and she did not feel her efforts were appreciated, ‘not good enough’ for parents’ ‘acknowledgement’. She was not being ‘validated’. Some resentment towards her parents.
ii) Sexual molestation – son of her mother’s friend had sexually molested her so she felt she ‘had been placed in danger’, but her mother would not accept that she had put her daughter in danger, so the client felt she was ‘not worth protection’ -> more resentment towards mother.
In recent years in her marriage, her husband was prone to unexpected, unprovoked explosive angry outbursts. She ‘felt in a dangerous place’ but had not known how to handle it. She recognised this was what had triggered the panic attacks.
Hypnotherapy:
Addressed the CESs representing: 1) ‘strong person’ and 2) the two situations ‘not good enough’ and ‘not worth protection‘. In brief, treatment involved addressing ‘emotional developmental needs’ of each CES that have been ‘unmet or violated’ by parents. That also involved addressing any ‘repressed anger’ (resentment) such as is held in i) and ii).
Child Sexual Abuse:
Note the role of Child Sexual Abuse here. CSA is not ‘one state fits all’ regarding trauma and its aftermath. What is significant is the meaning or impact and that varies with several factors:
(i) Obvious are severity of abuse (eg molestation without penetration vs violent rape) and frequency (eg one-off vs years of abuse).
(ii) A factor that probably has greatest impact is relationship to the perpetrator. If the abuser is someone the child is dependent on for care (eg father) then there is ‘betrayal of trust’ by the father and ‘violation’ by the father of the child’s need to ‘feel safe’ so this can have greater emotional impact than the abuse itself. This has been referred to as ‘betrayal trauma’. A complication of abuse by a father is the nature of the abuse (eg traumatic abuse vs a process of grooming, seduction, courtship, sexual ‘relationship’ whereby the daughter may become jealous of her mother, seeing her as a rival for her father’s affections). A further complication of the ‘relationship’ type of abuse is if years later, there is a revelation that the father has been having ‘secret sexual relationships’ with all his daughters so each feels betrayed by him for ‘cheating on her’ with her sisters. (Complex emotional damage here).
(iii) Very significant to the victim is the reaction of parents when told their child has been abused (ie being supportive vs disbelieving, indifferent, blaming the child).
(iv) Probably the worst impact is (ii) and (iii) combined, if the perpetrator is the father (or to a lesser degree some other family member such as a grandfather, uncle or brother). Here, the mother has divided loyalties and (particularly if she has been a victim of CSA herself), is most likely to support her husband (or son) and the sexually abused child may be blamed for seducing the father (or grandfather) or accused of lying. If it is a brother, abuse may be dismissed as kids experimenting. Often, abuse within a family is not revealed until years later and (unless there are siblings as witnesses who can back up the claims) family will tend to side with the father and accuse her of lying (particularly if she has had ‘mental health issues’ resulting from the abuse so her credibility is questionable). Then, the victim finds herself not only in a position of not having family support, but being ostracised by the family, an outcast.
In the instance of Case #2, the molestation was on the lower end of the scale, so for her, the impact was not the sexual molestation itself, but her mother’s response and attitude in not accepting any responsibility for her daughter being in danger and not providing comfort/ support. For this woman, the molestation on its own may have been unlikely to qualify as a ‘risk factor’ for Panic Disorder, but did serve to reinforce her view that her mother did not care about her, ‘not worthy of care’. It also provided further reason for resentment toward her mother.
Note also that CSA can result in diverse identities: ‘I am a survivor’ (I had to be strong to survive) vs ‘I am a victim’ (and victimhood does not come from a position of strength). Hence, CSA can contribute to either of the two Conflicting Identities of Panic Disorder.
Model of Panic Disorder:
The Conflicting Identity Model of Panic Disorder consists of two conflicting ‘self beliefs’ at the core of their identity:
1) ‘I am a strong person’ – an adaptive, positive, desirable quality.
2) ‘I am not good enough’ – dysfunctional, seen as negative, flaw, weakness.
Risk factors originating in childhood:
These two ‘self beliefs’ form during childhood as a consequence of ‘emotional developmental needs’ being ‘unmet’ or ‘violated’. These two factors pose a risk for Panic Disorder, if triggered by particular events as an adult.
1) ‘I am a strong person’
a) Due to – coping with ongoing trauma (CSA, physical abuse, unsafe/unpredictable environment, indifferent or hostile parenting,
severe emotional deprivation)
‘Harm’ may be ‘intentional’ or ‘unintentional’, parent ‘indifferent’ to harm caused.
