In today's uncertain and anxious world, the topic of panic attacks is becoming increasingly talked about. But what exactly are they, and how are they explained from a psychodynamic perspective (a term describing how internal psychological forces, conflicts, and experiences influence a person's thoughts, feelings, and behavior)? They are not simply "exaggerated fear" – this is a complex psychological and physical experience that is often associated with a sense of loss of control, rapid heartbeat, shortness of breath, and even a feeling that "something terrible is about to happen" (APA, 2022; Barlow, 2002).

For people who suffer from panic attacks, even ordinary everyday situations can become a source of anxiety. But with the right psychotherapeutic support, these episodes can be understood, managed, and even prevented.

What Are Panic Attacks and What Is the Difference Between Anxiety and a Panic Attack

Many people confuse anxiety and a panic attack, but they are essentially different phenomena (APA, 2022):

• Anxiety – a prolonged feeling of tension and insecurity, associated with anticipation of future threats. Symptoms include worry, muscle tension, fatigue, and difficulty concentrating. Anxiety can be moderate and even useful in everyday life.

• Panic attack – a sudden episode of intense fear or terror, often without a clear cause. The symptoms are dramatic and physically expressed: palpitations, shortness of breath, dizziness, a sense of loss of control. It usually lasts from a few minutes to half an hour.

Key difference: anxiety is gradual and associated with anticipation, while a panic attack is sudden and intense, almost "catastrophic" in feeling (Clark, 1986).

Psychodynamic Explanation of Panic Attacks

From a psychodynamic perspective, a panic attack can be understood as a signal of internal psychological processes and conflicts that are not fully conscious. It is not viewed merely as a fear response, but as an expression of tension between different parts of the psyche.

Suppressed Emotions and Unconscious Impulses

First and foremost, a panic attack can be seen as a signal of suppressed desires and impulses. Classical psychoanalysis views the panic attack not simply as fear, but as a signal from the unconscious parts of the psyche (the unconscious consists of thoughts, feelings, and impulses that are not accessible to consciousness but influence behavior). Anxiety is a signal from the Ego (a psychoanalytic term for the part of the psyche that balances between unconscious impulses and the demands of reality) that suppressed impulses are trying to break through into consciousness (Freud, 1995).

Early Childhood Experiences and Internal Conflicts

Panic can also be understood as a signal of unconscious conflicts related to significant others in early childhood. It may be connected to internalized objects (internal representations of significant others that influence emotional experience) and experiences from early childhood that are activated during stress or a sense of loss of control. These signals are often physically expressed and serve to draw attention to unresolved emotional conflicts that the psyche is unable to symbolize through thoughts or words (Brenner, 1975, Abraham, 1924).

Together, Freud, Abraham, and Brenner help us understand that the panic attack is a complex psychological and physical experience that carries information about internal conflicts and the need for awareness and acceptance of emotions.

Why Is a Panic Attack Experienced as a Catastrophe?

The psyche is built during early childhood development from the child's representations of significant others, the so-called "internal objects." These objects can be good – soothing and caring – or hostile, and they influence the way an individual experiences anxiety. A panic attack often arises when the sense of security provided by the "internal good object" disappears. That is why panic is often associated with primitive anxiety – anxiety connected to early emotional experiences, often felt as fear of disintegration or annihilation (Klein, 2005). Anxiety in this context is experienced as a sense of:

• Disintegration – a feeling that the inner world is falling apart

• Annihilation – fear of internal or external "destruction"

• Loss of control – a feeling that nothing can be managed

• Psychic death – a sense of complete internal catastrophe (Brener, 1975).

Wilfred Bion (1962) adds that when raw anxiety cannot be contained and processed into a more comprehensible and bearable form, it manifests through intense physical reactions that the patient perceives as catastrophic.

How to Help Someone During a Panic Attack?

A panic attack can be difficult for the person experiencing it, as well as for those around them. Appropriate support can help the symptoms subside more quickly.

Practical guidelines:

Stay Calm

Maintaining a calm presence can help the person feel safer and more stable. Short and clear sentences are helpful, for example:

• "Everything is okay, I am here."

• "Try to breathe slowly with me."

Avoid Intrusive Questions

Questions like "How are you?" or "Are you calm?" can be perceived as pressure during a panic attack. It is better to focus on supportive words and actions rather than continuous questioning.

Acknowledge the Sensations

Instead of minimizing the experience, you can say something like:

• "I understand that it's frightening, but you are safe."

Support Breathing

You can count together or direct attention to slow, deep breathing:

• "Breathe in… 1, 2, 3, 4… Breathe out… 1, 2, 3, 4."

Suggest a Quieter Place

If possible, being in a calm location or further away from noise and people can help the nervous system settle down.

Use "Grounding" Objects

You can invite the person to touch or hold an object nearby – such as a chair, a key, or a phone. This often helps to establish contact with reality and reduce tension.

Redirecting Attention

Helping the person focus on a specific task – such as counting, reciting a poem, or naming objects around them – can distract the mind from panicky thoughts and support the sense of control.

Avoid Physical Pressure

Pulling, shaking, and squeezing are generally not helpful, unless there is an immediate danger.

After the Attack

When the panic subsides, stay with the person and offer support. Listening and being present without judgment are valuable for recovery (Barlow, 2002; NIMH, 2022).

Presence and attention, without pressure or intrusive questions, support the person's sense of safety and support, which can reduce the intensity of symptoms.

Treatment of Panic Attacks Through Psychotherapy

1. Understanding the causes – the psychotherapist helps the patient connect panic attacks to specific internal conflicts, traumatic experiences, or unconscious fears.

2. Creating a safe space – the therapist functions as an "internal good object," allowing the patient to express their anxiety without fear of rejection.

3. Overcoming physical anxiety – through therapy, the patient gradually learns techniques for managing physical reactions, such as breathing, grounding, and symbolization of emotions.

4. Long-term stability – the goal is not simply to suppress the symptom, but to build a stable inner world that reduces the risk of recurrent panic attacks.

Panic Attacks as a Signal, Not a Verdict

Panic attacks are often experienced as a sudden internal catastrophe – a moment in which a person loses their sense of safety, control, and predictability. Despite the intensity of these experiences, they are not a sign of weakness or an irreversible psychological problem.

Behind the symptoms there often lie accumulated anxieties, internal conflicts, and emotions that struggle to find a place in conscious psychological life. A panic attack can be understood as a signal that the psyche needs attention, understanding, and space to process what has been experienced.

Through psychotherapy, a person can gradually restore their sense of inner security, understand the meaning of the symptoms, and build more resilient ways of coping with anxiety. When panic is understood, it ceases to be solely a source of fear and can become a starting point for deeper self-knowledge and personal growth.

Conclusion

Panic attacks can be terrifying, but they are understandable and treatable.

Through psychotherapy, a person can learn what lies behind these sudden episodes of anxiety, restore their inner sense of security, and acquire skills to cope with moments of crisis. There is no need to live in fear – the right support makes panic a manageable experience.

References

Abraham, K. (1924). Notes on the theory of panic attacks. In P. Gay (Ed.), Psychoanalytic writings of Karl Abraham (pp. 45–62). London, UK: Hogarth Press.

Василев, С. [VASILEV, S.] (2021). Съвременна клайнианска психоанализа [Contemporary Kleinian Psychoanalysis]. София: Колибри. [in Bulgarian]

Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). New York, NY: Guilford Press.

Bion, W. R. (1962). Learning from experience. London, UK: Heinemann.

Brener, C. (1975). Panic: Psychological and psychodynamic perspectives. New York, NY: Jason Aronson.

Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24(4), 461–470. https://doi.org/10.1016/0005-7967(86)90011-2

Фройд, З. [FREUD, S.] (1992). Отвъд принципа на удоволствието [Beyond the Pleasure Principle]. София: Наука и изкуство. [in Bulgarian]

Фройд, З. [FREUD, S.] (1995). Анатомия на чувствата. София: Евразия. [in Bulgarian]

Клайн, М. [KLEIN, M.] (2005). Любов, завист, благодарност [Love, Envy and Gratitude]. София: Лик. [in Bulgarian]

National Institute of Mental Health. (2022). Panic disorder. https://www.nimh.nih.gov/health/topics/panic-disorder