Many of my patients with panic attacks are afraid to take Xanax— even occasionally.

I often reassure them that, if they take it 2x/week, no habituation will occur. It’s also important that they take it a couple of times so they can experience its effectiveness firsthand and begin to regain confidence.

Confidence and self-assurance are crucial, especially for those who suffer from panic attacks. These individuals tend to be very relational, often people-pleasers, with a deep fear of rejection and abandonment. Many of them had a parent who was temperamental, or volatile, and this scared out of them what little self-assurance was there by nature.

As a result, they tend to be needy, for both other people, and for substances. They’re aware of this tendency and may react to it by becoming fearful of forming dependencies, including on medications.

Ironically, their fear is often misfounded, and a substance like Xanax can liberate them, and help get their self-assurance back, even if it is taken occasionally.

What’s important for those with panic disorder is overcoming this central conflict of needing others, but being wary of them too, and too wary of being abandoned.

Yes, I’m claiming that panic disorder is a unique type of attachment problem. There is a strong precedent for this in the observations of psychoanalytic work since the 1950s. Panic attacks, for starters, look a lot like the separation anxiety that we see in 1.5 year old children: the wary eyes, the heart rate, flushed skin, the breathing changes.

The point I wish to make here, is that substances (like Xanax) can take on the baggage and the feelings that we feel toward other people.

Take for example, the country song, ‘Tonight The Bottle Let Me Down’ by Merle Haggard.

Tonight the bottle let me down
And let your memory come around
The one true friend I thought I’d found
Tonight the bottle let me down

The bottle substitutes for a person, just as a pacifier substitutes for a nipple. And, interestingly, in those lyrics, there’s that same old fear that the substitute will betray you, too. Just like the person did.

Good treatment for panic disorder consists in helping a person re-establish their self-possession and self-assurance and self-reliance. The best way to do this is through assurance in the doctor and in the treatment, which is a substitute for the original parent.

Just like you don’t need a doctor forever, and don’t need parents forever, you should’t need Xanax forever.

In fact, most patients with panic disorder don’t need to take Xanax or any sedative regularly—only occasionally.

Often, the pills don’t even need to be taken. I’ve had patients who only need to think about the pills in their purse to calm their breathing. It’s as if the medication takes on a talismanic quality—like a lucky rabbit’s foot. As paranormal as that may sound, it’s surprisingly common. But for this effect to work, the person usually has to have taken the medication a couple of times first.

Drugs do not need to work in consciousness, necessarily. It is enough for them to work in the memory.

Just as we don’t need to be children forever, we don’t need most drugs forever. This is one of the reasons the Pharma and commercialized model of the management of psychiatric disorders- the daily pill- is profoundly misguided.