Although it is not in the DSM IV, I believe there is a personality style (or “disorder” if you will) called the “Panic Personality.” Having worked with anxious, panicked, and phobic people for the last twenty years, I have witnessed certain personality traits and life experiences that are common to many of these people A review of the literature confirms this impression. Understanding the etiology is crucial to effectively working with people with these types of symptoms and problems (unless, of course, one adheres primarily to the “biochemical imbalance” theory).
A panic attack may be a traumatic event for some people. The feeling of being overwhelmed, in mind and body, by uncontrollable and unpredictable severe anxiety is like a nightmare for the sufferer. The symptoms of panic include shaking, dizziness, chest pains, rapid heartbeat, nausea, sweating or chills, just to name a few. Along with this is the inability to think clearly; one feels confused or disoriented and fears that he or she is going insane, having a heart attack, dying, or just plain losing control, and devastated by the inability to control one’s mental, physical and affective state.
Approximately one in twelve people will have panic attacks in their lifetime, and generally this will happen in one’s twenties to a female. Fifteen years ago most of the people who came for treatment were women; for the past five years, at least half of my anxiety clients are men. I believe this is an equal-opportunity malady.
A panic attack may come on gradually, building to a peak of intensity, or suddenly, which is the way most people experience them initially. The attack may last several seconds or minutes, although some clients have reported them to last hours. However, even when the attack is short-lived, the fear of the next one coming “out of the blue” lives on in the sufferer. This apprehension about having another attack creates a state of anticipatory anxiety; this starts the anxiety cycle called “panic disorder.”
Chances are good that you have had a panic attack or more in your lifetime, or know others who have. For some people it just comes and goes, like a bad bout of the flu. Clearly, not everyone gets caught in the cycle of a panic disorder. Understanding the “panic personality” sheds light on why some people do get caught in the web of anxiety and fearful apprehension.
Panic disorder can best be understood by a “bio-psycho-social” model: the interaction of these three forces – biological sensitivity, psychological background factors, and stress – come together in the individual at some time(s) in her or her life.
There is some evidence that panic patients have a predisposition that has been genetically transmitted. The chances of developing a panic disorder in one’s lifetime is between 2 and 5 percent. However, if one has a first degree relative with panic, the risk is between 10 and 15 percent. Also, one early study found that identical twins are more likely to both develop a panic disorder than are non-identical twins. Studies are currently underway to better understand the role of the genetic contribution to panic disorder.
Another theory that shows some statistical evidence, and fits the description of many of my clients, involves childhood temperament. This child – shy, inhibited, cautious, or introverted – responds to unfamiliar situations with considerable distress, including greater physiological arousal (e.g. faster heartbeat). This child may be more prone to develop an anxiety disorder in later life.
Psychological childhood background factors play an important role in determining vulnerability to panic disorder. While there are differing theories as to the degree that this role may contribute to its development, there is evidence that certain childhood conditions that lead to an overreliance on others, lack of confidence in one’s ability to cope or survive on one’s own, or general feelings of a lack of safety in the world, are contributing factors. These vulnerabilities are created by being over-protected (usually by parents who are anxious themselves), being given too much responsibility at too young an age (e.g. when the child takes on a parental role), living in a chaotic or unstable environment (e.g. an alcoholic family), being overcriticized or getting approval only for certain accomplishments, suffering a traumatic loss or separation (e.g. the death of a parent), and lastly, abuse – physical, sexual, emotional, or neglect.
These types of stressful childhood environments are often experienced by the person who eventually develops panic disorder. Stressful negative life events during early development may produce long-term increases in one’s general anxiety levels, making the person more likely to have panic reactions when confronted with stressful life events later on.
Most discussions about a “panic personality” have come from clinical observations. However, the small amount of research done in this area supports the notion that a particular personality style are correlated with those who get a panic disorder.
“Panic personalities” try to avoid problems or stressful situations. Since they have not learned how to cope with difficult life events they deny or avoid them. This person may have difficulty handling conflict, dealing with anger, (one’s own or other peoples), or may have difficulty expressing feelings in general. She or he is usually nonassertive, at least in some areas of life, and has difficulty functioning independently. She or he is often fearful of other people’s judgment and how she or he appears to others, and may be perfectionistic as a defense against criticism. This person may have difficulties in interpersonal relations, as well as chronic anxiety, due to a lifestyle of trying to avoid stress rather than cope with it.
Now stress. The data points to the notion that stress plays a major role in the etiology of panic disorder. Studies have shown that at least 80% of patients reported negative or stressful life events prior to the onset of panic. In one study, 31% of the panic patients had suffered a major separation or loss, 30% had relationship problems, and 20% had taken on a new responsibility.
There are also other types of life changes that are known to precipitate panic attacks. Leaving home for the first time, the loss, or possible loss, of a relationship, or conflicts that represent a threat to an individual’s autonomy, are all life situations that trigger fears that impinge on the person’s vulnerabilities due to earlier childhood experiences.
In another study, the onset of symptoms occurred in a climate of interpersonal conflict, either with one’s parent(s) or a current spouse. In this study, 50% of the panic patients were threatened by the dissolution of a relationship prior to the onset of their first panic attack, the primary fear being the loss of security that the person(s) represents.
At this point, I will present a case: Lidia is a 30 year old married woman with two small children, a husband, and a job as a part-time nurse. Two months after the birth of her second child, she began to have panic attacks. At first, she thought it might have to do with a post-partum hormonal imbalance. Her doctor took some tests and gave her Ativan in the meantime. When the test results showed no signs of any abnormality, Lidia’s doctor suggested that it may be due to the stress of having a second child. So Lidia’s mother came to stay with the children for a few days so Lidia and her husband could go on a short vacation without the children. But the attacks were now more frequent and Lidia was afraid she was losing her sanity.
The above case is typical. It stands to reason that the stressor thought to be contributing to the panic attacks, as no physical problem could be found, must be the birth of the second child. The solution is also a typical one given – take some time away from the source of the stress – the baby.
Back to Lidia. At the age of 19, her first year way from home to college, Lidia had some difficulty with anxiety and depression. She moved back to her parents home, her anxiety and depression disappeared, and she got her degree from a college that was close by. Although her relationship with her mother had always been a conflicted one, and her relationship with her father was distant, both Lidia and her parents were glad she was back in their home. Lidia’s mother was an anxious woman who worried a lot about the health and safety of her children. Her father was a quiet man, prone to depression, who worked hard and long hours, and slept a lot when not working. Her parent’s marital relationship was not very satisfying for Lidia’s mother, and Lidia often felt responsible to be with her and lessen her mother’s loneliness.
Lidia lived at home until she married Jim, at the age of 25. Jim and Lidia’s mother did not get along very well – Jim thought her mother was meddling and overbearing. After the birth of their first child Lidia’s relationship with Jim became strained. Lidia thought that Jim was too aloof from her and their new baby. Jim thought Lidia devoted all her time to their new child, trying too hard to be the perfect mother, and excluded him. Two years later when Lidia was pregnant with their second child, the couple bought their first home, and Jim made sure it was far enough away from Lidia’s parents that they could not easily drop over. Now Jim was working longer hours to help pay their bills and Lidia found that she was alone all day and most evenings with the responsibility of the two children.
An anxious person may not choose a partner or spouse in the wisest way; often they are looking for someone they feel they can depend on, who seems very stable and offers a sense of security – someone to fulfil their childhood needs. The spouse may have similar characteristics to that of a parent, which sets them up for a conflicted or unfulfilling partnership.
Also, the panic prone person may not have learned how to recognize feelings, or the subtle distinctions in feeling states. Anger presents the greatest difficulty because physiologically, it is similar to anxiety. Also, many people learn that anger is an emotion that creates many problems, and therefore, the person may become anxious about his own anger if he or she is aware of it. As the above case demonstrates, there were many unresolved interpersonal conflicts and feelings that were not in conscious awareness or not expressed. When conflicts and feelings are denied or suppressed, they are not available to be acted upon, and the problems get no resolutions.
Very likely, Lidia, like many panic prone people, had been walking around with an elevated level of anxiety due to the unresolved frustrations and conflicts in her life for a long time before the first panic attack occurred. One often has such symptoms as headaches, fatigue, gastrointestinal distress, or sleep disturbances that precede the first panic attack by months or years. Then, one day another thing happens, perhaps a relatively minor event, and the person, whose anxiety level is already elevated, now has a panic attack. In this case, the latest stressor is the “last straw.”
Lidia was unaware of how the conflicts in her relationships were contributing to her anxiety. Her relationship with her mother was full of ambivalence, yet she felt depend on her, and angry at Jim for separating them geographically. She was hurt and angry at Jim’s emotional distance, nor was she aware of needing emotional support at all, therefore, not finding other ways to obtain it. Lidia put a lot of pressure on herself to be the perfect mother, although she didn’t know what that looked like. In the year prior to the onset of the panic there had been several major life changes – the move, a new mortgage, and the second child. Lidia had no awareness of how these changes, the conflicts in her relationships, the pressure she was putting on herself, and the lack of emotional support had any causal relationship to the anxiety she was now experiencing. Lidia believed that her life was just fine; it was the panic attacks coming out of nowhere that were the problem.
This is often how people first coming to therapy describe their bewilderment at what’s happening to them. This is often complicated by their contact with the medical establishment. Once the physician has determined that the symptoms are not of an organic nature, he or she might say that it’s “just nerves” and suggest to the patient to “take some time off and get away.” And quite often, the patient leaves with a prescription for a tranquilizer or antidepressant. While these might seem like rather benign prescriptions on the surface, I believe it may reinforce the denial and avoidance patters that underlie part of the problem.
The above case was presented to portray a person with a “panic personality.” While we may never see this diagnostic category in future DSM’s, awareness of it can aid us in working with the severely anxious people we see in our offices.