The Psychiatry Blog by John Deri, M.D.

Panic disorder is a terrifying, potentially disabling condition.  In my experience, it is a specific form of separation anxiety: separation from the self.

Richard was a 39 year old married man living with his wife and their two young children.  He was a self employed businessman.  He presented with an acute onset of panic attacks.  These episodes had been occurring with increasing frequency, during the weeks prior to our first session.

Richard and I worked together in twice a week psychotherapy for a period of four years.  His symptoms of panic disorder were relieved by high doses of antidepressant medication, during most of this time.

Early Life

Richard’s early life experience was powerfully influenced by his distant, critical, cynical father.  The father, a successful professional, was rarely at home.  Richard’s mother was comparatively more available to him.  However, she was primarily focused on her husband.  Moreover, she was largely preoccupied with her own painful feelings of isolation.  As a result, Richard was on his own emotionally.

Polysubstance Abuse

Like Sophia in my previous blog posting, Richard turned to alcohol as a young man.  He used alcohol as a way of deadening and escaping from his psychic pain.  Some years later, he began regularly using cocaine.

When I met Richard, he was drinking 6-9 drinks per day, as well as the occasional bottle of wine.  Despite this clearcut pattern of alcohol abuse and dependence, Richard was in complete denial about his alcoholism.

Themes in Therapy

The primary theme in Richard’s therapy was to draw his attention to his repetition compulsion.  He abandoned his family and himself much as he had been abandoned.  A recurring memory wove like a thread throughout the therapeutic work.  Richard had been put out in the back yard whenever he had cried as an infant.

A key dream, to which we often returned, consisted of a brief exchange between Richard and his mother.  In the dream, Richard told his mother, “I’m in pain.”  To which she replied, “I’m in pain, too.” In other words, Richard was entirely excluded from his parents’ minds.

As a young unemployed adult, Richard literally went hungry.  His wealthy parents withheld financial support.

As a mature adult, Richard abandoned his own family, through alcoholism and workaholism.  He was absent to himself as well.  He would often work for long stretches, without eating or sleeping.  He was entirely out of touch with his emotional states.  Alcohol and work were his psychic refuges of unconsciousness.

The Therapeutic Work

The initial therapeutic task was building Richard’s capacity for mindfulness regarding his own self states.  This work began with developing his attention and appropriate responsiveness to basic bodily sensations, e.g. eating when hungry.  This process of growing self awareness then extended to his emotional states.  During the early phases of our work, Richard would compulsively play video games, when he was neither drunk nor working.  Gradually, he learned to make space for his own psychic experience.  He developed an increasing repertoire of healthy activities in synch with his emotional states.

The next major hurdle in therapy was overcoming Richard’s denial of his addictions.  To put it briefly, this achievement was won as a result of a two year long intrapsychic and interpersonal tug-of-war.  Once Richard joined AA and CA, our therapeutic work truly blossomed.  The step work and the psychotherapy were mutually synergistic.

Within the context of the fourth step (“performing a searching and fearless moral inventory”), it became possible to draw Richard’s attention to his abandonment of his family.  This was an extraordinarily painful phase of the work.

Another key component in Richard’s healing process involved helping him to recognize and to neutralize his own inner critic.  This voice was a direct internalization of his critical father.

Finally, through a combination of the psychotherapy and the twelve step programs, Richard overcame his narcissism.  He developed a genuine, growing capacity for concern for others.  This transformation in his character was deeply moving for both of us.  Our own relationship with each other was immeasurably enriched accordingly.

Outcome

Richard became clean and sober.  His panic attacks resolved, off all medication.

His marriage dissolved.  His business went bankrupt.  His life, as he had known it, came crashing down around him.

Yet, paradoxically, Richard was happier and more grounded  than he had ever been in his life.  He had a greatly enhanced capacity for intimacy.

Once again, we encounter the archetype of death and rebirth: the phoenix rising from the ashes.

When I called Richard to request his permission to tell his story, he readily assented.  “I tell my story all the time in the [12 step] meetings,” he said.  “And, guess what?  I’ve just celebrated my fifth year of sobriety.”

When I ponder the question of the meaning of life, I no longer have to search for an answer.