A wealthy man’s recovery from panic disorder invokes Freudian theories and the philosophy of Albert Camus. Though not everyone agrees about that.
by JP Sutherland
Have you ever dreamed of an early retirement, having made a fortune in your early years? I think it’s a common wish, and people see themselves happily travelling, or playing golf, and maybe settling down in the late afternoon for an early cocktail. You would no longer have to get up in the morning and hurry through your usual routine. Work is often seen as a problem in people’s lives, and it certainly can have very negative effects. I see evidence of this when I have to sign people off from employment on health grounds, often because the particular pressures of their job have contributed to a major psychiatric illness. However, this is a story about someone who did achieve the dream of early and wealthy retirement, but in whom it did not turn out as expected.
“Now I’m set for life. How come I feel so bad?”
Jeremy was a 41-year-old man when he came to see me as an outpatient. His family doctor’s referral letter indicated that he had developed a panic disorder, and that this was proving resistant to treatment. General practitioners treat most of the anxiety disorders in the population, and do so effectively, which means that psychiatrists tend to just see the most severe or treatment-resistant illnesses. And this is a good thing since anxiety disorders are so common that there is no way that everyone suffering from panic disorder could get to see a specialist, there just aren’t enough of us.
When I went to collect Jeremy from the waiting room I saw a slim man, casually but carefully dressed, who pleasantly greeted me as we walked to my office. There wasn’t any obvious sign of anxiety at first glance, but that is not unusual.
“Your family doctor tells me you have panic disorder,” I began, “can you tell me what that is like for you?”
“It’s terrible,” he answered. “It starts almost as soon as I wake up. My chest feels tight, my breathing is heavy, and I can feel my heart pounding away. I thought at first I was having a heart attack but apparently I’m not.”
“I’m glad to hear it, but who told you that your heart was OK?”
“I went to the emergency room when it first happened, and they did a heart tracing and a blood test, and then told me it wasn’t cardiac.”
I was indeed glad to hear this. Panic attacks can certainly feel a little like having a heart attack, and although this fit and slim man didn’t seem to be an obvious cardiac risk, he was edging his way into his forties when the risks begin to increase for everyone regardless of their fitness or build.
“Chest pain, fast breathing, and heart palpitations.” I recapped. “Is there anything else?”
“I’m sweating furiously, and my hands won’t stop shaking.”
“Well, that certainly sounds like a panic attack. How long does it last?”
“About an hour. My GP told me to try deep breathing, but that only helps a bit. These are better.” He said, handing me a bottle of pills.
I took the container and read that they were lorazepam, a commonly used anxiety medication, sadly open to abuse as well as use.
“Have you taken one today?”
“Yes, when I woke up. That’s about three hours ago now.”
“I wondered why you looked so calm in the waiting room; do you think that might be the reason?”
“Yes. They last for a few hours, but I’ll probably have to take another one later.”
I asked him how this had started, and he explained that although he had always been a slightly anxious individual, these panic attacks only started after he sold his business a year ago.
“And that was the strange thing. I sold my company, and made a lot of money, so surely things ought to have got better.”
He told me that he had started a small packaging business straight out of school, and had devoted the last two decades to it. He was successful, and the company grew to have a dozen employees. When he received a generous buy-out offer from a competitor he was in two minds about whether to accept it or not. He knew that the business had been his whole world, yet at some level he knew that something was missing. He had married early, and they had stayed together, but only with a lot of tension. They had no children, and he was hoping that leaving work behind would allow him to mend his marriage and maybe start a family. So, he took the three million dollars that he was being offered, and as he put it…
“Now I’m set for life. How come I feel so bad?”
I didn’t try to answer that immediately but carried on with the usual pattern of any initial assessment, to make sure I wasn’t missing anything else that would explain his anxiety. He wasn’t especially depressed, and he wasn’t misusing drugs or alcohol, and his anxiety didn’t seem to be focused on particular places as it is in agoraphobia or social phobia. Although people can have anxiety in the form of a panic disorder that arrives out of the blue without any apparent cause, more often there is a precipitant, and I was looking for one when I asked my next question.
