2024 Author: Harry Day | [email protected]. Last modified: 2023-12-17 15:43
Why panic attacks don't lead to insanity
Ph. D. Ermakov A. A
The most common fears experienced during panic attacks are fear of death, fear of loss of self-control, and fear of insanity. Patients are often sure that some kind of catastrophe is happening in their body or psyche: myocardial infarction, stroke, schizophrenia. In reality, the content of thoughts during a panic attack is strictly subjective and obeys the laws of emotional logic, i.e. tendency to catastrophization. This, by the way, explains the fact that between panic attacks the patient reasonably reasonably understands that no one has died or gone mad from panic attacks, that a panic attack is a semblance of training for the body, but during an anxiety attack, all these defensive statements go where- then they evaporate.
So why isn't panic attacks going crazy? In order to understand this, first you need to explain what panic attacks are. Clinically, panic attack (PA) is manifested by the following symptoms (at least 4):
1. Tachycardia.
2. Sweating.
3. Trembling or shaking of the body.
4. Feeling of lack of air.
5. Choking.
6. Pain or discomfort behind the breastbone.
7. Nausea or stomach discomfort.
8. Dizziness, unsteadiness, or weakness.
9. Derealization (a feeling of unreality of the world around and what is happening) or depersonalization (a feeling of alienation of one's own body or the dissimilarity of one's own sensations).
10. Fever or chills.
11. Paresthesia (tingling sensation, numbness or "creeping").
12. Fear of dying.
13. Fear of losing control or going crazy.
Attacks can be repeated, unpredictable and not limited to any specific situation (as opposed to, for example: from social phobia - attacks in social situations, or agoraphobia - attacks in situations in which it is difficult to get help or get out of them). A panic attack can rarely last more than 30 minutes. Average duration 5-10 minutes. Avoidance of any situation in which a panic attack first occurred is formed for the second time, for example: being left alone, crowded places, repeating panic attacks - the so-called anxiety of anticipating an attack.
It is important to mention that panic disorder occurs in circumstances that are not associated with an objective threat, i.e. PA is caused by intrapsychic (intrasubjective) unconscious conflict. What links does this conflict consist of?
Panic attack is a classic manifestation of anxiety neurosis. The personality of a person predisposed to panic disorder is characterized by an integrated but rigid (ossified, inflexible attitudes and rules) superego, whose instrument is a generalized sense of guilt. As a result, in response to unacceptable needs in dependence and love, as well as to the emerging anger and hostility towards others, unconscious anxiety turns on, transforming into a somato-vegetative symptom - a panic attack.
Thus, PA is not a signal of impending death or insanity, but the result of self-punishment for an unacceptable (immoral - from the standpoint of child morality of a self-punishing super-ego controller) impulse. The figure shows the mechanism of formation of the PA:
Otto Kernberg (1975) identified 3 structural organizations of personality: neurotic, borderline and psychotic. Panic attacks are the prerogative of a neurotic nature, in which the development of psychosis, for example: schizophrenia or paranoia, is not possible.
What is the difference between a neurotic personality and a psychotic one?
The neurotic organization of the personality is characterized by a "welded" Self - a clear boundary between the self and ideas about others (between one's thoughts and feelings and fantasies about others). A holistic identity, in which conflicting images of the self and others are integrated into a holistic picture. That does not allow the loss of connection with reality, even with significant stress. In addition, on the guard of the boundaries of the Self - a strong Ego with productive, more mature psychological defenses: rationalization, repression, reactive education, isolation, destruction, intellectualization. The ability to test reality - the ability to distinguish between I and not I, the intrapsychic and environmental factors are preserved.
So why is the psychotic personality vulnerable to developing schizophrenia?
1. The psychotic organization of the personality (in which the development of psychosis is possible and obeys the concept of stress diathesis, ie, increased "vulnerability" to stress) is characterized by an ambiguous, but still hereditary predisposition.
2. The psychotic personality is characterized by the weakness of the ego, which does not cope with anxiety, does not control impulses and has only primitive psychological defenses, is not capable of sublimation.
