I have noticed over the years that many of my patients with panic attacks are afraid to take Xanax, even occasionally.

I usually reassure them that if they take it a couple times per week no habituation will occur. And I remind them that it’s important they take it a couple of times to begin with, so they can experience its effectiveness firsthand, and begin to regain confidence. Panic attacks often are associated with a) a loss of self-confidence and self-sufficiency, b) a feeling of not having control of one’s heart rate or breathing, and c) a vague feeling as if your body does not belong to you.

Taking Xanax the first couple times helps them get back a sense of self-reliance, ownership, and control. Confidence and self-assurance are crucial.

Not just anybody gets panic attacks. “It is more important to know what sort of person has a disease, than to know what sort of disease a person has.”— Hippocrates. For instance, narcissistic people never get panic attacks. Neither do control freak types. Rather, panic attacks tend to occur in more passive, people pleaser types. Impulsive people are also the type to get panic attacks. These individuals tend to be very relational, outward, people-pleasing. With this, comes a deep seated fear of rejection and abandonment. Many of them had a parent who was temperamental, or volatile, always ready to explode. And this scared out of them what little self-assurance they had by nature.

As a result they tend to be needy, both for people and for substances. They’re aware of this tendency, took, and they may react to it by becoming fearful of forming any sort of dependency, including a dependency on medications. Because the role of the medication is to soothe them, the medication (i.e. Xanax) can take on the feelings they have towards loved ones in their life. “Can I really depend on it?…Will it let me down? …What if it works, but then I get sucked in, dependent, and then suddenly I get left high and dry?”

Their fears are misfounded, and an occasional thing 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 attacks is overcoming this central conflict of needing others, but then being wary of depending on them too, and wary of first getting attached and then abandoned. Often these patients will worry if they can rely on me, too.

Panic disorder is a unique type of attachment problem. There is a strong precedent for this in the observations of psychoanalytic theorists since the 1950s. Panic attacks do have a lot in common with the separation anxiety that we see in one and a half year old children: the darting eyes, the fast heart rate, the flush red skin, the breathing changes.

For a deeper dive into Panic Disorder, see my other blog entitled ‘Panic Attacks: A Loss of Bodily Ownership.’

The point I wish to make here is that people often feel toward Xanax how they feel towards people. The drug takes on the baggage and expectations and feelings that the sufferer of panic disorder feels towards loved ones.

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

He is lonely, and the bottle is obviously a substitute for a person. Just as a pacifier is a substitute for a nipple. Interestingly, in these lyrics, you can see that same ambiguity between person vs. substance, the same fear that the substitute will betray you, too. Just like the person did. “The one true friend I thought I’d found… Tonight the bottle… let me down.”

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, the drug, and in the treatment plan, all of which are a substitute for the original parent, who let them down.

Just like you don’t need a doctor forever, you don’t need parents forever.  You take their love and you grow up. You shouldn’t need to take Xanax forever, either. In reality, the fear of Xanax is really a fear of one’s own love and dependency and neediness. It also conceals an immaturity, and a wish to not grow up.

But, in fact taking it is a path to not taking it. That is a proper attachment relationship with any drug, with any parent.  Or with any treatment.

Most patients with panic disorder don’t even need to take Xanax or any sedative regularly—only occasionally.

And 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 down. 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. Some patients merely need to glance at the glovebox where a Xanax is located, and they can slow down their heart rate. It is like a memory of a friend. The drug functions in a healthy way like a healthy attached relationship with a person whom you do not always need to see.

But for this effect to work, the person must ‘know’ the medicine first, just like knowing a person. This is why I tell patients, you must take the medicine a couple of times first so that you can trust it and have confidence in it, just like trusting a person.

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 why the Big Pharma commercialized model of the management of psychiatric disorders—  the daily pill—  is profoundly misguided.

It ignores the fact that what we get from a drug is an experience, a memory, and we take away something from that— something that is internalized, even when we are sober, and alone— just as we keep people near and dear to our hearts even when we are far away…