Sunday, November 4, 2012

Exhaustion following Panic Attack

A young Lithuanian immigrant, who came to the States when he was about 10, and who is now 27 years old, reported that after an intense Panic Attack, that lasted for 45 minutes, he went into a state of severe exhaustion that went on relentlessly for 8 days. After emerging out of his exhaustion he showed up for therapy session couple of days later and remarked that though he is out of the phase of severe exhaustion and somewhat energetic again some symptoms linger for example like there is no desire to talk to anybody. Then he expressed hope that in a few days he should be completely out of this funk.

The patient added, "The state of exhaustion was characterized by a feeling that it will never end. I tried everything mentally and physically to get my body going but it was of no use. In fact I could hardly feel my body. As if I did not exist. I missed school. I could not do homework. I slept for 13 to 14 hours a day but still felt exhausted on waking up. Physical work including even exercising, which, as you know, I am such an enthusiast of, could not motivate me. What do you think was happening to me?"

"Your system generated a massive depressive reaction to control your anxiety. When anxiety looks like it is completely out of control there is triggering of depression in some people to put an end to anxiety. The severe fear, which is what panic really is except that you don't know the cause of the fear, must have triggered an excessive secretion of neurochemicals, primarily acetylcholine,  that caused mental inhibitions on an entire range of functions, including  muscular activities, your thoughts and your emotions. This appears to be a mechanism that goes way back in to our phylogenetic past, perhaps as far back as when we were insects. Not just higher organisms but even the fish in the oceans go into a freeze when they are confronted by the predator face to face. If escape is not an option, for the killer is too close, then the last ditch effort is to play dead and hope that lack of any activity will make the predator mistake you to be part of the inorganic background. Perhaps the melancholic reaction in humans has its origin in this freezing behavior as a response to fear of death that got genetically implanted when animal organisms had not even emerged out of the oceans."

"Could it be a reaction to my stopping Zoloft ?" The patient had been put on Zoloft (Sertraline) sometime back for panic and depression. About 8 weeks before it had been stopped because of alarming weight gain.

"Yes, perhaps it is a reaction to the Zoloft being stopped. Zoloft had blocked out your panic attacks and was keeping your depression at bay. And then we stopped it. So perhaps the bottled up anxiety and depression returned with a vengeance. All these medications more or less work by suppressing some brain functions to allow others to work with less competitive interference. Antidepressants suppress emotions thus enabling a person to be not overwhelmed with emotions and once engage in the general concerns of the world. So when they are stopped these inhibitory emotions - anxiety and depression - may come back with renewed vigor."

Patient agreed with that and added, "Since I stopped the Zoloft I am waking up from sleep drenched in sweat. I do not feel any anxiety, but this kind of sweating must be a form of anxiety. For during the day, if things are rough, I get similar sweat attacks. At night when I am about to drift into REM sleep, I think the anxiety emerges to block me from doing so, perhaps because I must dream terrible things in my REM. I don't remember my dreams because I don't enter the REM state, which I believe must happen in order for the dreams to become recallable on waking. Anyway, the net result is that I am not getting enough REM sleep. I am always falling asleep during the day because at night I don't enter in to the REM phase and then my system tries to make up for that loss REM by attempting to do so in daylight. But here too the anxiety frustrates the attempt, and instead of falling asleep I break into a sweat."

Impressed by patient's metapsychological speculation, and feeling that he is in all likelihood right, I responded, "So that massive attack of panic was a breakthrough of the anxiety/fear. Your defense mechanisms failed to keep that anxiety muted, allowing only one component of it the sweating to emerge as actual behavior, and instead a full blown panic attack followed. But why did it happen? Is it because Zoloft was still exerting some lingering protection up to two months but then when its influence was completely lost a full blown panic attack became possible?"

"No," the patient disagreed. "Zoloft's discontinuation did not have that much of a role. The panic came after I did bad in an examination. The last couple of years have been nothing but my putting myself down. I constantly berate myself for not having done this or that in the past. I put tremendous pressure upon myself and I feel there is a tremendous pressure upon me from my family.  This must be a reaction to what I put my family through with my addiction. My family suffered greatly when I was abusing heroin. Now that I am on Suboxone, and not abusing drugs, and back to college, my family is happy. But I am able to do all these good things by constantly putting pressure upon myself and imagining that my family is really counting upon me. And how proud they will be if I do really well in the classes. After all that I have put them through they deserve that from me. And then when I nearly failed in the exam, I had the panic attack." At this point he broke down and started crying.
So the panic made its appearance when there was a failure of obsessive defenses. The metapsychological process in this young man must have gone through some such process: his aggressive/cruel tendencies, mostly arising from genetic predisposition, had first found expression against his family, whom he put through hell by abusing drugs. Perhaps drugs played another role in that by taking them he could lower the inhibitions that were preventing him from acting out his aggressive impulses towards others. Once the aggression had found enough satisfaction, the remorse had set in, and with the aid of Suboxone and psychotherapy, he could put a stop to his drug abuse and torturing of his family. Then to make amends, and to "undo" the cruelty of the past, he built up a whole range of obsessive thinking, which was mainly berating himself that he should have done this or that better, and keeping his mind occupied with other good intentions like getting good grades at school. As long as he could take refuge in these obsessive thoughts and do other good deeds obsessively like getting good grades he could keep the fear that he will be punished by fate (parental substitute) for his past misdeeds at bay. Though this fear of punishment was trying to make a breakthrough in sleep and dreams from which he would wake up in cold sweat. The fear would also emerge every now and then during the day, when he would have attacks of sweating (muted panic attacks).  

Why did the exhaustion came after the panic? The exhaustion was a muted form of depression. Once again the patient did not feel sad, just profound motor inhibition that extended to his thinking. But that appears to be the modus operandi of his defense system: have a somatic instead of a psychic reaction, at least in the first stages. Instead of feeling the affect of anxiety and fear all he did was to sweat profusely. Similarly, instead of feeling sadness and pain following the failure at his exam he felt a profound motor inhibition. After 8 days of punishment the cyclothymic neuronal circuits of his system kicked him out of the depressive phase and put him in the upswing. The above in a way describes how anxiety leads to obsessions and how when obsessive defenses fail and massive anxiety emerges depressive reaction is triggered to control the anxiety and then manic behavior follows to reverse the melancholia. So origins of Bipolar Disorder too can be traced to anxiety.

The patient asked as to why did not he continue to be just anxious and not fall in to depression. And I tried explaining to him that perhaps anxiety takes greater toll upon the body by keeping all the body's, including the cardiovascular, revved up. It is far more painful to anticipate punishment than to take control and just inflict punishment upon oneself and get it over with. The pain of depression is sometimes preferable over anticipation of impending harm.

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