Severe Panic Disorder in a Middle-Aged Man

The following describes the case of Mr B, who sought treatment for panic and acute anxiety. The case involves at least one diagnostic or therapeutic decision point. We invite your comments below. Dr Busch will review your responses and give his feedback in coming weeks.

Questions to consider when reading the case:

1: What psychodynamic conflicts were likely triggers for the patient’s panic attacks?
2: What psychodynamic approaches aided in relief of his panic?

CASE VIGNETTE
Mr B experienced a severe panic attack 2 days after his 39th birthday. When he was evaluated in the clinic, he scored 12 out of 28 on the Panic Disorder Severity Scale (PDSS), a questionnaire used by clinicians to measure the severity of panic disorder.

The therapist initially explored the circumstances surrounding panic onset. Although Mr B acknowledged that he had been “stressed,” he was puzzled about the source of the panic attacks. He focused initially on problems at work: he was not comfortable with the pressure at work since his recent promotion. As therapy progressed, he realized that he had experienced some of the symptoms of panic several weeks before the full-blown attack when he had to reprimand or fire employees. Specifically, he felt tremors in his arms and a sense of loss of control.

Mr B had a difficult background. His father was a temperamental man who was especially intolerant of his son’s early reading and writing difficulties. He described his mother as self-absorbed, often neglecting him. On 3 occasions, his parents sent him away from home, once to relatives and twice to boarding schools, for reasons he did not understand at the time. As a child, he assumed he was sent away because he was “bad,” or he was being punished for losing his temper with his mother. His parents often fought and ultimately divorced.

Although his relationship with his father improved over the years, his mother became a lonely embittered woman who viewed herself as a victim of unfair life circumstances. She pressured Mr B to take care of her, which he perceived as attempts to draw him away from his wife and job. Although he was angry at his mother’s refusal to take better care of herself, he felt guilty saying no to her.

Intervention/Treatment
Mr B entered treatment for panic disorder in a research protocol that compared panic-focused psychodynamic psychotherapy (PFPP) with applied relaxation therapy, and he was randomized to receive 24 sessions of PFPP. The therapist and Mr B identified that at the time of panic onset, he was struggling with guilt and disappointment over being asked to reprimand and fire some of his employees. He was reluctant to acknowledge his anger, but he did admit to feeling “frustrated” with colleagues he believed were poor managers and had been responsible for the layoffs. In addition, despite his view that his mother caused significant problems in his life, he experienced guilt over his feelings of anger toward her.

In therapy, it emerged that Mr B feared these feelings of anger would disrupt his relationships. These fears were linked with his abandonment fantasy of being sent away from home as a child for being “bad.” Thus his angry feelings triggered guilt and anxiety and were typically denied or minimized (for example, he stated that he felt “frustrated” but not angry). To avoid anger and feelings of abandonment, Mr B believed he needed to respond “perfectly” and succumb to the needs of others. His inability to be “perfect” with his employees and with his mother compounded the guilt and anxiety. A mandate to fire some employees and his anger at his colleagues intensified these conflicts and fears, eventually leading to panic onset.

PFPP helped Mr B identify the emotional triggers that led up to his panic attacks. The therapist pointed out that anger was not a threat to his relationships-a belief he had held since childhood-and that his resentment toward his mother was understandable given her problematic behavior. An increasing identification and tolerance of these feelings diminished the patient’s fear that anger would disrupt his close relationships. As a result, his panic attacks rapidly resolved during treatment.

Outcome
As Mr B’s fear of abandonment diminished, he felt less pressured to submit to the needs of others to have relationships in which he was “perfect.” His relationships improved as he became more comfortable asserting himself appropriately with his mother, his wife, and coworkers. Through PFPP, he learned (1) to identify situations that could trigger intense anxiety and panic and (2) to develop more effective ways of coping with feelings that arose from these situations.

[Editor’s note: For further information, see the discussion at Panic-Focused Psychodynamic Psychotherapy, by Drs Fredric Busch and Barbara Milrod, from which this case is adapted].