Perspective Chapter: Panic Disorder – A Real-World Case Due to Covid

Abstract

This chapter presents a “real-world” case of extreme panic disorder and details the treatments that were brought to bear in efforts to reduce the panic. Unlike most cases of panic which appear to arise unpredictably and from unknown causes and last for a short amount of time, this one was attributed to an underlying neurological condition and many of the extreme panic episodes persisted for full days. The condition producing this panic was autoimmune encephalitis which appears to have arisen because of a Covid infection. The eventual resolution of the panic disorder took almost 2 years of daily struggles and are detailed within the chapter.

1. Introduction

Many of the chapters in this book on the Psychology of Panic deal with important topics such as the etiologies of panic, its characteristics, its epidemiology, and interventions. What will be presented in this chapter is a real-world case of Jordan with whom I have been directly involved as a treating psychologist and who has experienced extreme and extended bouts of panic which appear to have resulted from Covid exposure and resulting neurological inflammation.

Before delving into the case, it is important to consider what a panic attack might be like on a personal level. The DSM-5 [1] provides specific criteria for defining panic and these specifics are addressed in more than one chapter in this book. But such analytic descriptions with their enumeration of a series of diagnostic criteria provide a somewhat antiseptic and emotionally detached view of a disorder that is difficult to identify with unless the reader has experienced panic attacks themselves. So let us try a different approach.

Imagine that you are driving home on a dark stormy night where the windswept rain is so intense that your car’s windshield wipers, although on high, make the road ahead almost indistinguishable. You are on high alert and are driving slowly to avert any storm related difficulties and you can feel your heart beating because of the stress of driving through this intense storm. You come to a familiar railroad crossing and as you begin to approach it you both hear and feel your car’s engine begin to run rough and stumble. Suddenly the engine dies and although your foot is off the brake, the car comes to a stop directly on the railroad tracks. Your fear level is now intensified. You are stuck on the tracks. Suddenly, you see brightly flashing red lights and ringing and realize that the railroad barrier arms are coming down in front of and behind your car and are a signal of an approaching train. You are trapped between the barriers and your car is sitting right in the middle of the tracks. A bright white light begins to appear out of the drenching rain, and you hear the horn of the train growing louder as it is rapidly approaching. You now are desperately trying to restart the car to move it either backward or forward to get off the tracks. You are gripped by a wild fear of impending annihilation by a locomotive that is now clearly in view and growing both louder and larger. You can feel the vibrations of this massive train as it literally shakes the tracks that you and your car are sitting on. You are about to be crushed and now your body tenses as you close your eyes knowing that in the next instant you and your car will be annihilated.

That feeling of being completely out of control and unable to affect your environment while also experiencing the extremely intense fear of annihilation is what a panic attack might feel like. The level of fear is so intense that all reason and problem solving become nonexistent. It is as if the thinking part of the brain has been shut down and an animal-like, reflexive, fleeing or freezing response takes hold. The term “fear” does not do justice to what a panic attack might feel like. It is a primal experience that is far beyond fear. It is often unimaginably intense and renders the suffer helpless and frantic.

According to the Diagnostic and statistical Manual of Mental Disorders [1] under normal circumstances panic attacks are relatively brief and can come on suddenly and unexpectedly. For example, one can be in a relaxed state or even emerging from sleep and suddenly experience a panic attack. In Jordan’s case the panic attacks would often go on for hours and often consume a major part of the day. These extended episodes of panic are unusual and were later seen as originating from nervous system impairment due to Covid infection.

2. Case description

I had seen Jordan on and off for several years for a series of relatively minor issues that might be described as problems of living. He had self-doubts about his capabilities although he was both bright and well educated. As a 51-year-old he experienced bouts of depression, but these too were relatively mild and might be better described as episodes of melancholy. He also had a relatively low-level generalized anxiety disorder. He seemed unable to develop long term committed relationships despite having dated numerous women who he met on a variety of dating apps. Jordan was able to live on his own in New York City but often received financial support from his twin sister and his mother. At the time of his decent into panic, he was working as an adjunct professor teaching a variety of graduate and undergraduate psychology courses and three different universities.

Jordan’s mother became infected with the Covid virus at age 75 and experienced a series of long-haul symptoms that lasted nearly a year. These included body pains, extreme fatigue, balance problems, memory difficulties and disorientation. The doctors who ultimately treated Jordan believed that although he likely caught Covid from his mother and he initially experienced only mild to minimal symptoms of Covid, as time progressed his symptoms slowly began to worsen. Their final diagnosis was that his Covid infection triggered autoimmune encephalitis whereby the immune system, in an overreaction to viral infection, began attacking the healthy tissue of Jordan’s brain.

According to Younger [2], viruses can attack the body and produce a response the follows a specific sequence. The first stage of this sequence is the viral infection. This is then followed by an immune response and this response is followed by and manifests itself as an inflammatory process. Infection, immune response, and inflammation is referred to by Younger as “I-cubed” (p. 7). The immune system responds to the newly present virus as a pathogen that exists in the nervous system and attacks the nervous system to ward of the invader. Over time a neural cycle develops in which panic or pain become almost reflexive behavioral responses to invasion by the pathogen [3]. Treatment is often aimed at reducing the inflammation that was caused by the body’s overactive immune response. Common outcomes of the inflammatory response are pain, depression, anxiety, fatigue, and attention problems. In Jordan’s case his primary responses were extreme anxiety and panic, debilitating fatigue, and moderate depression.

3. Developmental course

Jordan reached out to me while he was still employed as an adjunct professor. Although popular and well regarded as a capable instructor, he reported that he was experiencing increasingly intense bouts of anxiety and that he was having difficulty getting through his day. Normally he was at ease and confident as an instructor, but he was now experiencing feelings of failure and simply getting himself into the classroom to teach was becoming increasing frightening and difficult. He felt that he could not present the material clearly and that students were noticing that his lectures were more and more disorganized. His normal easygoing demeanor was being replaced by an unhappy, ill at ease presence. Although he was able to see his classes through until the end of the semester, he knew that he would be unable to return. The anxiety he was experiencing made the thought of returning to the classroom a challenge that he was unable to meet.

Over time he began to become increasing anxious and feel threatened in situations that were normally soothing to him. For example, he enjoyed going to his gym which had a swimming pool. Swimming for Jordan was a stress reliever and a form of meditation. He was able to clear his mind of daily problems while swimming back and forth in the pool. All of this changed following his Covid infection. Eventually the thought of immersing his head in water evoked extreme apprehension. His difficulties with the pool and with water became so troublesome that he found himself unable to even dangle his legs into water while sitting on the edge of the pool. This apprehension spread to the gym itself. The last time he went there, he had such an extreme panic reaction that the personnel at the gym called the police to remove him. The police arrived and Jordan refused to leave. A scuffle broke out and resulted in Jordan biting one of the officers. The police used a Taser on him, and he was taken to a jail cell. His sister was called to retrieve him. The police brought no charges as they saw Jordan as irrational and out of control.

Once in his sister’s apartment, Jordan continued to be overwhelmed with panic and in an attempt to end his intense suffering, attempted to jump from a sixth story porch. His sister was able to convince him that he needed hospitalization. One the way to a well-known hospital in New York City, Jordan opened the car door, jumped out, and in what appeared to be a suicidal gesture, threw himself in front of oncoming cars. When questioned about this extreme act he claimed that he was not really trying to kill himself but rather trying to end the intense pain brought on by panic. It was clear to all that Jordan was progressively descending into irrational behavior and thought in reaction to the pain of his extended panic attacks.

It is difficult to accurately convey the intense level of suffering brought on by Jordan’s panic. He has used the term, “seizure” to describe the sudden grip of intense fear that unpredictably but regularly fell upon him. During one of these “seizures” he would often thrash around maniacally, smashing objects and even hitting those who were nearby. At one point he punched his mother in the face and the next day, on seeing her blackened eye, asked if she had fallen. He had no memory of having hit her. It was clear that his panic attacks were rendering him an irrational, frightened, and crazed individual who was often unaware of what he was doing and who later had only minimal recall of what his behavior had wrought.

4. Secondary trauma

Before delving into Jordan’s treatment, it is important to consider the impact that his extreme panic attacks had on his family. When an individual is traumatized as was Jordan, their emotional distress is transferred to those who have a close bond with that person. Typically, this group includes family members but can also include other caretakers such as therapists, physicians, nurses, etc. [4]. The process by which trauma is transferred from one individual to those who have a close and extended relationship with that person is referred to as secondary traumatization [5]. In Jordan’s case his sister, who was a twin, and his mother who presumably spread Covid to her son, suffered the emotional pain of Jordan’s distress. They felt powerless to alleviate his pain despite valiant efforts to coordinate treatment teams, find hopefully effective treatment facilities, and obtain a veritable army of occupational therapists, health aides, psychologists, psychiatrists, dieticians, and others. They clearly felt Jordan’s pain and agonized over their inability to find some magical combination of therapeutic elements that would stop the suffering of their beloved family member. Jordan’s sister would often take it upon herself to advise the physicians of the appropriate modes of treatment based upon her frenzied search of the internet. This proved to be counterproductive because after a while the physicians began to become defensive and non-responsive to her incessant questioning of their decisions. What she eventually came to understand was that Jordan’s treatment team was not being negligent or uncaring but that they simply did not know how to alleviate Jordan’s torturous panic attacks and his occasional thrashing both of which appeared to be brought on by the inflammation and oversensitivity of his ailing nervous system.

5. Psychological intervention

In general, panic attacks are treated both psychologically and pharmacologically [6] and this section will spotlight the former. Cognitive-behavioral therapy (CBT) interventions are often used, and these are frequently coupled with breathing techniques and meditation. Prior to engaging in interventions, it is important to assure the patient that panic disorder is a known phenomenon that afflicts approximately 2–5% of the general population [7], that a panic attack is not life threatening, and that it is often associated with feelings of extreme dread, trembling, extremity numbness, disorientation, hyperventilation, dizziness, and other symptoms. It is not uncommon for patients who experience panic attacks to fear that they might die or become insane. Assurance that these are common beliefs during a panic attack can be helpful in lessening the dread that the panic sufferer may encounter. It is also often helpful to provide the panic victim with information sources to reduce the chances of engaging in catastrophic thinking. This providing of information and perspective can be seen as cognitively oriented intervention that helps to allay extremely negative and fatalistic beliefs.

Another CBT intervention specifically targeted Jordan’s tendency toward catastrophic thinking. In his case the catastrophizing involved the belief that “My life is over,” “I will never get better.” Jordan and I worked together in such a way that allowed him to understand that there was no evidence to support such a negativistic view, and that there was abundant evidence that people recover from AE based panic. Jordan was encouraged to engage in his own scientifically based skepticism of such thoughts and was generally able to do so. This technique was practiced between episodes of panic because once in the throes of a panic attack, logical and rational thinking are unavailable to most sufferers.

In Jordan’s case a specific breathing exercise was also practiced that involved inhaling through the nose for 4 s, holding the breath for 5 s, and exhaling for 7 s. This exercise provided him with a tool to control the hyperventilation that he commonly experienced during a panic attack and reduced some the dizziness and tingling that were associated with this hyperventilation. He stated that the breathing exercise reduced the intensity of his panic but did not eliminate the disorder. He was clearly suffering but his pain was less than that which would normally be occurring without intervention. Unfortunately, it became apparent that unless I was guiding him in the controlled breathing exercise, he was unlikely to do it on his own. As I was unable to be with him daily to guide him through the breathing exercise, I taught the approach to his sister and mother with whom he spoke multiple times during the day. This helped considerably as they were able to get Jordan to engage in controlled breathing daily and often more than once during any given day.

Meditation techniques were coupled with the controlled breathing. Once Jordan had gained some level of control using the breathing techniques, a guided meditation was used. The meditation had to be guided because the concept of simply clearing his mind of intruding thoughts as is common in many forms of meditation, was beyond his capability given the ongoing panic disorder. One meditation that proved to be helpful was the “Mountain Meditation” [8] in that it provided the self-view of strength and imperviousness. The meditation is usually done in a sitting position where one directs one’s attention to the characteristics of a mountain. One’s lower extremities are viewed as the base of the mountain which is solid and imperturbable. The arms and shoulders are seen as projections from the mountain that are unchanged by winds, rain, or any other environmental events. The head as viewed as the top of the mountain that stands above and is unaffected by the travails and disturbances that people commonly encounter. The entire meditation takes approximately 20 min and emphasis is placed upon strength, endurance, and ability to be unmoved and unshaken. The images of strength and immobility help to counter the agitation and vulnerability commonly experienced by those enduring panic attacks. Other meditations were also used like the “Lake Meditation” which emphasizes stillness and tranquility [8]. Despite disturbances on the surface of the water, the lake ultimately returns to stillness and serenity. Imagining himself to have the characteristics of the lake helped Jordan to reduce his agitation.

A final form of psychological intervention for both Jordan and his family was supportive counseling. Jordan’s illness seemed to come out of the blue and was terribly disruptive to him and extremely anxiety provoking to his mother and sister. Everyone seemed to benefit from encouragement and assurance that things would get better and that the brain had a natural tendency to move in the direction of self-repair and self-cure. A good example of this is the impressive recoveries made by those who have experienced brain damage due to strokes. Many of the functions lost to strokes are often recovered with various exercises that combine cognitive and physical activity. Jordan and his family were encouraged to read numerous anecdotal reports of people who recovered from the disability wrought by AE. These reports and the provision of emotional support went a long way in facilitating Jordan’s eventual improvement.

6. Pharmacological, medical, and physiological intervention

When Jordan was first taken to the hospital following his initial irrational behaviors and attempts at self-injury, the hospital staff appeared to be at a loss. His doctors thought he had some form of psychosis and treated Jordan with antipsychotics, antianxiety and antidepression agents. The sedating effect that these medications resulted in some reduction of his anxious thrashing, but his panic disorder persisted, and he continued to verbalize the desire for his life to come to an end. The flailing about for some method of treating this agitated patient went on for several months until it was finally decided to do a spinal puncture. The results of this procedure led the involved neurologists and psychiatrists to conclude that he was suffering from autoimmune encephalitis. This diagnosis provided some direction for treatment, but the concept of a “cure” continued to be a distant hope.

Autoimmune encephalitis was first reported in the 1960s [9] and was initially described as limbic encephalitis (LE). LE encompassed symptoms including seizures, movement disorders, behavioral changes, mood disorders, cognitive impairment, and an altered level of consciousness. Except for the incoordination seen in movement disorders, Jordan appeared to be displaying all these symptoms. The disorder is now seen as affecting various brain structures, not just the limbic system, and is now termed AE or autoimmune encephalitis, a disorder involving the immune system’s attack on various brain structures [10].

Having arrived at a diagnosis of AE, a twofold treatment was decided upon. The first was the use of steroids. The goal here was to reduce inflammation of the nervous system. The second line of attack was intravenous immunoglobulin (IVIG) infusion. The latter was aimed deactivating the immune system’s attack on health neural tissue. Jordan received two such treatments of combined steroids and IVIG in the hope of a remission of his symptoms. However, the treatments not only proved ineffective in the short run, but it appeared that after the use of steroids his symptoms of agitation, panic, and thrashing became worse. Why this occurred is unclear because there were anecdotal reports from his treatment team that this intervention appeared to have reduced symptoms in other cases of AE that his physicians had encountered. On the other hand, there are researchers who report that available evidence shows that the combination of IVIG and steroid intervention continues to be ineffective for a significant number of patients suffering from AE [11]. The latter view certainly appeared to be valid in Jordan’s case.

Given the obvious lack of progress in Jordan’s behavior following two administrations of combined IVIG and steroids, the decision was made by his treatment team to provide him a second line of treatment called rituximab. Rituximab is a medication that is often used in the treatment of rheumatoid arthritis and is said to specifically inhibit B cells of the immune system. It is also used when the combined IVIG-steroid treatment fails stop the immune systems attack on healthy neural tissue that occurs in autoimmune encephalitis [12]. The rituximab treatment was done on two occasions approximately 6 weeks apart. One of the concerns voiced by Jordan’s physicians was that because rituximab suppresses the immune system, the patient then becomes vulnerable to any potential infection to which he or she might be exposed. Jordan’s treatment was taking place a time of increased infection rates of Covid in New York City so the concern for infection was realistic. In fact, the routine of the hospital was to isolate Jordan after the rituximab treatments. Visitors were required to be fully vaccinated, to wear masks, and to also wear latex gloves.

The idea that he might be immune compromised did nothing to help Jordan with his panic attacks. In the immediate aftermath of his rituximab treatments, he would be on the phone with his family all day. His sister once noted that that he had made approximately 150 calls on 1 day. Approximately 1 month after his last rituximab treatment, there did appear to be some diminishing of the intensity and frequency of Jordan’s panic attacks. They were continuing to occur multiple time per day but there were periods, especially in the early afternoons, where he did seem to be less tormented by anxiety.

At around this time Jordan was transferred to another hospital in Yonkers, NY which specialized in the treatment of patients with specific neurological disorders such as encephalitis and traumatic brain injury. This hospital was one of the few placements that would accept him. The uncontrolled thrashing about and occasional breaking of objects in his hospital room during extreme panic attacks resulted in his being a patient that no one wanted in their facility. One novelty of his placement in Yonkers was that he was able to go outside unattended. He would occasionally go to a local basketball court to practice his shooting. Often the overstimulation of having been outside would precipitate a panic attack, so his increased freedom turned out to be a mixed blessing.

As a rule, physical exercise has beneficial effects on psychological and neurological functioning [13]. There is considerable speculation as to why this is the case but one of the more popular view sis known as the endorphin hypothesis [14]. Exercise is said to result in the release of the endogenous opiate beta-endorphin which is said to produce a calming effect on the nervous system and to result in mood elevation. The hypothesis is not without its critics who, among other critiques, note that beta endorphins do not cross the blood–brain barrier and therefore are unlikely to have an impact of neurological and psychological states. A competing hypothesis for the benefit of exercise is referred to as the endocannabinoid hypothesis [15]. Endocannabinoids, which are like the THC found in marijuana are released during exercise and are said to be capable of crossing the blood brain barrier. Regardless of theoretical view, it appears that in Jordan’s case mild exercise such as shooting baskets or having a brief leisurely walk, proved beneficial in terms of reducing his level of panic, whereas more strenuous exercise had the opposite effect and precipitated intense panic reactions.

7. Transition to supportive care

Jordan was transferred to a private long-term care facility in Pennsylvania following his stay at the medical center in Yonkers, NY. At the time of his transfer Jordan had been in and out of various hospitals and neurological care facilities for 22 months. It was only at the time of his latest transfer that his panic attacks began to subside. He continued to be moderately anxious, depressed, and often felt overwhelmed, but the extreme panic disorder that he endured for almost 2 years, now appeared to be a torturous event of the past.

The question that arises is what was responsible for the reduction in his panic attacks. It is possible that the psychological supports and interventions that were put in place eventually took hold and helped Jordan deal with his anxieties. It is also possible that the medical interventions such as IVIG, steroids, and rituximab brought about the panic reductions by reducing the immune system’s response and inflammation. Mild exercise and family support might also be pointed to as having been beneficial to him. However, if we objectively view what is known in Jordan’s case, we must come to the somewhat unsettling conclusion that any of these interventions or some combination of them were what proved beneficial. It is also possible that none of them were responsible for change and that the brain’s tendency to move in the direction of self-healing, as is seen in cases of stroke, is what eventually brought about change, e.g., [16]. This self-healing position suggests that, given sufficient time and effort to change one’s behavior, the brain itself is the healing agent.

8. Conclusion

Jordan now resides in a supportive care facility where he has psychologists, psychiatrists, nurses, and recreational therapists. He is kept socially engaged and participates in both individual and group psychotherapy. He is receiving therapeutic doses of antianxiety and antidepression agents but no neuroleptics and no immune system targeted medications. His panic attacks have subsided and plans are to integrate him into the community by encouraging him to attend various social events and attempt to find employment. Given Jordan’s background as a psychology professor, there is some discussion of having him provide counseling services to others within the supportive care facility. His training and difficult experiences with a severe case of neurologically induced panic, make him an ideal candidate for such a position.

Jordan views himself and his situation realistically. He sees himself as having endured the neurological torment of autoimmune encephalitis and that, for reasons unknown to him, he is beginning to recover. He is thankful that the panic that once gripped his life is no longer present. Each new day brings further improvements in terms of his willingness to engage in social events, to participate in therapeutic activities, and in his overall hopefulness that he will continue to improve to the point where he can get back to his former life. My impression, as one of his treating psychologists, is that he will not only be able to regain that which he once had, but that the traumatic experiences he has endured because of his illness will have given him greater depth and perspective. There is a possibility that his overall functioning may be better than it was prior to his illness. This is a relatively common outcome that is seen among those who have lived through various forms of trauma [17]. At this point, his treatment team is of the opinion that Jordan will make a complete recovery.