Or
b) Due to – ‘adult responsibility’, ‘reverse parenting’, parents ‘not available/supportive’
Harm ‘unintended’, parent ‘unaware’ of harm caused.
2) ‘I am not good enough’
Due to belief – inadequate, unworthy, undeserving, poor Self Worth
Distinguish between Strengths:
Since belief in being ‘strong’ is a key component of this model, it is necessary to distinguish between different kinds of strength.
(i) Strong ‘personality’ – assertive, aggressive, opinionated, outspoken, insensitive - not real strength.
(ii) ‘Inner strength’ – ‘innate’ strength, all have this to some extent, not on public display, not give much thought to it, gets us through the ups and downs of life, tested by life events, ‘what doesn’t kill you makes you stronger’ – real strength.
(iii) ‘Adaptive’ strength – acquired or learned in adverse childhood circumstances – marked sense of their identity, a ‘strong person’ as an adult.
This ‘acquired’ strength is ‘adaptive’ and is not the same as innate ‘inner’ strength. As a child, they had to be strong to survive or cope with their circumstances. There may have been trauma through mistreatment such as sexual or physical abuse or severe emotional deprivation - parents were abusive, environment was unsafe/unpredictable. Alternatively, the child may have been expected to take on an adult role/responsibilities, may be ‘reverse parenting’ (ie child takes care of an invalided parent or mother leans on the child for emotional support), lacked validation and parents unsupportive, emotionally unavailable.
Children do need to learn responsibility so they can grow into independent, self-sufficient, mature, capable adults. However, responsibilities need to be ‘age appropriate’, but when the child believes that their role is to ‘be an adult’ and they are expected to relinquish or sacrifice childhood to meet parental expectations/approval, this is not healthy. People may comment that they are ‘mature for their age’ but ‘missing out on childhood’ is not a shortcut to maturity. Merely ‘acting as an adult’ is NOT an adult, cognitively or emotionally. Abused children may be emotionally stuck at the age abuse began. For both situations of ‘acquired’ strength, there is a violation or failure of parental responsibilities and a sense of ‘missing out’ on childhood. This may be accompanied by some degree of anger/resentment (which may result in conflicted feelings towards the parents) which has to be ‘repressed’,
‘I am a strong person’.
This ‘acquired’ strength served as an adaptive or protective purpose for the child, but as an adult, is no longer useful or healthy – and is really no longer needed because the adult has ‘inner strength’. The relevant ‘inner child’ still carries this strength and responsibility as a burden - and that child needs to be relieved of that burden – and be given permission to be a 'care free' child – as they deserve – and to be able to trust that the adult has ‘inner strength’. With hypnotherapy, I contact the relevant CES and instruct the client on the process of doing that – and the homework I provide to reinforce therapeutic changes helps build the CES’s confidence that it is safe to relinquish their role and they can trust the adult to take over.
I digress here for a moment – I was taught in using a strategy such as ideomotor, where the hypnotherapist is working ‘in the dark’ because they are limited to questions with ‘yes’ and ‘no’ answers signalled via a body part (eg finger). The hypnotherapist may call on a ‘strong part’ or a ‘protective part’ or a part willing to take on this responsibility, towards helping with a particular resolution or healing.
My caveat is – be aware of ‘who’ is likely to respond. It may be a CES who has taken on an ‘adaptive’ role of ‘being strong’ or ‘protective’ and they may well respond because that is (or has been) their responsibility. They are not going to say, ‘Nah! Not my job – someone else can do it”. They were created for the role of being responsible for survival and self-preservation so they are likely to respond. They are already carrying a heavy burden and need to be relieved of that burden and given permission to become a carefree child - but instead, they respond to being asked to take on an additional burden because that is what they need to do to gain parental approval. (CESs live in a time warp so are not aware they no longer need parental approval). Taking on an additional burden is not a healthy solution – so if using this ideomotor strategy, make sure you are calling on the ‘inner resources’ to provide a strong or protective part.
‘I am not good enough’.
On the matter of what they ‘deserve’, the belief in ‘not being good enough’ is based on the child’s belief that the parents don’t believe the child is worthy of protection and caring for their physical and emotional needs. They may even believe the parents think they deserve mistreatment, not deserve to be cared for and be a carefree child. For the child taking on an ‘adult role’, in order to gain parental ‘approval’ there may actually be lack of validation. There may be ‘reverse parenting’ (where the child has to take care of the parent). Parents may actually be grateful for the child’s help, but busy parents may overlook the fact that the child is still a child, with child ‘emotional developmental needs’. Hence, the child may feel that in spite of their efforts and sacrificing their childhood, they have failed to meet parental ‘approval’. Hence, they believe they are not regarded as good enough to be taken care of or their efforts acknowledged with a ‘thank you’, a smile and a hug – and therefore, not deserving of childhood fun, not worthy of validation. Note: This is often accompanied by some degree of resentment or anger (which has to be repressed).
Manifestation of Panic Disorder:
Beginning with the two conflicting childhood beliefs in being a ‘strong person’ and ‘not good enough’. As an adult, there occurs unpleasant circumstances or an unexpected event that they do not cope with very well – not as well as they thought they should have, considering they are a ‘strong person’. That is, they react with a panic attack. This challenges their belief in being ‘strong’, shakes that belief and weakens their confidence. At the same time, this reaffirms their belief in being ‘not good enough’. Previously, the two conflicting beliefs have existed juxtaposed in some sort of compromise balance, but after the challenge, the balance is tipped in favour of ‘not good enough’.
Thereafter, they live in fear/expectations of panic attacks. They live in expectation of more events that they will not cope with - that is, fear/expectations of further evidence that they are not the strong person they believed they were. This fear can exist even in safe places in time of peace and calm, because catastrophe can strike anywhere anytime when least expected. This means that the person has to be constantly vigilant, alert for unexpected danger/mishaps ie panic attacks. They may not have had anxiety prior to the first panic attack, but they sure have it now.
Hence, in the official diagnostic criteria ‘fear of further panic attacks’ – the fear is really fear of further evidence they are not that ‘strong person’. This is scary because if their ‘positive’ belief in being a ‘strong person’ is demolished entirely, all they are left with of their identity is ‘not good enough’ (a negative, weak factor) – and that can be demoralising. Which leads us to the next topic of Comorbidities.
Comorbidities:
Panic Disorder and Depression:
Which comes first – the chicken or the egg? With Panic Disorder and Depression, either one can come first. Psychiatric literature does not attempt to examine the connection or the order of occurrence, actually disclaiming any causal relationship between them. There appears to be a tendency to gloss over it with what I would describe as a lazy attitude that – anyone with a crappy childhood or family history of depression and anxiety is going to be prone to anxiety – and anyone prone to anxiety is going to be prone to any anxiety disorders and also depression – therefore the relationship between Depression and Panic Disorder is not causal but simply random and coincidental, even virtually inevitable – but nevertheless, meaningless. That is not helpful, not even informative since it is not true anyway. The relationship between a 'crappy childhood’ and Panic Disorder is specific so manifestation is not random or inevitable. People with Depression or Panic Disorder don’t necessarily have a prior history of anxiety – and ‘familial’ is generally taken to mean biological or genetic even though generally what has been ‘inherited’ has been ‘role modelling’ or ‘learned emotional reactions’. The ‘Conflicting Identity’ Model can demonstrate a causal role in Comorbidity between Depression and Panic Disorder which is bi-directional – ie, it can account for either Panic Disorder or Depression being first with the potential to lead directly to the other.
Panic Disorder first:
If the belief in being a ‘strong person’ is totally destroyed by repeated panic attacks, all the client is left with of their identity is, “I’m not good enough”. There is loss of identity – grief is a response to loss of something important to a person – it does not have to be an actual death - loss of identity can produce grief – the person has lost the positive strong part of their identity that they took pride in and all they are left with of their identity is the negative part they regard as a weakness or a flaw. That can be pretty demoralising - plus they keep having these panic attacks that are controlling and stuffing up their life – they feel helpless and pessimistic about the future – it would be surprising if that didn’t lead to depression eventually.
Depression first:
Depression has nothing to do with people being weak. Strong people are not immune to depression. However, if a person holds the belief that only weak people can become depressed – and if they have the self belief of being a ‘strong person’ as crucial to their identity – then experiencing depression can be the event/circumstance that challenges their belief in being ‘strong’ and triggers the first panic attack – and the depression is not going to go away on its own so it keeps triggering panic attacks.
Panic Disorder with Agoraphobia:
Agoraphobia is a condition where individuals become anxious in unfamiliar environments or where they perceive that they have little control so will be unable to escape without difficulty or humiliation. Agoraphobia can exist without a history of Panic Disorder. However, where Panic Disorder is accompanied by Agoraphobia, the individual may fear having a panic attack in these ‘unsafe’ situations so tends to avoid them - even to the extent of reluctance to leave home. This has led to the common view that agoraphobia is a ‘fear of leaving the house’ or even, a fear of ‘open spaces’. However, the actual fear is ‘having a panic attack in an unsafe place’ hence the preference to remain at home, (a ‘safe’ place) rather than risk going to all those unpredictable, potentially risky places.
some other significant authoritative source such as a cult-like or hell-fire-and-brimstone religion which emphasises to child members that they are sinners, not good enough, unworthy of God’s love. Striving to be ‘good enough’ may lead to them erroneously being labelled as a ‘perfectionist’.
