Online narratives about panic attacks: interpreted within a psychodynamic framework

ABSTRACT

The objectives of the study were to investigate what individuals posting narratives on four online forums dedicated to the issue of panic attacks wanted to discuss and how they made meaning of their experiences related to panic. A narrative approach was used to analyze 208 posts sampled randomly. Online discussions were centered around attempts to uncover, and make sense of, the hidden meaning of panic attacks occurring unpredictably by linking events and experiences from the past and the present with emotional reactions. The onset of panic tended to be related to life transitions that interacted with relational issues of emotional commitment as well as with expectations of increased independence or with separation and loss. Dysfunctional attachments in childhood may impair the integration of affective and cognitive information leading to problems with the recognition and expression of affects. Online forums provide fresh avenues for exploring narration of sensitive topics from an inside perspective.

KEYWORDS:

• Panic
• narrative
• psychodynamic
• attachment
• separation
• individuation

The Internet has transformed the way people communicate, socialize, explore identity issues, and seek advice (Gardner & Davis, 2013; Spies Shapiro & Margolin, 2014; Wood, Bukowski, & Lis, 2016). Over the last few years, numerous online discussion forums have emerged providing a platform for computer-mediated communication without face-to-face interaction. Changes in how people live their lives and how people socialize and connect with each other require new areas of research. Recent research has revealed an increased tendency to seek contact with others via the Internet who share similar worries, concerns, and problems in life (Appleton, Fowler, & Brown, 2014; Frost & Casey, 2016).

Anxiety is a state of apprehension, uncertainty, and fear resulting from anticipation of threat. Mental suffering that in various ways is characterized by debilitating tension and heightened sympathetic activation is classified as belonging to different forms of anxiety disorders, according to the Diagnostic and Statistical Manual of Mental Disorders, DSM-5 (American Psychiatric Association [APA], 2013). Panic disorder is categorized as a type of anxiety disorder characterized by repeated sudden and unexpected panic attacks (DSM-5, APA, 2013). A panic attack is an episode of intense fear that triggers physical symptoms such as heart palpitations, shortness of breath, chest pain, sweating, trembling, and dizziness. These physical symptoms are often associated with a sense of impending doom or danger and loss of control. Individuals who suffer from panic attacks tend to selectively focus attention on internal physiological sensations and to misinterpret these sensations catastrophically (Schmidt, Joiner, Staab, & Williams, 2003).

The frequency and severity of panic attacks vary widely between individuals. The condition can be severely debilitating as individuals who have experienced panic attacks can develop chronic stress due to anticipation of future panic attacks which causes them to isolate themselves and restrict their lives (Davidoff, Christensen, Khalili, Nguyen, & IsHak, 2012). Panic disorder is therefore often associated with the development of agoraphobia, an intense fear of having a panic attack in a situation from which escape would be difficult, such as, for example, when riding in an elevator, using public transporting or being in a crowded area (DSM-5, APA, 2013).

Panic disorder has a high prevalence of about 10– 12.8% (de Jonge et al., 2016; Roca et al., 2009). The etiology of panic disorder appears to be multifaceted involving interacting biological, psychological, and environmental factors (Klauke, Deckert, Rief, Pauli, & Domschke, 2010; Petrowski, Wintermann, Kirschbaum, & Bornstein, 2012). Research has shown that panic disorder tends to arise during times of stress in life (Nay, Brown, & Robertson-Nay, 2013; Scocco, Barbieri, & Frank, 2007). One risk factor that has consistently been found to correlate with developing panic attacks is childhood adversities such as parental neglect (de Ruiter & Ijzendoorn, 1992; Silove, Parker, Hadzi-Pavlovic, Manicavasagar, & Blaszczynski, 1991), a history of parental mental illness (Moreno-Peral et al., 2014; Nocon et al., 2008), childhood abuse (Goodwin, Fergusson, & Horwood, 2005) and experiences of separation or loss in childhood due to, for example, divorce, parental illness, or parental death (Coryell, Noyes, & Clancy, 1983; Kossowsky et al., 2013; Lewinsohn, Holm-Denoma, Small, Seeley, & Joiner, 2008; Tweed, Schoenbach, George, & Blazer, 1989).

