Panic attacks are among the most common and most distressing symptoms I see as a therapist. Not only do people encounter some of their most primitive existential fears, such as feeling like they are dying or going crazy, panic sufferers also have to deal with the repetitive (and often unpredictable) nature of panic, and the fact that others cannot fully appreciate the intensity of the experience.
Search the web and you’ll find a ton of strategies to deal with panic attacks. In my opinion, very few (none in fact that I have found) adequately address different types of panic attacks. While I do not explicitly address tips for dealing with panic here, I believe we can optimize our coping strategies for anxiety attacks by first identifying what the panic is and what it is signifying. I identify six types of panic that I have observed in clinical practice below. I do not accept that panic attacks “come out of nowhere.” While cues may not be easily identifiable, experience has taught me that there is ALWAYS a reason for experiencing intense feelings.
Looking at broader categories of basic, primitive fears can be extremely informative when it comes to understanding and coping with panic. Below is a list of some of the most common classes of panic I see. This list may not be exhaustive, nor are these classifications mutually exclusive; However, if you suffer from panic attacks, one or more of these should resonate at an intuitive level.
Key point: it’s my belief that symptoms, like panic, are generated by personalities. If personalities are the mechanics of a person’s mind and ways of relating to the social world, then symptoms are inefficiencies or mis-attunements between the personality and its social environment. An ill-fit between personality and society can stem from a society that provides a very narrow range of healthy adaptations. It similarly can come from a dysfunctional family environment that demands adaptations ill-suited for the broader social context. Psychotherapy is much better at dealing with the latter than the former.
1. Losing Control – The Obsessive-Compulsive Personality:
Practicing in New York City, compulsive desire to be in control is ubiquitous. A former supervisor and I used to joke that we should propose “NYPD,” or “New York Personality Disorder” as an addition to the Diagnostic and Statistical Manual to account for the high frequency of anxiou and obsessive goal-directedness for which the city is known. “Obsessing” can take many forms, ranging from “Type A” driven-ness, to perfectionism as well as chronic constipation. It’s characterized by hyper-focus at the expense of feeling, and/or thinking and doing as a means of attaining mastery over emotions. Following rules instead of one’s instincts is a hallmark. In the obsessional who values control above feeling, routine almost universally supplants spontaneity.
The obsessional can experience panic in a number of different contexts. Commonly, any situation that involves giving in, letting go, being overwhelmed, experiencing a flood of emotions, exhausting all familiar means of exercising one’s will. Falling or showing up for a test unprepared are common dreams of the obsessional. Whenever maintaining the fantasy of perfection or mastery cannot be maintained in an emotionally charged situation, panic attacks can appear.
2. Abandonment – The “Borderline” Personality:
As social creatures, we all fear exclusion, ostracization and abandonment. However, the centrality of this fear and the degree to which it expresses itself varies. Abandonment is especially problematic for people with poorly defined senses of self, identities, as well as significant problems regulating emotions. Other people, especially romantic partners and children are used as extensions of the self to compensate for the aforementioned deficits. The problem with using other people to fill our internal voids is that we don’t have the capacity to control others (although we can maintain this illusion in infancy and in regressed relationships). Panic, resulting from fear of abandonment, is evoked when the illusion of omnipotent control over others breaks down. For example, your partner doesn’t respond to a text during a night out with friends, or when a spouse leaves the house in the middle of an argument.
Fear of abandonment is the defining characteristic of Borderline Personality Disorder, but can also be seen in a disguised form in Narcissistic Personality Disorder (rejection of reality through grandiosity alongside rigid insistence on the right to control others). Primitive fantasies and dreams are frequently are characterized by impotent rage and despair, often taking the form of damaged creatures, destruction, violence, and decay.
3. Devoured – The Narcissistic/Schizoid Personality:
Panic about being devoured is often the reciprocal of abandonment anxiety. An empty, identity-less person will long to consume the entity that possesses what the devourer lacks. Being devoured is not an experience of being suddenly attacked; rather it is an experience of being stalked, in a deliberate, unyielding fashion. Panic resulting from this core existential dread feels like a psychological boa constrictor. The devourer’s hunger may first feel like a warm embrace. But as time goes on, the squeeze intensifies and breathing becomes more difficult. Past a certain point, moving, speaking, and acting are impossible.
What the constrictor imagery illustrates about the annihilation anxiety behind being devoured is that danger is not immediately apparent. What first feels like a gratifying (and voluntary) pursuit of feeding the starving caregiver/companion gradually becomes an unrelenting demand. The more you give, the more the other takes, the less you know your own desires, and the less able you are to speak about the danger in which you find yourself.
This interpersonal pattern of feeling suffocated, drowned, paralyzed, catatonic, and/or depleted can begin to establish itself as early as 4 months of age. Infants naturally need to avert their gaze away from their mother, both to establish themselves as separate and to find relief from the intensity of face to face contact (in the natural world, prolonged eye contact precedes the two F’s–fighting and fucking, and is thus highly stimulating). A mother (or other caregiver) who feels rejected by the infants turning away, or perhaps insatiably chases the feeling of being fully attuned with the child, feeds herself instead of the infant. The child learns implicitly that the caregiver comes first, and that there is no escape from the needs of the powerful caregiver–the adult upon whom the child’s survival depends entirely. A template for relationships forms that is akin to Seligman’s learned helplessness paradigm; i.e., an inescapable situation from which escaping is not possible. In the animal kingdom, this resembles the anesthetized surrender before being devoured by a predator.