Then, one day, something terrible happens that is completely outside their control and they feel they were not strong enough to prevent the event or deal with the outcome very well. They may not have even been present so couldn’t have done anything to prevent the ‘terrible event’. Regardless, this event hits at their self-validating belief as a ‘strong person’, undermining their sense of self. In addition, what this does is confirm the competing belief that they are ‘not good
enough’. Thereafter, they live in anxiety, fearing future events that will further undermine their sense of being a ‘strong person’ and further confirm their belief in ‘not being good enough’. This is a scary prospect because if their self-validation
as being a ‘strong person’ is destroyed completely, all they are left with is identifying with the invalidating belief of being ‘not good enough’. If they believe in the stigmatizing misconception that depression is a sign of weakness, then the loss of the self-validating belief in being a strong person associated with the Panic Disorder can leave them vulnerable to depression.
Alternatively, there is another potential Panic Disorder-Depression pathway. For someone whose identity is tied up in their
belief of being a ‘strong person’ – and they believe that only weak people can become depressed - the precipitation of an episode of depression can be the ‘terrible event’ that triggers the first panic attack. For a vulnerable individual who holds the two competing beliefs, Panic Disorder can come first and may (or may not) lead to depression, or depression can come first and may (or may not) lead to Panic Disorder.
Any treatment for Panic Disorder (and depression linked with Panic Disorder) needs to address the issues associated with the two competing beliefs.
Caveat:
No claim is made that this is THE definitive model that applies to all cases of Panic Disorder. What I am presenting here is a model based on treating my clients: what experiences they had in common and a successful treatment outcome.
Anxiety in Society
Our biology is designed for delf reliance in survival in the wild – the main mechanism being fight/flight - aided by our perceptual system which is designed to make an instantaneous assessment of a situation based on minimal or incomplete information. Therefore, fear invoking fight/flight is a natural reaction to a life-threatening situation. However, in the West, humans now live in relatively civilised societies so the situations that trigger fight/flight system are generally non-life-threatening which results in semi-arousal of fight/flight - experienced as ‘anxiety’. The fight/flight mechanism is hijacked by interpersonal or social situations that are a threat to our ego or emotional (or financial) security rather than our personal safety.
Much of our anxiety is learned reactions to these non-life-threatening situations – based on our fears, expectations, imagination. We can all experience some anxiety on occasions, it resolves and we move on. But when anxiety escalates in intensity and frequency or becomes chronic to such an extent that it impacts on a person’s ability to function optimally, that is pathological and people may seek professional help.
All anxiety is not the same and DSM provides different labels to different expressions of anxiety. What they have in common when they manifest as an adult, is a prior existing vulnerability created in the childhood environment – even PTSD (Martin Seligman found war veterans had pre-existing vulnerabilities that resulted in ‘negative attitude’). A one-off panic attack is not of any significance – so anyone experiencing one need not expect that they will inevitably develop Panic Disorder. One attack can be a reaction to a situation that leaves no lasting consequences. Likewise, having a bad day feeling down in the dumps or ruminating on how shitty your life is doesn’t mean you have ‘clinical depression’ or are likely to.
As therapists know, often the ‘presenting problem’ that has manifested as an adult and prompted that person to seek professional help, has an earlier precursor ‘sensitising event’ or circumstances in childhood - which also needs to be addressed in therapy.
In longitudinal research and psychodynamic results for Panic Disorder, the focus seems to be on merely identifying a list of childhood risk factors – job done. There does not appear to be any attempt to explain the link between negative childhood experiences and later psychopathology. Therefore, the co-existence of so-called ‘risk factors’ is not in itself evidence that all these play a causal role. There appears to simply be an acceptance that kids with undesirable childhoods are going to be anxious and fearful anyway, therefore this is sufficient to account for any increase in risk of experiencing any anxiety disorders as adults. However, the link with Panic Disorder is not in the earlier trauma itself simply creating a long standing anxiety. Hence, we need to know not just about childhood factors, but what has happened in the child’s mind, what have they ‘learned’, how has it impacted on their emotional developmental foundations such as ‘self beliefs’ and how they ‘perceived’ they were valued by their parents. As therapists, to provide effective treatments, we need to know the specific risk factors, not just a generalised ‘crappy childhood’. For those factors that are relevant, we need to know why and how they impact the child – we need to know not just what factors are relevant but also what is significant about those risk factors that are responsible for the vulnerability in some kids but not for others.
These important questions are addressed in the explanation of the ‘Conflicting Identity’ Model of Panic Disorder. The answers to these questions also indicate where therapy needs to be targeted for complete resolution.
Panic Disorder:
To clarify what Panic Disorder is, here is a brief description.
Definition: Panic Disorder is an anxiety disorder characterised by recurring unexpected panic attacks.
Symptoms: Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something terrible is going to happen, based on a perceived threat rather than an actual danger.
Defining criteria: ‘Fear of repeated panic attacks’. (A self-fulfilling belief)?
Diagnosis: If the person becomes afraid to leave home in case they have a panic attack, then agoraphobia is added as a qualifier to the diagnosis - Panic Disorder with Agoraphobia or Panic Disorder without Agoraphobia.
Early case Examples:
Case #1.
My client, a young male, started having panic attacks after his fiancé was mugged and robbed at an ATM while he was visiting a distant city on business. She was fine, no aftermath, just grateful she was not really hurt and the mugger was caught. The young man, who was not even present to witness the event, developed Panic Disorder.
Exploring his history: At age 14, his father had died after a lengthy illness. During this time, the father had impressed on his son his future role, as the ‘man of the house’ and he was relying on his son to ‘take care of his mother and sister’. The fourteen-year-old had a deep sense of responsibility to live up to his father’s expectations by taking care of his family (ie gaining his father’s ‘approval’). There were also other issues around him ‘not feeling good enough’ (believing he had not lived up to his father’s prior expectations). As an adult, he was confident that he had carried out this role as ‘man of the house’ and felt a sense of pride in that - until his fiancé was mugged. He felt he had failed to protect her which hit at his belief in his ability to be a ‘strong protector’ - irrational since he was not even there – and more importantly, also failed to live up to his father’s expectations, thereby reaffirming his belief in ‘not being good enough’.
Case #2.
My client was a married woman in her forties. She had been having panic attacks for several years but was unable to identify a specific triggering event or when it had actually started. During the assessment interview, beliefs about sense of self were identified and her childhood explored.
Identity 1) ‘Strong person’.
She felt she had to become ‘an adult when young’, because she had taken on ‘adult responsibilities’ and subsequently missed out on her childhood. When she was eight-years-old and her sister was ten, they were ‘handed a baby sister to take care of’ plus cooking, cleaning, washing, while the parents worked long hours to provide for their family.
Identity 2) ‘Not good enough’.
i) Her parents paid her $50 per week for her work, but she felt she was being ‘bought off’ for not being able to be out playing with her friends, felt she did not ‘deserve to be playing’ and she did not feel her efforts were appreciated, ‘not good enough’ for parents’ ‘acknowledgement’. She was not being ‘validated’. Some resentment towards her parents.
ii) Sexual molestation – son of her mother’s friend had sexually molested her so she felt she ‘had been placed in danger’, but her mother would not accept that she had put her daughter in danger, so the client felt she was ‘not worth protection’ -> more resentment towards mother.
In recent years in her marriage, her husband was prone to unexpected, unprovoked explosive angry outbursts. She ‘felt in a dangerous place’ but had not known how to handle it. She recognised this was what had triggered the panic attacks.
Hypnotherapy:
Addressed the CESs representing: 1) ‘strong person’ and 2) the two situations ‘not good enough’ and ‘not worth protection‘. In brief, treatment involved addressing ‘emotional developmental needs’ of each CES that have been ‘unmet or violated’ by parents. That also involved addressing any ‘repressed anger’ (resentment) such as is held in i) and ii).
Child Sexual Abuse:
Note the role of Child Sexual Abuse here. CSA is not ‘one state fits all’ regarding trauma and its aftermath. What is significant is the meaning or impact and that varies with several factors:
(i) Obvious are severity of abuse (eg molestation without penetration vs violent rape) and frequency (eg one-off vs years of abuse).
(ii) A factor that probably has greatest impact is relationship to the perpetrator. If the abuser is someone the child is dependent on for care (eg father) then there is ‘betrayal of trust’ by the father and ‘violation’ by the father of the child’s need to ‘feel safe’ so this can have greater emotional impact than the abuse itself. This has been referred to as ‘betrayal trauma’. A complication of abuse by a father is the nature of the abuse (eg traumatic abuse vs a process of grooming, seduction, courtship, sexual ‘relationship’ whereby the daughter may become jealous of her mother, seeing her as a rival for her father’s affections). A further complication of the ‘relationship’ type of abuse is if years later, there is a revelation that the father has been having ‘secret sexual relationships’ with all his daughters so each feels betrayed by him for ‘cheating on her’ with her sisters. (Complex emotional damage here).
(iii) Very significant to the victim is the reaction of parents when told their child has been abused (ie being supportive vs disbelieving, indifferent, blaming the child).
(iv) Probably the worst impact is (ii) and (iii) combined, if the perpetrator is the father (or to a lesser degree some other family member such as a grandfather, uncle or brother). Here, the mother has divided loyalties and (particularly if she has been a victim of CSA herself), is most likely to support her husband (or son) and the sexually abused child may be blamed for seducing the father (or grandfather) or accused of lying. If it is a brother, abuse may be dismissed as kids experimenting. Often, abuse within a family is not revealed until years later and (unless there are siblings as witnesses who can back up the claims) family will tend to side with the father and accuse her of lying (particularly if she has had ‘mental health issues’ resulting from the abuse so her credibility is questionable). Then, the victim finds herself not only in a position of not having family support, but being ostracised by the family, an outcast.
In the instance of Case #2, the molestation was on the lower end of the scale, so for her, the impact was not the sexual molestation itself, but her mother’s response and attitude in not accepting any responsibility for her daughter being in danger and not providing comfort/ support. For this woman, the molestation on its own may have been unlikely to qualify as a ‘risk factor’ for Panic Disorder, but did serve to reinforce her view that her mother did not care about her, ‘not worthy of care’. It also provided further reason for resentment toward her mother.
Note also that CSA can result in diverse identities: ‘I am a survivor’ (I had to be strong to survive) vs ‘I am a victim’ (and victimhood does not come from a position of strength). Hence, CSA can contribute to either of the two Conflicting Identities of Panic Disorder.
Model of Panic Disorder:
The Conflicting Identity Model of Panic Disorder consists of two conflicting ‘self beliefs’ at the core of their identity:
1) ‘I am a strong person’ – an adaptive, positive, desirable quality.
2) ‘I am not good enough’ – dysfunctional, seen as negative, flaw, weakness.
Risk factors originating in childhood:
These two ‘self beliefs’ form during childhood as a consequence of ‘emotional developmental needs’ being ‘unmet’ or ‘violated’. These two factors pose a risk for Panic Disorder, if triggered by particular events as an adult.
1) ‘I am a strong person’
a) Due to – coping with ongoing trauma (CSA, physical abuse, unsafe/unpredictable environment, indifferent or hostile parenting,
severe emotional deprivation)
‘Harm’ may be ‘intentional’ or ‘unintentional’, parent ‘indifferent’ to harm caused.
Or
b) Due to – ‘adult responsibility’, ‘reverse parenting’, parents ‘not available/supportive’
Harm ‘unintended’, parent ‘unaware’ of harm caused.
2) ‘I am not good enough’
Due to belief – inadequate, unworthy, undeserving, poor Self Worth
Distinguish between Strengths:
Since belief in being ‘strong’ is a key component of this model, it is necessary to distinguish between different kinds of strength.
(i) Strong ‘personality’ – assertive, aggressive, opinionated, outspoken, insensitive - not real strength.
(ii) ‘Inner strength’ – ‘innate’ strength, all have this to some extent, not on public display, not give much thought to it, gets us through the ups and downs of life, tested by life events, ‘what doesn’t kill you makes you stronger’ – real strength.
(iii) ‘Adaptive’ strength – acquired or learned in adverse childhood circumstances – marked sense of their identity, a ‘strong person’ as an adult.
This ‘acquired’ strength is ‘adaptive’ and is not the same as innate ‘inner’ strength. As a child, they had to be strong to survive or cope with their circumstances. There may have been trauma through mistreatment such as sexual or physical abuse or severe emotional deprivation - parents were abusive, environment was unsafe/unpredictable. Alternatively, the child may have been expected to take on an adult role/responsibilities, may be ‘reverse parenting’ (ie child takes care of an invalided parent or mother leans on the child for emotional support), lacked validation and parents unsupportive, emotionally unavailable.
Children do need to learn responsibility so they can grow into independent, self-sufficient, mature, capable adults. However, responsibilities need to be ‘age appropriate’, but when the child believes that their role is to ‘be an adult’ and they are expected to relinquish or sacrifice childhood to meet parental expectations/approval, this is not healthy. People may comment that they are ‘mature for their age’ but ‘missing out on childhood’ is not a shortcut to maturity. Merely ‘acting as an adult’ is NOT an adult, cognitively or emotionally. Abused children may be emotionally stuck at the age abuse began. For both situations of ‘acquired’ strength, there is a violation or failure of parental responsibilities and a sense of ‘missing out’ on childhood. This may be accompanied by some degree of anger/resentment (which may result in conflicted feelings towards the parents) which has to be ‘repressed’,
‘I am a strong person’.
This ‘acquired’ strength served as an adaptive or protective purpose for the child, but as an adult, is no longer useful or healthy – and is really no longer needed because the adult has ‘inner strength’. The relevant ‘inner child’ still carries this strength and responsibility as a burden - and that child needs to be relieved of that burden – and be given permission to be a 'care free' child – as they deserve – and to be able to trust that the adult has ‘inner strength’. With hypnotherapy, I contact the relevant CES and instruct the client on the process of doing that – and the homework I provide to reinforce therapeutic changes helps build the CES’s confidence that it is safe to relinquish their role and they can trust the adult to take over.
I digress here for a moment – I was taught in using a strategy such as ideomotor, where the hypnotherapist is working ‘in the dark’ because they are limited to questions with ‘yes’ and ‘no’ answers signalled via a body part (eg finger). The hypnotherapist may call on a ‘strong part’ or a ‘protective part’ or a part willing to take on this responsibility, towards helping with a particular resolution or healing.
My caveat is – be aware of ‘who’ is likely to respond. It may be a CES who has taken on an ‘adaptive’ role of ‘being strong’ or ‘protective’ and they may well respond because that is (or has been) their responsibility. They are not going to say, ‘Nah! Not my job – someone else can do it”. They were created for the role of being responsible for survival and self-preservation so they are likely to respond. They are already carrying a heavy burden and need to be relieved of that burden and given permission to become a carefree child - but instead, they respond to being asked to take on an additional burden because that is what they need to do to gain parental approval. (CESs live in a time warp so are not aware they no longer need parental approval). Taking on an additional burden is not a healthy solution – so if using this ideomotor strategy, make sure you are calling on the ‘inner resources’ to provide a strong or protective part.
‘I am not good enough’.
On the matter of what they ‘deserve’, the belief in ‘not being good enough’ is based on the child’s belief that the parents don’t believe the child is worthy of protection and caring for their physical and emotional needs. They may even believe the parents think they deserve mistreatment, not deserve to be cared for and be a carefree child. For the child taking on an ‘adult role’, in order to gain parental ‘approval’ there may actually be lack of validation. There may be ‘reverse parenting’ (where the child has to take care of the parent). Parents may actually be grateful for the child’s help, but busy parents may overlook the fact that the child is still a child, with child ‘emotional developmental needs’. Hence, the child may feel that in spite of their efforts and sacrificing their childhood, they have failed to meet parental ‘approval’. Hence, they believe they are not regarded as good enough to be taken care of or their efforts acknowledged with a ‘thank you’, a smile and a hug – and therefore, not deserving of childhood fun, not worthy of validation. Note: This is often accompanied by some degree of resentment or anger (which has to be repressed).
Manifestation of Panic Disorder:
Beginning with the two conflicting childhood beliefs in being a ‘strong person’ and ‘not good enough’. As an adult, there occurs unpleasant circumstances or an unexpected event that they do not cope with very well – not as well as they thought they should have, considering they are a ‘strong person’. That is, they react with a panic attack. This challenges their belief in being ‘strong’, shakes that belief and weakens their confidence. At the same time, this reaffirms their belief in being ‘not good enough’. Previously, the two conflicting beliefs have existed juxtaposed in some sort of compromise balance, but after the challenge, the balance is tipped in favour of ‘not good enough’.
Thereafter, they live in fear/expectations of panic attacks. They live in expectation of more events that they will not cope with - that is, fear/expectations of further evidence that they are not the strong person they believed they were. This fear can exist even in safe places in time of peace and calm, because catastrophe can strike anywhere anytime when least expected. This means that the person has to be constantly vigilant, alert for unexpected danger/mishaps ie panic attacks. They may not have had anxiety prior to the first panic attack, but they sure have it now.
Hence, in the official diagnostic criteria ‘fear of further panic attacks’ – the fear is really fear of further evidence they are not that ‘strong person’. This is scary because if their ‘positive’ belief in being a ‘strong person’ is demolished entirely, all they are left with of their identity is ‘not good enough’ (a negative, weak factor) – and that can be demoralising. Which leads us to the next topic of Comorbidities.