“Jeremy, when you wake up in the morning, what is the thought that you have as the anxiety hits you?”
“I’m thinking ‘here it comes again’, and ‘where are my pills?’”
“I’m sure you are. But is there any other thought, before the anxiety hits? Anything that might help us understand why this is happening?”
“What am I going to do? The days are long, and there are so many of them.”
“Maybe your work gave you all the occupation and direction you needed for life?”
“It did, I know it did. But I also wanted to stop. I’d given it everything for twenty years. Surely that’s enough?”
Sigmund Freud is famously quoted as saying that work and love are what a healthy individual should be able to do, and it has been extrapolated to mean that both work and love are important Freudian foundations of psychological health. Interestingly, Freud never wrote such a phrase, and the first record of him having said it came twenty-four years after his death, as pointed out by Alan Elms at UC Davis. But whether he said it or not, the theme is in keeping with a lot of Freud’s writings, and I would agree that having an occupation (paid or unpaid) that engages someone and supplies a purpose in life is indeed hugely important. There are surveys suggesting that early retirement may be linked with a premature death for just this reason, although I can also think of patients whose mental health improved when they were able to leave an unsupportive workplace. However, I had never had a patient in whom leaving work had led to such a massive change in mental health as Jeremy, and although I thought that his occupation ought to be part of a treatment plan, I wasn’t wholly sure of my ground. I would want to suggest the importance of work of some kind for him, but I would also treat his anxiety disorder in more traditional ways.
“If you knew how bad the anxiety was you wouldn’t be suggesting lifestyle changes or psychobabble.”
“There are three broad approaches to treating anxiety disorders,” I said, “and I think we should look at all three. Firstly, there are medications.”
“That’s what I want you to do. My family doctor has tried five different drugs and I think they’re running out of options.”
“Well, there are way more than five medications available, but I think it was very reasonable for them to refer you to me after five unsuccessful trials. We’ll come back to medications in a minute but let’s look at the other approaches. Secondly, there is psychotherapy, and it is equally effective as medication.”
“Do I have to? I once went to a psychologist and to be honest I didn’t get anything out of it. What I want is a medication answer.”
My heart sank a little when I heard this, as it often does. Patients vary in how much they are willing to accept any one treatment approach. Some people are afraid of medications because they think they are addictive, or prone to serious side effects. Most of what I prescribe isn’t addictive (though the lorazepam that Jeremy had taken that morning is an exception), and side effects only happen in a minority of patients, and when they do it is often possible to avoid the problem by switching to a different medication. Other people, like Jeremy, want medications and are opposed to the concept of a ‘talking therapy’. This has a doubly bad effect on their treatment options, because although someone reluctant to take medication may be persuaded to try it and then benefit, someone opposed to psychotherapy is unlikely to benefit even if I can persuade them into trying it, because a successful therapy requires patient motivation to engage and change. I wasn’t going to let the therapy option go without trying again, but his attitude told me that it was already looking a little unlikely to help. But before I returned to his favoured modality of pharmacological treatment, I needed to address the third option.
“The final choice for treatment is about how you spend your time. Do you think that finding another way to occupy your time would help, like your business used to?”
“I know I need to find something to do, and I am looking. But that won’t be enough, I know it won’t. If you knew how bad the anxiety was you wouldn’t be suggesting lifestyle changes or psychobabble.”
“Message received,” I replied, “Let’s look at the medications.”
Engaging a patient into treatment is a vital part of being a doctor, and maybe more so in psychiatry than anywhere else in medicine. It is a little like a dance, where both parties are to some extent guiding the process. As the physician I feel like the leader of the pair, yet I know that to make it work I must be perpetually aware of where my partner wants to go, and accommodate that as well as my own direction. This made me start with Jeremy’s wish, the medications. His family physician had tried multiple classes of medications; SSRIs, SNRIs and even a tricyclic. They had titrated the doses to good levels, for what were certainly adequate periods of time. The lack of response made the chances of a good response to a different medication unlikely, and this was one of the reasons why I wanted him to look at the psychotherapy and social occupation routes to treatment instead of just focusing on biological agents. But guided by him, I opted for some combinations of medications, and used other drugs for augmentation, which persuaded him that I was taking the biological therapy seriously. In return he agreed to start work with a cognitive therapist, and to try to find himself a meaningful occupation for his time.
For a long while things got no better. I tried combination after combination of psychotropic medications, but he still woke up and was incapacitated by panic before he could get out of bed. I managed to reduce his use of lorazepam as much as I could but in the worst panic attacks he still needed it. Any doubts I might have had about how ill he was got answered when he proceeded to have a panic attack in my office one morning, and I saw first-hand the sweating, the heaving chest, and the terror in his eyes. When he got it, he certainly got it badly.
His psychotherapy wasn’t going any better than the medication treatments. He had rapidly fired his first therapist saying, ‘He just wanted me to channel happy thoughts, and it felt like kindergarten.’ He was more tolerant of their replacement, but it was clear that he kept going mostly because I said so, and that he wasn’t well motivated to benefit from the sessions.
That made me very keen to emphasise our third line of approach, finding a satisfying occupation for his time, but that was no more productive than the other two modalities. He had tried volunteering with Meals on Wheels, and had offered his management advice to a potential start-up company, but in both cases he had disengaged again once he found the individuals hard to relate to.
“You mean shock therapy?” He looked wary. “Do you still do that?”
“Why isn’t any of this working?” he asked one day, clearly disheartened.
“It’s a good question,” I answered, “and I’m sorry that things are no better. Sometimes that happens. I will continue to find different biological treatments for you, and I’m pleased that you are still going to therapy. What are you going to do next about occupying your time?”
He said he was going to join the board of a regional organisation helping local business owners, and I thought that this sounded promising.
“It’s OK, and I’ll keep doing it, but I know it’s not going to be the answer to panic that you think. What treatment have you got next for me?”
I counted up the list of different pharmacological treatments and combinations that we had tried, and saw how it was getting disappointingly long.
“Sometimes when we don’t seem to be getting anywhere with medications, we can switch to neurostimulation treatments. You may have heard of the oldest, and most reliable, of them all – ECT.”
“You mean shock therapy?” He looked wary. “Do you still do that?”
“Yes. Rarely, and more for depression than anxiety, though they often go together, and you do have some symptoms of depression too.”
“Am I really ill enough to need that?”
“In most ways no,” I said, thinking of how ECT is usually reserved for inpatients in hospital, “though we do use it for less ill people when we are getting stuck. However, there is also a more recent kind of neurostimulation that doesn’t need an anaesthetic or an epileptic seizure; it’s called TMS.”
“I’ve never heard of it. What does TMS stand for?”
“Transcranial Magnetic Stimulation. It’s an outpatient procedure done every day for a few weeks. You sit in a chair, and they focus magnetic beams on the areas of your brain most involved in emotion. It’s quite painless. Unfortunately, it’s not covered under publicly funded healthcare, so you would have to pay.”
Having seen his face cloud with worry when I was suggesting ECT, I now saw the opposite. I think the ‘newness’ of the treatment gave him hope, and maybe having to pay for it made him value it more highly. He was certainly relieved by not having to consider ECT, and almost before I had finished my explanation of what was involved, he was enthusiastically wanting to sign up for TMS. I promised to make the calls to the private clinic that would do the treatment, but said that I wanted him to continue with the psychotherapy and volunteer work as well.
“You don’t give up on those,” he said, smiling, “I’m pretty much done with therapy I can tell you, but the board I’ve joined has a project for me to organise so I’ll do that.”
The project that he was taking on was providing consulting advice to would-be entrepreneurs trying to set up their first businesses, and it sounded ideal to me. As he talked about it, I was looking to see if there was a spark of enthusiasm in his eyes. His words were positive, but somehow his tone wasn’t as optimistic as I would have hoped. And it turned out that I wasn’t hiding my preferred approach very well.
“You truly believe that the non-profit thing will cure me, don’t you?” he said. “Well, I’m going to do it, but what I really need is TMS.”
His tone told me that my dance partner might be thinking of leaving, and I quickly agreed to make the referral. Yet I was quietly thinking of Sisyphus.
“Therapy, and Freud, and all that stuff is so old. TMS is the future.”
In Greek myth, Sisyphus was an errant king who so angered the Gods that they condemned him to an endless task of rolling a boulder up a hill, only for it to roll away from him at the top, starting the process all over again. Pointless tasks have therefore been called Sisyphean, and there have been no shortage of people willing to describe their working lives in this fashion. The French philosopher Albert Camus took this myth as a metaphor for the meaninglessness of existence in general, though he made sure to mention that it was modern work that was particularly Sisyphean. His main question was why if life was so absurd, should one not die by suicide. And his answer was that ‘truths perish from being acknowledged’ and once Sisyphus realises his position, he can be mentally freed from it. Camus ends by saying that Sisyphus contentedly accepts his role and so ‘we must imagine Sisyphus happy.’ I have always struggled with Camus’ writing, as I did with most of French philosophy (or even philosophy in general). However, the image of Sisyphus smiling always resonated strongly with me, and it still does as I write this.
At some level I can see the argument about the pointlessness of existence; we will all die, and we are cosmically insignificant, living on Sagan’s pale blue dot, whose existence and history will be destroyed by a ballooning sun in due course. Yet on a day-to-day basis I see meaning in so many things; in love, and friendship, and music, and art, and science and in the beauty of the natural world. Although in some ways I see Camus may be right, and I may have my own Sisyphean repetition – if I treat Jeremy successfully for his anxiety disorder and discharge him, then there will be another anxiety disorder for me to treat, and then another, and so on – yet I do imagine Sisyphus happy. This applies to me in my work, and I think applied to Jeremy in his. If work is not exploitive or excessive, then I would agree with Freud that it is a pillar of mental health.
Jeremy duly went ahead and received his TMS. It cost him five thousand dollars, but he could obviously afford it. As I write this years later, the treatment is finally beginning to get covered by publicly funded healthcare, but back then it was still relatively new and unproven.
And he got better! Finally, as both his TMS proceeded and as he threw himself into enthusiastically helping people with their start-up business plans. He no longer hid in bed in the morning, panicked by the endless plains of pointless existence stretching before him. While he started the day chatting with his wife at the breakfast table, he would soon take his coffee with him into his home office, keen to move on with the next stage of his new occupation.
I saw this outcome as a full endorsement of Freud’s ideas, and I pictured Jeremy rolling his own rock up the hill, with a broad grin on his face, and then happily descending to start again with a new start-up client. TMS treatment appeared coincidental to his recovery rather than causative, and part of me wished that we could have held it in reserve until seeing how his occupational engagement helped him. But that is the approach of the scientist, carefully separating out different experimental conditions so as to see clearly which treatment aligns with which result. The clinician, and even more the patient, is concerned only with a successful outcome and cares much less if this is achieved with a single modality of treatment or using whatever is available in a belt-and-braces approach. I knew that Jeremy had been ill so long that his recovery was indeed the most important truth here, rather than any certainty of knowing its cause.
For his part, Jeremy had no doubts about the reasons for his recovery either. He had read some psychological theories during his long period of illness, and had divined my thoughts on the process, and as he took his discharge he left me with a telling comment.
“I’m very grateful for your help, but you psychiatrists really need to get with the twenty-first century. Therapy, and Freud, and all that stuff is so old. TMS is the future.”
All names and other identifying details have been changed to protect patient confidentiality.
JP Sutherland 