Over my ten years in private practice, I’ve noticed that my patients with panic disorder are some of the nicest people.  They tend to be compliant and eager to please. They are hesitant to be assertive, and they tend to go with the flow. They don’t need to be in control.

But over the years, I got to thinking. Panic disorder patients do make my job easy… but is this necessarily good for them?

Perhaps niceness is part of their problem?

As the ancient physician Hippocrates said: “It is more important to know what sort of person gets a disease, than to know what sort of disease a person has.”

Even minor personality flaws— e.g., extreme niceness— may be intimately related to someone’s presenting problem.

Usually, when you take a family history of a person with panic attacks, there’s a volatile, angry parent. I see a lot of panic disorder in Millennial children of Boomer parents. “I’m guessing your mom or dad had an explosive temper,” I remark. “How did you know?”

I knew because mental health problems often occur in dyads. The term ‘dyad’ comes from family therapy. It means that it is impossible to diagnose a child without simultaneously diagnosing a parent. The prominent family therapist Carl Whitaker once said: “There are no individuals in the world, only fragments of families.”

Over time in my practice, I began to hypothesize that whenever a child has panic attacks, a dyad is at play.

We can examine panic attacks from the other side of the dyad: the explosive, volatile parent. The first thing to notice— it is an amazing fact— is that if I look at a room full of people with anger-problems, let’s say a hundred of them, and if I ask them all, how many of you have ever had a panic attack? The number is close to zero. Among narcissists who are prone to rage, true panic is exceedingly rare.

Then, there is the other type of angry person: the obsessional control-freak. This is the sort of person who explodes at a toddler for making a mess of finger-paint.

Among control-freaks the lifetime incidence of panic attacks is again, very rare. I’d say close to zero. Which is not surprising. Panic feels like a loss of control, and the whole personality of an obsessional is built to resist that.

So, the two categories, panic and anger, tend to be mutually exclusive.

This is interesting.

It is interesting because, when you look at panic and anger as symptom patterns, there are similarities, and the similarities are surprising. To outside observers, those suffering from panic attacks get:  1) shallow, fast breathing, 2) pounding heart, 3) flushing of the face, and 4) tunnel vision.   But look at the pattern for anger: Is it that different? Angry hotheads get: 1) huffy, with shallow breathing, 2) climbing heart rate, 3) flushed face, and 4) a type of tunnel vision called “seeing red.”

If the symptoms mirror one another… what does this mean?

What it likely means is that panic and anger are flip-sides of the same coin.

We know the two are patterns that occur in the same area of the brain (the hypothalamus), and that both involve similar downstream effects: adrenaline, sympathetic nerves, i.e. the fight-or-flight response. Even the very phrase ‘fight-or-flight response’ is a clue that the two are closely linked.

At this point some narcissistic, obsessional, or controlling people will disagree with me. They will say they don’t feel intense fear… only annoyance.

But if you look at how prone they are to exploding at family members, and if you lift up their problem like a rug so you can get a vacuum underneath, what you often find are deep-seated fears.

Rage is a way to conceal fear.

For example, an abusive, narcissistic man is afraid of being abandoned by a woman. But instead of having a panic attack, he uses fear to compel the girlfriend to stay. He needs to feel powerful, and he doesn’t want to feel any fear or acknowledge being afraid. So instead, he makes the girlfriend feel the fear he avoids feeling. The girlfriend is now the one afraid. He was originally afraid of her leaving, but now she is afraid to leave. You can see that there is a sort of dark symmetry in this arrangement.

You can also see how a symptom dyad is at work.

It’s obviously misguided of the narcissistic man, and he only drives her away. However, it is interesting that his goal was for her to stick around by feeling a fear he didn’t want to feel. Rage is counter-phobic in the sense that it is a way for a person to try to ward off fear. People with anger problems need to learn to sit with fear. Without making anyone else feel it.

I’ve seen psychedelics cause dramatic benefits to angry people. Chronically angry people who use psilocybin often become much more honest about being alone in the world. For whatever reason, the psychedelic forces them to confront a fear of abandonment. (N.B. due to DEA rules, I can’t recommend psilocybin. In this instance I merely report.)

Interestingly, psychedelics eliminate anger but may also cause panic attacks. One of the well-known adverse effects of psychedelics is panic.

This of course makes total sense if anger and panic are, roughly speaking, the same phenomenon.

There is an old idea in Aristotle’s writings, that a person’s wellbeing lies in the mean— the average, or middle— between extremes. You find the idea in his Nicomachean Ethics, where he says for example that courage is a point ~50% of the distance from timidity to recklessness. The timid person needs to be less like himself, and more like the reckless. If he becomes brave, he goes in the direction of recklessness, so naturally bravery will feel to him like recklessness. Conversely, if the reckless person becomes brave, he moves down the line toward timidity. He feels anxiety because, for the first time, he cares about the outcome.

As I said before, if symptom patterns occur in dyads, then to cure people we need to move them towards their opposite.

We must tell an angry person to learn to be afraid. Angry people need to stop making other people feel afraid, and instead feel it themselves.

But what about panic?

Do those with panic need to be angry?

Yes. They do.

They need to stand up for themselves, and I have long recommended people with panic attacks to work on assertiveness. Even gangster rap, of all things, can reduce panic attacks. Learning to brag a little, or learning to have a more forceful social presence, can reduce panic as well. The idea of boss-ownership of your heart rate, your breathing, and your body is another. E.g. “I caused that pounding, fast heart-rate. Why else would it have happened?”

Those with panic maintain the security of relationships through obedience, and people pleasing. They tiptoe around angry people for fear of suffering loss. Instead they need to learn that self-assertiveness also maintains the security of relationships. It does so through open communication. Studies show healthy couples have little fights from time to time. Being unafraid to show a little anger ironically helps the security of a relationship.

Anger has a natural function: justice, social stability. In small amounts, it is appropriate. It may be very necessary for the health of an organism, for protection and security.

A little fear is useful, too. Fear is the “beginning of wisdom” according to the Old Testament.

Snake-poison has medicinal properties, and that is why the symbol of medicine is a snake.

That is also why change is uncomfortable for people. It forces people in the direction of an opposite. And it forces people to confront what is totally lacking in their personality.

What people often need to heal is precisely what they’ve been running from.