3. With the psychotic organization of the personality, reality testing suffers. It can be defined as the ability to distinguish between I and not-I, to distinguish the intrapsychic from an external source of perception and stimulation, as well as the ability to evaluate one's affects, behavior and thoughts in terms of the social norms of an ordinary person. In clinical research, the following signs tell us about the ability to test reality: (1) the absence of hallucinations and delusions; (2) the absence of clearly inadequate or bizarre forms of affect, thinking and behavior; (3) if others notice the inadequacy or strangeness of the patient's affects, thinking and behavior from the point of view of the social norms of an ordinary person, the patient is able to feel empathy for the experiences of others and participate in their clarification. Reality testing must be distinguished from distortions of the subjective perception of reality, which can appear in any patient during psychological difficulties, as well as from the distortion of attitude to reality, which is always encountered both in character disorders and in more regressive psychotic states.
4. In addition, the psychotic organization of the personality is characterized by "diffuse identity" (self-perception and self-understanding). Clinically, "diffuse identity" is represented by poor integration between self and significant others. A constant feeling of emptiness, contradictions in the perception of oneself, inconsistency of behavior that cannot be integrated in an emotionally meaningful way, and a pale, flat, meager perception of others are all manifestations of a diffuse identity. Psychotic structural organization, involves a regressive rejection of the border between the self and others, or the vagueness of this border. In the mental organization of the borderline personality, there is a fairly clear barrier between the self and the other.
With the psychotic organization of the personality, there can be attacks of annihilation (vital) anxiety, but unlike panic attacks, they are characterized by originality and staging:
1st stage of psychosis - delusional mood. When a person is confused and anxious.
2nd stage - delusional perception, when the awareness and perception of the environment changes, everything that happens is recognized as having something to do with the patient.
3rd stage - of special importance. Everything is perceived by the patient in accordance with some special meaning and meanings of objects and phenomena.
The symptoms observed in borderline patients are similar to those of ordinary neuroses or character pathologies, but a combination of some features is characteristic precisely for cases of borderline pathology. The following symptoms are especially important:
1. Anxiety. Borderline patients have a chronic, all-pervading, “free-floating” anxiety.
2. Polysymptomatic neurosis. Many patients have one or another set of neurotic symptoms, but here we mean only those cases when the patient has a combination of at least two of the following symptoms:
but. Multiple phobias, especially those that significantly limit the patient's activity in daily life.
b. Obsessional symptoms, which for the second time became Ego-syntonic (acceptable to the Self) and acquired the quality of “overvalued” thoughts and actions.
in. Multiple complex or bizarre conversion symptoms, especially chronic ones.
d. Dissociation reactions, especially hysterical twilight states and fugues, as well as amnesia, accompanied by impaired consciousness.
e. Hypochondria.
e. Paranoid and hypochondriacal tendencies in combination with any other symptomatic neuroses (a typical combination that makes one think about the diagnosis of a borderline personality organization).
3. Polymorphic perverse sexual tendencies. This refers to patients with severe sexual deviations, in which several different perverse inclinations coexist. The more chaotic and plural the patient's perverse fantasies and actions, and the more unstable the object relations that develop around such sexuality, the more reason to suspect a borderline personality organization.
4. "Classical" prepsychotic personality structure, which includes the following features:
but. Paranoid personality (paranoid traits appear to such an extent that they come first in a descriptive diagnosis).
b. Schizoid personality.
in. Hypomanic personality and cyclothymic personality organization with pronounced hypomanic tendencies.
5. Impulsive neurosis and addiction. This means such forms of severe pathology of character, which in behavior are manifested by a "breakthrough impulse" to satisfy instinctive needs, and such impulsive episodes of Ego-dystonic (alien to the I) when remembering them, but Ego-synthones (acceptable to the I) and bring great pleasure at the very moment of their performance. Alcoholism and drug addiction, some forms of psychogenic obesity or kleptomania are typical examples of this.
6. Violations of the "lower level" character. This may include some forms of severe character pathology, typical examples of which are chaotic and impulsive characters.
Used Books:
Kernberg O. F. Borderline conditions and pathological narcissism. - New York: Jason Aronson. - 1975. - P. 125-164.
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