Drowning and futile attempts to escape characterize dreams and fantasy when this existential fear is most pronounced. Narcissistic personalities and Schizoid (detached, more interested in internal fantasies than the world around them) are adaptations to early environments where the fear of being devoured was most salient. Both of these personality structures are based on maintaining separateness at all cost to intimacy and connection to large portions of unsavory social reality.
4. Mutilated – The Dependent/Avoidant Personality:
Mutilation is the risk of action. We can only be maimed when we undertake a difficult challenge with a valuable reward. Being in the world, acting in the world, and assuming a position of agency inevitably leads to negotiating conflict and reconciling your desires with fellow actors when each agent’s respective ambitions are in direct conflict–i.e., being an actor in the world means risking serious injury. For the male spirit (I use spirit since increasingly we see biological women identify more as male), fear of mutilation was termed by Freud as “castration anxiety.” For feminine agents, mutilation tends to focus on general threats to bodily integrity, especially non-consensual penetration.
When mutilation is your existential fear, avoidant and dependent character traits often emerge. In classical terms, when the threat of castration looms too large, a regression back to childlike insulation and dependency is a natural–though highly costly–solution. Panic is likely to occur when you are forced to confront an avoided conflict and/or situation, or have no choice but to complete a difficult task alone. Internal conflict is characterized by competing feelings of anger and need to depend on others. Whenever this internal tension increases, the likelihood of a panic attack increases.
5. Disappearing – The Histrionic Personality:
Early neglect or misattunements with caregivers can lead to repression the detachment of thoughts from feelings), or more primitively, dissociation. In less technical terms, not being seen puts young children in a state of extreme anxiety. Without internal or external means of soothing themselves, decoupling consciousness from pain is often the default defense. Consequences of this are that the child does not feel “together” or “anchored” in a sense of what s/he is feeling. States of panic can arise in adulthood when circumstances conjure states of being neglected, unseen, dismissed, etc.
Increasingly rare, the personality type most likely to feel as if they do not exist or are completely unseen is the histrionic personality, or dramatic/flamboyant character type. Anger and rage about being ignored are supplanted by attention-grabbing theatrics, highly seductive behavior, and/or concrete, physical ailments that are more difficult to dismiss than emotional pain. Changes in culture have made this type of personality both rare and slightly changed, but at its core, the histrionic closely resembles Freud’s first patients.
6. Death – Post-Traumatic Stress Disorder (non-specific to personality):
Perhaps the most straightforward existential fear, death, especially when a significant traumatic event has occurred, can lead to intense panic attacks. During both brief and prolonged exposure to violence, death, destruction, and other forms of danger, a common way we deal with terror is to detach our consciousness from experiencing the traumatic event. Because the event cannot be tolerated, the experience is put into a kind of psychological lockbox. The problem is, these events require that we adjust our behavior to avoid them in the future, so these experiences cannot simply be annihilated from our minds. Any cue from a dissociated traumatic event, whether central or contextual to the trauma, can intrude into our awareness at unexpected times. In my experience working with 9/11 first-responders, any number of cues were capable of bringing the responders back to the scene of the attack. Tall buildings, certain smells, bridges, planes, sirens, crowds, etc. could all bring about a flooding of consciousness with vivid experiences from the locked-away experience. Panic attacks can certainly follow from intrusive imagery of a life-threatening event.
While this type of panic can arise in response to disguised, apocalyptic fantasy, the hallmark of this type of panic attack is often the “flashback” quality, where you “relive” traumatic events in what feels like a high-fidelity simulation. The earlier (developmentally) and more confusing the trauma (children don’t always recognize that they are being victimized), the more likely panic will follow from more abstract cues that are difficult to connect to direct past experience.
Conclusion:
I have presented in this post a framework for classifying types of panic attacks as a means of helping people better understand the contextual features that precipitate sometimes “uncued” attacks of anxiety. This framework is built upon core psychological anxieties; that is, anxieties about the annihilation of our psychological, conscious, selves. Of these annihilation anxieties, I have included the following: losing control, being abandoned, being devoured, being mutilated, disappearing, and dying. I have also made an effort to connect distinct experiences with panic with specific types of maladaptive personality organizations. These categories of panic are based on my clinical experience, theory, and some empirical data. They are not meant to be mutually exclusive, and many people will experience panic multiple types of panic and/or panic attacks that include features of several of these classifications. I will address coping strategies that are most likely to help when one of these types of anxiety is most salient.
Let’s have a dialogue to better clarify and spread the word about existential anxiety, panic, and types of personality structure! Comment below, sign up for my mailing list, and/or follow me at @mindsplain on Twitter.
Further Scholarly Reading on Annihilation Anxieties: