Fear of fear: panic attack therapy

"The subterfuges of hope are just as ineffective as the arguments of reason" (Cioran, 1993) when the heart beats wildly, the breath becomes labored, the body seems to be crossed by a high voltage electric current and the mind runs fast, looking for of a solution to those feelings that one cannot explain. The need for help and protection, as well as the attempt to escape from that situation that you only want it to stop, prevents any attempt to be able to control oneself and one's reactions. Then, suddenly, everything ends, leaving the same feeling of devastation produced by a tsunami, in this psychological case. Until the next time. We have just taken a walk in crippling fear; the one that terrifies, the one that annihilates. But how can it happen that from a natural fear it is possible to structure a real disorder, which the person cannot get rid of? Fear, as our endowment of nature, comes before and after everything, pushing us to act in anticipation of the same mind, with speed and precision. At the same time, precisely because of the characteristics described, when it attacks us it destroys all the rest and reason is shipwrecked, fear surpasses itself and becomes a limitation from a great resource; becomes panic.

Panic understood as a psychological disorder is a modern diagnostic category, although the characteristic reaction as a response to conditions of extreme threat, or the defined “fear panic”, is the most archaic of emotions. WHO (World Health Organization), in 2000, defined panic disorder as the most important existing disease, affecting 20% ​​of the population. From a nosographic perspective, in the DSM (Diagnostic and Statistical Manual of Mental Disorders), panic attacks have been contradictorily included within the category of anxiety disorders.
While, from an operational point of view, it appears that it is not anxiety that triggers fear, but it is fear that triggers the physiological reaction of anxiety, which increases more and more with the heightening of the perception of individual threat, transforming itself thus from functional loss of control activation mechanism. Following this logic, if the activation of anxiety is an effect of the perception of stimuli internal or external to the organism, the privileged ways of treatment become the management and transformation of perceptions that activate the reactions of the subject in moments of crisis, while the classification of panic attacks among anxiety disorders leads to a distortion of observation and evaluation of the disorder, indicating as the most adequate solution the anxiety inhibitory drug therapy itself. It is no coincidence that the first false positive in the diagnosis of panic is represented precisely by generalized anxiety disorder, where in reality the total loss of control typical of panic is missing; the state of alarm is constant, with an increase in physiological parameters, which however do not reach the tilt.

From the etiological point of view, although the really rigorous methodology to understand how a pathology works is represented by the type of therapeutic solution capable of solving it, most of the time the perspective remains the traditional one that searches in the past for the causes of the present problem. However, during a panic attack, the person is terrified of his own feelings of fear towards the threatening stimulus he will try to fight, as we will see, thus increasing them; the effect therefore becomes cause. Therapeutic change can only take place within the present dynamic of persistence of the problem, thus acting on the way in which the individual perceives threatening stimuli and, reacting to them, instead of managing them functionally, is overwhelmed. The focus of the study is the interaction of the organism with its reality, to which it responds by modifying it and being modified by it. Panic is defined by many as the most extreme form of fear which, if below a certain threshold represents a resource that allows the organism to be alerted to dangerous situations, above this limit it becomes pathological. There are several situations in which the thrill of fear envelops the person in its coils, but the operating structure of the vicious circle that creates and maintains the fear itself is similar, until it becomes panic.

Analyzing the most usual reactions to a perception of intense fear, we can observe some constant redundancies in different people and situations:

a) The attempt to avoid or shun what frightens, which makes one feel less and less capable of facing that monster that assumes ever more gigantic proportions in the mind of those who are afraid
b) the search for help and protection, which makes us feel safe on the spot, but then, even if we succeed, it will only be a buffer that will take effect until the next time.
This is because a sort of delegation to the other takes place in facing fear which, being an individual perception, can be exorcised only and only by those who feel it;
c) the unsuccessful attempt to keep one's physiological reactions under control, which paradoxically causes one to lose control, for which one becomes even more agitated.

The repetition over time of this type of interaction increases the perception of fear leading to an exasperation of the physiological parameters that are activated naturally in the presence of threatening stimuli, up to the explosion of panic. If, on the contrary, one manages to interrupt these dysfunctional interactions, fear falls within the limits of functionality (Nardone, 1993, 2000, 2003). This last statement was the very hypothesis from which George Nardone and collaborators, have taken the first steps for the development of specific intervention protocols: if avoidance, request for help and failed control attempt are really what transforms a fear reaction into panic, then ensure that a person suffering from this disorder interrupts such response scripts should lead to the extinction of the disorder. In 1987, the first application of a specific therapeutic protocol for panic attacks with agoraphobia was carried out, based on a strategic sequence of therapeutic stratagems that created the planned random events, which led the subjects first to experience the corrective emotional experience, to then gradually being exposed to the feared situations, touching the new skills acquired.

La first research-intervention published in 1988 (Nardone, 1988) represented the milestone of all the work on panic developed in the following decades to date, demonstrating its extraordinary effectiveness and therapeutic efficiency in breaking the rigidity of the dysfunctional phobic-obsessive perceptive-reactive system. Currently, the therapeutic treatment developed, and thus tested and proven, represents the "best practice" in the therapy of panic attacks, responding to all the criteria established to be able to evaluate, from an epistemological and empirical point of view, the scientific validity and application of a therapeutic intervention model. In particular:
- the therapeutic changes obtained are maintained over time, with the possibility of relapses of the disorder reduced to a minimum; as proof of this, the experimental studies conducted with a control group and randomized samples, the video recordings of the therapeutic processes, and the comparison with other therapeutic techniques, i.e. evaluations both qualitative and quantitative (efficacy);
- the therapeutic strategy produces results in a reasonably short time, months and not years, otherwise the change could be the effect of fortuitous events (efficiency);
- the therapeutic techniques and their process can replicate the results on different subjects presenting the same pathology (replicability); - during application, the effects of each single therapeutic maneuver can be predicted within the entire sequence of the model (predictivity);
- the model and all its techniques are constantly taught and passed on to other colleagues so that they can, by applying them, obtain similar results (transmissibility). Initially, the unlocking maneuvers acted by blocking the request for help and protection through a restructuring aimed at creating a greater fear that inhibited the present one, resuming the observation that a greater fear is cornering, and those who hear it often pull out. a winning courage even in the most adverse conditions. To act on avoidant behavior, a series of suggestive prescriptions were devised capable of distracting the subject during exposure to feared situations (counter-avoidances), such as the prescription of the pirouette and that of the apple (Nardone, 1993; 2003). Finally, to interrupt the attempt to repress one's reactions, the “logbook” was devised, that is a sort of apparent monitoring of panic episodes, but actually aimed at producing emotional detachment.

This, starting from the observation that, when the subject reacts to the frightening situation pushed by some reason or stimulus that distracts him from it, he acts without thinking and, only afterwards, he realizes what he has done successfully. Studies on the neurophysiology of panic (Nardone, 2003; 2016) have then highlighted two fundamental processes that occur during a panic attack: on the one hand, the phobic perception involves the limbic system (amygdala, hippocampus, locus coeruleus, hypothalamus ...), which reacts in thousandths of seconds by immediately conveying a response to the periphery, activating the "flight or fight" reaction, (or I flee or fight), to which "freezing" has currently been added thanks to the stimulation of the autonomic nervous system, in particular of the sympathetic section.
On the other hand, after thousandths of seconds, the sensation reaches the cortex, which is responsible for the conscious evaluation of external stimuli and modulates voluntary behaviors; for the amygdala to respond to fear reactions, the medial prefrontal cortex must be deactivated.

The problem arises when the modern mind, therefore the cortex, confuses the healthy mechanism described with something dangerous, realizing itself beyond its control, and what scares the most begins to be no longer the fear itself, but the reaction of loss. control of the organism, which leads reason to try to control, and the more it tries to control the more it loses control, up to the physiological tilt of the panic attack. It was therefore necessary to introduce a technique capable of successfully intervening in panic attacks in the absence of a real threatening source, or in those cases in which the frightening threat does not come from outside, but derives from being afraid. of the fear that triggers the paradoxical escalation to panic. Paradoxically, fear turns into a self-fulfilling prophecy without the need for any external triggering situation.

The technique of the "worst fantasy", the result of constant research-intervention in the field and concrete examples of the success of the paradox in history. We think of the stoic courage of Seneca who, condemned to kill himself by cutting his veins with his own hands and after seeing his wife suffer the same fate before him, managed to overcome fear by spending the period before the execution imagining all the fantasies more terrible about that atrocious horror film of which he would inevitably become the protagonist.

Specifically, the technique consists in asking the person to retire every day to a room where no one can disturb him and, making himself comfortable, he will dim the lights and create a soft atmosphere. She will set an alarm clock to go off half an hour later and in this half hour she will begin to indulge in all the worst fantasies about what could happen to her. And, in this time, she will do whatever she has to do: if she feels like crying she cries, if she comes to scream she screams, if she gets to hit the ground she does. When she rings the alarm… STOP… it's all over; she turns off the alarm, goes to wash her face and goes back to her usual day. So the important thing is that for the whole half hour, whether she gets sick or not, she stays there, indulging in all the worst fantasies that could happen. She does whatever comes to do, but when she rings the alarm… STOP… it's all over. She turns off the alarm, washes her face and goes back to her usual day. A half hour of daily passion, then.

The results of the application of the paradoxical injunction to panic (Frankl, 1946) are extraordinary: patients induced to immerse themselves in all the possible worst fantasies about panic, instead of being frightened, relax, creating a counter-paradoxical effect (Nardone, Balbi, 2008) compared to the paradox of escalation from fear to panic, sometimes even falling asleep. After a rigorous training, which sees the evolution of the technique from half an hour to five minutes five times a day in which the person has to make scheduled appointments to their fears to familiarize themselves with the experience for which the more they seek fear, the less it is it will show up, you come to use the technique before doing something feared (look fear in the face so that it becomes courage ”) and when fear unexpectedly arises (I touch the ghost when it appears to make it vanish).

In 2000, the evaluation study on 3482 treated cases, of which over 70% suffered from panic attacks, showed a therapeutic efficacy of 95% and with a duration of treatments reduced to seven sessions. Hundreds of thousands of cases have been successfully treated since then, with an average success rate in international statistics exceeding 85%. But the most surprising finding is that patients get rid of the invalidating disorder within 3-6 months and that these results, as the follow-up measurements after the end of the therapies show, are maintained over time in the absence of relapses and symptom shifts. This is thanks to the application of an isomorphic logic to that of the persistence of the problem, therefore non-ordinary, and to a form of suggestive persuasive communication (Nardone, 2016; Castelnuovo et al., 2013; Nardone, Watzlawick, 2005). Fear, therefore, if pushed, rather than shunned or repressed, becomes saturated in its own excesses (Nardone, 2016), becoming the clearest demonstration of the fact that "There is no night that does not see the day" (Nardone, 2003).

Dr. Elisa Balbi (Official Psychologist-Psychotherapist of the Brief Strategic Therapy Center)

 

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