Comorbidities:
Panic Disorder and Depression:
Which comes first – the chicken or the egg? With Panic Disorder and Depression, either one can come first. Psychiatric literature does not attempt to examine the connection or the order of occurrence, actually disclaiming any causal relationship between them. There appears to be a tendency to gloss over it with what I would describe as a lazy attitude that – anyone with a crappy childhood or family history of depression and anxiety is going to be prone to anxiety – and anyone prone to anxiety is going to be prone to any anxiety disorders and also depression – therefore the relationship between Depression and Panic Disorder is not causal but simply random and coincidental, even virtually inevitable – but nevertheless, meaningless. That is not helpful, not even informative since it is not true anyway. The relationship between a 'crappy childhood’ and Panic Disorder is specific so manifestation is not random or inevitable. People with Depression or Panic Disorder don’t necessarily have a prior history of anxiety – and ‘familial’ is generally taken to mean biological or genetic even though generally what has been ‘inherited’ has been ‘role modelling’ or ‘learned emotional reactions’. The ‘Conflicting Identity’ Model can demonstrate a causal role in Comorbidity between Depression and Panic Disorder which is bi-directional – ie, it can account for either Panic Disorder or Depression being first with the potential to lead directly to the other.
Panic Disorder first:
If the belief in being a ‘strong person’ is totally destroyed by repeated panic attacks, all the client is left with of their identity is, “I’m not good enough”. There is loss of identity – grief is a response to loss of something important to a person – it does not have to be an actual death - loss of identity can produce grief – the person has lost the positive strong part of their identity that they took pride in and all they are left with of their identity is the negative part they regard as a weakness or a flaw. That can be pretty demoralising - plus they keep having these panic attacks that are controlling and stuffing up their life – they feel helpless and pessimistic about the future – it would be surprising if that didn’t lead to depression eventually.
Depression first:
Depression has nothing to do with people being weak. Strong people are not immune to depression. However, if a person holds the belief that only weak people can become depressed – and if they have the self belief of being a ‘strong person’ as crucial to their identity – then experiencing depression can be the event/circumstance that challenges their belief in being ‘strong’ and triggers the first panic attack – and the depression is not going to go away on its own so it keeps triggering panic attacks.
Panic Disorder with Agoraphobia:
Agoraphobia is a condition where individuals become anxious in unfamiliar environments or where they perceive that they have little control so will be unable to escape without difficulty or humiliation. Agoraphobia can exist without a history of Panic Disorder. However, where Panic Disorder is accompanied by Agoraphobia, the individual may fear having a panic attack in these ‘unsafe’ situations so tends to avoid them - even to the extent of reluctance to leave home. This has led to the common view that agoraphobia is a ‘fear of leaving the house’ or even, a fear of ‘open spaces’. However, the actual fear is ‘having a panic attack in an unsafe place’ hence the preference to remain at home, (a ‘safe’ place) rather than risk going to all those unpredictable, potentially risky places.
some other significant authoritative source such as a cult-like or hell-fire-and-brimstone religion which emphasises to child members that they are sinners, not good enough, unworthy of God’s love. Striving to be ‘good enough’ may lead to them erroneously being labelled as a ‘perfectionist’.
Then, one day, something terrible happens that is completely outside their control and they feel they were not strong enough to prevent the event or deal with the outcome very well. They may not have even been present so couldn’t have done anything to prevent the ‘terrible event’. Regardless, this event hits at their self-validating belief as a ‘strong person’, undermining their sense of self. In addition, what this does is confirm the competing belief that they are ‘not good
enough’. Thereafter, they live in anxiety, fearing future events that will further undermine their sense of being a ‘strong person’ and further confirm their belief in ‘not being good enough’. This is a scary prospect because if their self-validation
as being a ‘strong person’ is destroyed completely, all they are left with is identifying with the invalidating belief of being ‘not good enough’. If they believe in the stigmatizing misconception that depression is a sign of weakness, then the loss of the self-validating belief in being a strong person associated with the Panic Disorder can leave them vulnerable to depression.
Alternatively, there is another potential Panic Disorder-Depression pathway. For someone whose identity is tied up in their
belief of being a ‘strong person’ – and they believe that only weak people can become depressed - the precipitation of an episode of depression can be the ‘terrible event’ that triggers the first panic attack. For a vulnerable individual who holds the two competing beliefs, Panic Disorder can come first and may (or may not) lead to depression, or depression can come first and may (or may not) lead to Panic Disorder.
Any treatment for Panic Disorder (and depression linked with Panic Disorder) needs to address the issues associated with the two competing beliefs.