Psychodynamic approaches of mental health have conceptualized how childhood adversities increase the risk of developing mental health problems such as anxiety. In the pioneering work of John Bowlby, mental health problems are proposed to be attributed to insecure attachment to caregivers in early childhood (Bowlby, 1969, 1988). Bowlby’s attachment theory is a relational theory providing important theoretical insights into how the quality of the relationship between child and caregiver influences the child’s emotional, cognitive, and social development. Interactions with accessible and responsive caregivers provide a context in which the child can gradually learn to recognize affective signals, understand feelings, put feelings into words, self-sooth and thereby also take over affective regulation strategies (Fonagy, Gergely, Jurist, & Target, 2005). Developments in attachment theory and research supports that dysfunctional attachments in childhood impair the integration of affective and cognitive information leading to problems with the recognition of affect and expression, regulation and understanding of feelings (Fonagy et al., 2005; Tull, Stipelman, Salters-Pedneault, & Gratz, 2009; Verhaeghe, Vanheule, & De Rick, 2007). Affects that are not cognitively processed become indistinguishable from bodily sensations (Galderisi et al., 2008; Tull et al., 2009; Verhaeghe et al., 2007).

The Internet has removed communication barriers and provided flexibility for people, separated by time and space, to come together on topic-based online discussion forums. On online forums dedicated to the topic of panic attacks people can share their experiences, feelings, and thoughts around panic. After a thorough literature review, it was concluded that self-published stories on online discussion forums focusing on the issue of panic have not yet, as far as the author is aware, been explored in previous studies. In the present study the decision was, therefore, made to sample postings from four online forums for people who experience panic attacks. The combination of factors such as anonymity, availability, access to reciprocal peer support, connectedness, and ability to choose level of engagement may be especially appealing to individuals suffering from panic attacks. Furthermore, online peer-to-peer discussion data have unique qualities and provides a new angle compared to data from interviews conducted for research purposes or in a therapeutic setting. People who suffer from panic attacks are on these online discussion forums brought together because they share similar concerns and want to vent emotions with others who can relate to and empathize with their situation. This online venue is free of the power differential present in a traditional therapeutic setting, people can use their own voice freely in the context of their everyday life.

The issue of how online discussion forums are used by individuals who suffer from panic attacks is poorly understood; what do people who suffer from panic attacks want to discuss when they turn to an online discussion forum and how can their narratives be of value for clinicians? Posts illuminated how people who suffer from panic attacks constructed and framed their lived experiences through naturally occurring discourse. The primary objectives of the present study were to investigate what individuals posting narratives on online forums dedicated to the issue of panic attacks wanted to discuss and to also investigate how they made meaning of their experiences related to panic. Interpretations of these narratives were made within a psychodynamically based narrative framework (Crossley, 2000; Dallos & Vetere, 2009; Riessman, 2008).

Method

Four International online forums were explored. Data collection comprised conversations from these four online forums dedicated to the issue of panic attacks. A single message, or conversation, is on these online forums called a post. A post can be replied to by anyone and by as many people as so wish. In total 208 posts, involving 199 user names, were selected randomly from the four different online forums on panic attacks. Six dice were rolled and the numbers achieved every time were added up and guided selection of the next post. These randomly chosen posts comprised data in the present study. Posts were in the present study also referred to as online narratives. All of the 208 online narratives about panic attacks were reviewed. These narratives had been posted between 2003 and 2019.

Ethical considerations

Ethical considerations were made, in the present study, in line with previous studies conducting research using content posted on online discussion forums open to the general public (Appleton et al., 2014; Eysenbach & Till, 2001; Pestello & Davis-Berman, 2008; Pfeil & Zaphiris, 2010). The status of content on a website in the public domain has in these previous studies been equated to published material why no consent is required for research purposes. The rights of the posters on the four chosen online forums were protected by not revealing their user names nor which online forums their posts had been collected from. The study was carried out in line with the appropriate ethical research standards applied at the university where the study was carried out, ensured by the Head of the department and by a professor at the same department.

Data analysis

A narrative method was applied when analyzing the postings sampled from four online forums devoted to discussing issues of panic attacks (Crossley, 2000; Riessman, 2008). The narrative approach proposes that human beings are active in giving meaning to their experiences. People naturally create stories over time when attempting to connect life events. Through such storytelling individuals describe, explain, make sense of, and understand their own feelings, reactions, and behaviors. Constructing and sharing one’s story offers a possibility to process experiences. The story can help bring order and meaning to lived experience. Scattered and confusing events, behaviors, reactions, and emotions can be arranged and linked in a coherent story. Storytelling might hereby produce benefits by providing personal insight into an array of feelings, concerns, challenges, and reactions. The ability to cope with stress and challenges in life is subsequently influenced by the stories people construct about themselves and their lives (Crossley, 2000; Riessman, 2008). Furthermore, storytelling is often a reciprocal event between a teller and an audience. The character of a person’s story depends on to whom the story is being told. It may be easier to connect with others who can relate to suffering from panic attacks. The narrators in the present study chose to post their narratives on online forums for people who shared their experiences related to panic. The narrators thus chose to connect with others who could understand their suffering.

In the present study, the striving of individuals who experienced panic attacks to create meaning of their experiences related to panic was traced using a psychodynamically based framework (Dallos & Vetere, 2009). All narratives were first read closely in order to become acquainted with the data and establish a broad and deep understanding of the data. Each narrative was subsequently reread and examined closely with an eye toward identifying recurrent themes discussed by posters. Relevant and salient content and patterns that held interest to the researcher in light of the research question were identified. Posts conveying information about attempts by posters to narrate meaning of their experiences related to panic attacks were thus selected in order to obtain an inside perspective and learn more about posters’ meaning making processes. Frequently occurring themes were then identified. The themes were closely examined for their content and clearly defined and named. Furthermore, the tone and the structure of the narratives were examined (Crossley, 2000; Riessman, 2008).

Results

The structure of the narratives was generally unstable and reflected loss of agency and loss of control where the individuals expressed feelings of being overwhelmed by the unexpected nature of their panic attacks. The stories conveyed anguish, chaos, and uncontrollability. The unstable structure suggested absence of sense of coherence. The posts typically started negatively reflecting how distressed the posters were feeling. The general tone of the narratives was thus pessimistic. Five themes emerged from the data. These five identified themes were labeled: A) Loss of personal control in life, B) Attempting to reinforce agency in life by avoiding triggers, C) Preoccupation with not feeling safe in life due to childhood adversities, D) Vulnerability when facing transitional demands, and E) Sensitivity to loss and separation in life. Below are examples of narratives reflecting the challenges faced by individuals who were discussing panic attacks and their attempts to understand and construct narrative meaning of their own experiences related to panic. For all posts original spelling, grammar, and punctuation were retained.

Loss of personal control in life

Panic attacks were described as terrifying. Narrators illustrated their catastrophic interpretations of bodily sensations during panic attacks. In the two accounts below narrators described fearing that something was seriously wrong, urging them to contact the emergency room, and even fear of dying:

Panic attack is truly terrifying. People who have never experienced this never know how it feels like! When I get a panic attack, I get dizzy, numbness and tingling sensation in my legs and arms, chest/throat tightness, choking sensation, hot flashes, then I feel like I’m losing control of myself. Even if I know it’s just a panic attack, it makes me feel like something is seriously wrong and I feel the urge to run to the ER.

I get dizzy, tingles throughout my body and a list of other feelings. My biggest fear is passing out. I have never passed out, yet. I have too been to the ER a few times because I bought I was dying. It’s horriable but I am trying to lean to live with it and not have it controll me.

Posters also described how they dreaded future panic attacks and experienced persistent worries about the consequences of such additional attacks. They were also ruminating about the catastrophic experiences during previous panic attacks. Anticipation of a new panic attack reduced their quality of life: “The worst thing about a panic attack is thinking about the next one, for sure!” Narrators articulated the perceived uncontrollability of the panic attacks, in turn illustrating the common frustration expressed due to lack of personal control in life. The narrators were trying to make meaning of why they were experiencing panic attacks but they were unable to understand and make sense of their experiences related to panic. They strived to find a pattern that could explain the onset of panic, but the attacks seemed to come out of the blue: “Nothing in particular sets them off so I can’t pinpoint any particular situation.” Their accounts thus displayed inability to attain narrative coherence in their stories related to panic:

There are things that I stress about and things that I worry about. But I don’t really have a trigger for my anxiety. There is nothing happening in my life that hasn’t happened before or is any more stress than things I’ve experienced in the past.

I have been having panic attacks for the past 16 years. I was very young when I had my first one and the doctors has put me on medication. I have tried several times weaning myself off them but with no success. Over the years the reason for having a panic attack varied. From going crazy, having food allergies and can’t breathe to heart problems.

Attempting to reinforce agency in life by avoiding triggers

In the posts narrators described the vicious cycle created from dreading future panic attacks causing restriction in everyday activities. They articulated how their worlds were getting smaller and smaller. Narrators were preoccupied with the need to maintain safe and the wish to avoid situations that could trigger a panic attack: “ … have gotten to a point where I do nothing socially because of my anxiety and fear of having a panic attack.” Below are the accounts of another two narrators:

I had severe panic attacks for three years with agoraphobia some of the time. I went from not being able to go anywhere, to not being able to stay home alone, to finding what I thought were ‘safe’ people to go out with, fear of swallowing …. … . the list goes on.

My first real attack was 10 years ago. Over that I’ve set so many boundaries in my life that I forgot what it’s like to be completely free. Over the past few years I just kinda gave up and just avoided places that cause me to panic. I don’t drive over long bridges and I don’t fly.

Preoccupation with not feeling safe in life due to childhood adversities

Some of the narrators connected the development of panic attacks to adversities in childhood. Parents were described as unavailable, unsupportive or rejecting, leaving narrators with a feeling of being unprotected and unsafe in life. The online forums examined in the present study appeared to have taken a therapeutic form for marginalized individuals seeking practical and emotional support. In the post below the narrator described having suffered from anxiety as a child and of being disregarded by parents when in need of care:

I suffered from anxiety as a child. I remember being about 10 years old and sitting on my bed in my room in fetal position thinking I was about to die. was always depressed. my parents aren’t very nurturing and every time I said something was wrong theyd tell me its all in your head.

The narrator below lost her mother at the age of 16. She was then left with only her father and he was unavailable due to working out of town:

I lost my mother when I was 16, and it was horrible. I only had my father and he was always out of town for work and I was very lonely and extemely depressed and suicidal. I had horrible panic attacks one was so bad I had to go to the hospital and my heart rate was so high I couldnt breathe and they came over with the crash cart and injected me with something to bring my heart rate down.

In the following post, the narrator disclosed experiencing panic since childhood. Her mother had suffered from a terminal illness and passed away when the narrator was a teenager: “I have suffered from panic disorder since childhood. The situation which led me to this disease was the fact that my mother had a terminal illness. She eventually passes away when I was 13. Current age is 47.”

In the post below the narrator expressed suffering from a dysfunctional upbringing which she perceived to be the reason for why she and her sister turned into anxious and panic stricken people:

My upbringing was my Dad every day yelling and my Mom suffers from mental illness, you don’t realize until you get older how sick she was. Still suffers today at 85. My sister and I both suffer from the years of mental abuse and in turn we are anxious panic stricken people.

The narrator below could recall experiencing panic attacks as a child and also described having difficulties remembering her childhood:

Anyway, I remember having these attacks happen as a child. I was physically abused and mentally abused for many years. I started doing some research and found some things on PTSD. I read that it is hard to recall childhood memories and something about memory problems. I have a very difficult time remembering childhood and my “forgetfullness” is kind of a family joke.

Vulnerable when facing transitional demands

Some narrators displayed more sense of coherence in their ability to connect the onset of panic attacks with situations or relationships. Their narratives reflected attempts to understand panic attacks against the background of current life circumstances. The outbreak of panic attacks seemed for some individuals to be connected with transitional steps that involved conflicts around independence and dependence. Growing up is associated with developmental changes demanding increased autonomous functioning and also emotional engagement in relationships with a partner. The narrator below associated the development of panic attacks with moving out of the parental home in order to enter an adult life style living with a fiancé. The narrator described being excited at first about the prospect of increased independence from parents, but subsequently becoming overwhelmed by anxiety and fear of abandonment:

Hello, I’m in the middle of moving out of my parents’s house to live with my fiance. I was both nervous and excited, making plans and thinking about all the things we could do together but the closer it got to moving day the more anxious I got. I had several panic attacks for four days and couldn’t stop crying,come moving day I completely broke down and I was overwhelmed with terror, misery and isolation and when my attacks get really bad I “regress” and I felt like I’d been abandoned and I was frantic and begged my parents not to leave me.

Relationships seemed to be experienced with great ambivalence. In the two posts below the narrators articulated how relationships with their girlfriends caused anxiety by, for example, fear of being abandoned:

During High School, me and this girl were together. But during that time for reasons unknown, I would have moments where I would get very attached and fear losing her. Ultimately, that fear itself drove her away. But every time I get close to someone, even when it was with her, I get very nervous. Even thinking about her, I get anxious and my breathing becomes labored. After we broke up after 3 years, we started talking again about a year later. We both admitted we still liked each other, and conversations started flowing.” “I had my anxiety and problems under control, but now they’ve come back.” “I’ve also started feeling like even if she did want to get back together, I’m not good enough for her and she’ll leave me for someone else.

The catalyst for most if not all my panic attacks is my girlfriend. It hurts a lot to say this. I fear I may have difficulties to commit to someone I love a lot. This is the first time I have felt this way for someone. We’ve been together for 3 months and I know it sounds crazy but I can see myself spending the rest of my life with that person. But not like this. It’s creeping me out. She knows about it and deep down I know she understands and will do anything for me, but I keep having doubts and anticipating the worst case scenarios over and over. It has come to a point where I cannot talk to her without feeling a deep malaise and/or physical discomfort. I overthink/overanalyze every single thing she does or says and it’s truly scaring me.

In the post below the narrator articulated being held back from advancing in a career as a result of experiencing panic attacks at work. Becoming an adult is connected with demands and expectations in a variety of areas in life, including working life. The narrator described debilitating anxiety at work:

I have panic attacks before I new what they were. I still get them pretty often. They affect me at work and really hold me back from being the best I can be. I take that back I’m am the best I can be. People do not know what life is like who does not have them. Sometimes I feel totally dysfunctional. It like at times I have no control over my emotions. Whwn I get the I can not breath or stop crying. I trying not to be to hard on myself because recently it really affect me so bad I step down from my job. Now I wonder how I’m going to pay all my bills because I had to take a big cut in pay.

Sensitivity to loss and separation in life

Some narrators associated the onset of panic attacks with loss of a loved one through, for example, death or separation. Triggers of the initial panic attack thus appeared to have been loss of an individual who represented an important source of support and security. The narrator below described how the death of an attachment figure, in this case the mother, resulted in onset of panic attacks:

I lost my mother last month and am just now having alot of depression and anxiety symptoms. I had a major panic attack at work the other day and had to be taken to the hosptial. I’m ok physically, but am embaressed. Is this normal?

Other narrators articulated that a separation from a partner was the event that they related to panic onset: “A bad bad breakup in 2009 triggered all of this for me. It was so traumatic for me.” Another narrator wrote: “I ‘ve been battling depression and anxiety my entire life but started suffering panic attacks every day since my separation. I have two beautiful girls who don’t deserve what I ‘m putting them through”

Some narrators connected the development of panic attacks with relational losses and separations that had occurred a long time ago. Below is an account of accumulative trauma in life due to loss of and separation from family members:

I am 25 years old and I have been suffering with anxiety disorder for more than 5 years now. My dad passed away when i was 9 months old and my brother died 8 years ago. both of cardiomyopathy (oversized heart) So nonetheless, i feel my anxiety disorder was always there but it was not triggered until my mom got sick and went into the hospital about 5 years ago for diabetes.

Discussion

The narratives analyzed in the present study revealed that online discussions about panic were centered around attempts to make sense of, explain, and understand the hidden meaning of panic attacks. The narrators thus appeared to be particularly motivated to discuss the reasons for why they were experiencing panic attacks in order to understand the causes behind their panic symptoms. The online forums appeared to have taken a therapeutic form where narrators tried to unravel something entangled and traumatic in their past of which panic symptoms were manifestations in the present. The unpredictable and terrifying nature of panic attacks posed a challenge to narration. Narrative structure was, however, attempted in order to frame life’s chaos by connecting events and experiences in the past and present with emotional reactions.

Panic attacks were described as excruciating experiences of terror. The physical symptoms caused some posters to believe that their very physical survival was in question as revealed in the theme: loss of personal control in life. The motivation to spare themselves from reexperiencing future panic attacks lead narrators to restrict their lives as revealed in the theme: attempting to reinforce agency in life by avoiding triggers. In some narratives it was evident that panic attacks were perceived to come out of the blue, no predictable pattern could be detected. Anxiety anticipation of future panic attacks was associated with narrators’ perceptions of loss of control over their bodies and over their lives. The narratives of these individuals reflected lack of narrative coherence. The unexpected nature of panic attacks may be related to lack of conscious awareness of the meaningful affects that triggered preverbal conflicts in turn leading to panic (Galderisi et al., 2008; Rudden, Milrod, Target, Ackerman, & Graf, 2006; Verhaeghe et al., 2007). Several narrators connected their experiences related to panic with adverse childhood experiences as seen in the theme: preoccupation with not feeling safe in life due to childhood adversities. For other narrators, the onset of panic tended to be more clearly associated with current separation and loss in life as revealed in the theme: sensitivity to loss and separation in life. Other vulnerable times in life were transitional phases as seen in the theme: vulnerable when facing transitional demands.

The narratives analyzed in the present study can be interpreted within a psychodynamically based framework. According to attachment theory, available and responsive parenting is required, through mirroring of the child’s affective states, in order for healthy emotional development to take place (Bowlby, 1969; Verhaeghe et al., 2007). Inadequate parental mirroring of a child’s affects may cause somatic reactions due to inability to process signals of affect. Parents can, for various reasons, be unable to understand the affective states and the intentions of the child. In the narratives analyzed in the present study, some parents were described as unavailable due to mental health problems during the narrators’ upbringings whereas others were unavailable due to terminal illness or as a result of being out of town for work. When parents are themselves experiencing stress and adversities in life they may not be able to provide the child with sufficient care and attention. A parent may then instead reject, scare, or confuse the child by reacting only from his or her own affective state without consideration of the child, making it impossible for the child to understand own affective states (Fonagy et al., 2005). Inability to recognize affective signals leaves a person unable to regulate affective states and to express affects into words (Galderisi et al., 2008; Rudden et al., 2006). Affects can thus not be translated into feelings and distinguished from bodily sensations. Reduced capacity to understand and regulate affects induced by stressful events can make individuals especially vulnerable later in life when facing transitions that trigger pre-verbal conflicts. Panic attacks may hereby be reflections of defenses against the intense affects that precipitating events have evoked.

The theme of one set of life transitions perceived as particularly stressful typically involved increased commitment in romantic relationships. Relationships appeared to be experienced with intense ambivalence. Such ambivalence may stem from insecure attachments. It is well established that dysfunctional attachment in childhood is associated with difficulties related to interpersonal functioning (Blum, 2004). Developmental steps involving formation of romantic relationships may trigger dormant conflicts by being a link to earlier fears of abandonment. The underlying conflict may be characterized by an unconscious fear of being emotionally dependent on another person (Scocco et al., 2007). An unconscious communication appeared to take place between the mind and the body during the anticipatory anxiety stages (Verhaeghe et al., 2007). The sudden onset of panic and regression effectively immobilized the narrators’ increased emotional involvement with a romantic partner. The panic symptoms may thus have solved the conflict.

Narrators also described that life transitions requiring increased autonomy and responsibility in, for example, working life was associated with anxiety and panic. Insecure attachments can result in internal working models containing relational expectancies of abandonment inhibiting a natural strive for independence (Kossowsky et al., 2013). Individuals who have not been able to separate and individuate from their parents may suffer low self-esteem, self-doubt, and persistent difficulties transitioning into independence (Blum, 2004; Verhaeghe et al., 2007). Adults are expected to be able to provide financially for themselves by holding a job and to perhaps also advance professionally. Expectations of autonomy and competence at work may stimulate anxiety due to unsupportive family interactions in which primary caregivers have been unable to offer accessible and emotionally responsive care. As a result, internal working models that comprise fear of independence are formed (Kossowsky et al., 2013). Acceptance of increased responsibility may gradually result in increased energy spent on doubting the ability to master various tasks and increased concerns about failure. Individuals who perhaps seem to be functioning well in life may suddenly hit a wall when they try to excel professionally or move out of the parental home. These life transitions may have hooked into previous childhood trauma and hereby have triggered pre-verbal conflicts regarding autonomy. The underlying meaning behind panic symptoms may hereby represent the wish to be independent and at the same time defenses against this wish (Chorpita & Barlow, 1998).

As mentioned above, other life events associated with the onset of panic were loss of loved ones and separation from loved ones. Childhood experiences of separation from or loss of loving attachment figures are deeply damaging to development (Coryell et al., 1983; Kossowsky et al., 2013; Lewinsohn et al., 2008; Tweed et al., 1989). Loss of individuals that are important sources of security may reduce sense of safety in individuals vulnerable to panic and constitute a demand on them for more independence. Unresolved developmental issues may hereby be especially likely to break through during experiences in life involving loss and separation. Individuals can experience difficulties tolerating and defining inner affective states associated with unconscious conflicts about separation and autonomy as well as experience rage and anger directed toward important loved ones. The underlying meaning of panic attacks due to loss or separation may thus be related to reexperiencing unconscious memories and feelings of overwhelming helplessness and abandonment. Experiences reminding of such prior trauma may stimulate early drama of abandonment to be reenacted resulting in panic attacks (Verhaeghe et al., 2007).

It thus appeared from the narratives as if the stress associated with various life transitions and experiences of loss and separation uncovered a psychological vulnerability. Entering adulthood involves expectations and demands of increased independence but also increased emotional dependence in relationships with a romantic partner. Themes of independence and dependence are proposed to be particularly conflicted for individuals suffering from panic attacks (Blum, 2004). Dormant issues and conflicts of separation and individuation can strongly come to the fore when in the process of transitioning from childhood to adulthood. The trauma being triggered may be impossible for the person to comprehend, and put into words, due to lack of parental mirroring of affective states. Bodily sensations become the only means of communicating affective signals. The conflict characterized by ambivalence toward independence and dependent functioning was avoided via a panic attack, the narrators were left helpless. Panic symptoms may thus represent the least threatening solution to the conflict experienced and hereby be reflections of defenses against the intense affects that precipitating events have evoked (Blum, 2004; Verhaeghe et al., 2007).

There may be a need to recognize how psychologically painful childhood experiences of loss, separation, rejection, neglect, manipulation, and abuse can be and how such experiences often play a role in the development of mental illness later in life. Panic symptoms may particularly be related to problems working through the separation and individuation process due to insecure attachments. The narratives analyzed revealed illness in families and other forms of suffering or difficulties which possibly rendered parents unable to be emotionally available to the needs of their children. Psychodynamic approaches provide a framework for making sense of issues that are persuasive in panic disorder. Dysfunctional attachments in childhood impair the integration of affective and cognitive information leading to problems with the recognition and expression of affect (Verhaeghe et al., 2007).

Psychodynamic psychotherapies focus on relationships and associated affects (Knekt et al., 2008). These types of therapies actively work in order to improve patients’ capacity for reflection by helping them recognize and tolerate internal reactions related to attachments. Exploration of life events and feelings surrounding panic attacks may begin to elucidate unconscious conflicts related to panic. Attunement to the meanings of these conflicts could reveal various forms of communication and defenses (Verhaeghe et al., 2007). Bodily sensations are sometimes the only form of communication of early trauma if other levels of meaning are not available. Clinicians may need to be attentive to that individuals who experience panic attacks could be especially helped by the formation of a stable and secure relationship during therapy that could facilitate the development of a more adaptive attachment pattern (Roche, Runtz, & Hunter, 1999). Clinicians should work on building a positive transference by creating an emotionally safe environment receptive to conflicts related to dependence and independence, encouraging clients to express such conflicts mediating understanding through a secure sense of connectedness. In this way, clinicians can create a safe base from which clients are free to explore affective states. Assistance in expressing affects, verbally, that are perceived as overwhelming can increase tolerability of such affects reducing vulnerability to panic. Increased sense of coherence and reflective functioning can be achieved through increased understanding of affective states that are core components of panic.

Future research should learn more about how online peer discussion forums are used by tracing patterns of communication; if they serve as long-term sources of support that contribute to overcoming challenges or rather short-term resolutions to loneliness and acute needs to vent emotions. The emergence of online discussion communities has transformed the way people communicate and interact. Taking time to write a life story online, where a coherent and explanatory narrative is created, may facilitate understanding of negative experiences in life and mental illness. The reciprocal peer-to-peer interactions that take place on online discussion forums may incorporate features that are especially appealing to people who experience social isolation due to stigma, perceived discrimination, and other everyday barriers due to challenges posed by debilitating anxiety. The secure feeling of being anonymous online may allow individuals to be comfortable sharing their innermost thoughts and feelings freely. The present study contributes with a new angle providing an inside perspective to how people communicate with others who can empathize with their experiences related to panic attacks. Narrative approaches constitute research tools that put forward lived experiences by tracing attempts by individuals to make meaning of their experiences in life. Internet-based social networking on online forums provide an opportunity for the first time in history for marginalized individuals to tell their stories to the public. Their narratives are valuable and provide insights that can be educational for clinicians and other health-care professionals.

Despite interesting results, limitations have to be acknowledged. People consulting Internet forums dedicated to panic attacks may somehow differ from people seeking healthcare in a medical practice, compromising the generalizability of the results. It is further acknowledged that the lack of demographic data about participants in the current study limits the extent to which information about, for example, age and gender as well as information about diagnosed panic disorder of narrators can be confirmed. Furthermore, online conversations differ from conversations offline. The researcher could, for example, not review the accurateness of narratives by requesting narrators to clarify their stories or to elaborate their stories. Furthermore, the amount of narrative information obtained from the postings on the online forums was immense, and only a fraction of this material was possible to examine and include as quotes in the present study.

Disclosure statement

I have no conflict of interest to disclose.