Dear therapist,

I am a father of a young girl in her 20's who has been having recurrent "anxiety/panic attacks" and I am at a loss as to how to help her? I am not sure that the "attacks" are really panic attacks but rather tantrums or shall I say a call for attention. She is not in school and doesn't work despite being an intelligent young lady. She no longer goes out with friends and is attached to myself and her mother. I realize that she may suffer from separation anxiety resulting from her youth. However its only in the last year that she really began acting out and my wife and I see that she isn't at all happy and completely unmotivated. We have given her many job opportunities but she will always find an excuse not to follow through. Her hysterical behavior and outbursts of feeling dizzy and nauseous land us in the Emergency room on many occasions. However she is rarely admitted since the hospital can find no justification to keep her or she would refuse by snapping out of it and demand that she go home. My wife and I don't know what we can do and these "attacks/tantrums" occur daily.

She has seen many psychiatrists and she has been on different medications but we still don't see any change. She is currently in therapy to help address these and other issues that she suffers from. I wonder what else we can do for our child we want for her to eventually get married and have a family of her own. We are all realistic that she is not well enough now to venture that way. Please advise if there is anything else we can do?

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Dear Concerned Father:

It sounds like you have done your very best to help your daughter access help for her difficulties and have not seen much success with medication treatment, although you remain hopeful that her current therapy may get to the root of the issues. I hope this will be the case for you. Without knowing the intimate details of a particular case, it is always a little hard to comment- but I will offer you a thought or two about what might be going on for you to address with your daughter's therapist if it seems appropriate to do so.

From your description, it sounds like your daughter's "anxiety attacks" seem to be a way that she communicates with others, as opposed to just a "symptom". It's like her way of "talking" or expressing a need for something; she "talks" through actions rather than words. This fits in with the overall picture that you describe, which includes several deficits in your daughter's functioning and relationships including separation anxiety, dramatic "emergency" episodes which seem attention-seeking in nature, lack of ability to follow-through with tasks, etc.

My thought is that your daughter's symptoms may be part of an overall set of missing skills in her personality, such as knowing:

• how to interact effectively and negotiate with other people;
• how to seek out healthy attention;
• how to express independence;
• how to soothe herself when she feels distressed and others are not available;
• how to follow-through with goals.

My recommendation in a situation like this is for your daughter to receive a type of intensive psychodynamic therapy which can activate the emotional feelings that she has in attachment relationships (such as with you and your wife) and help her learn new skills for being thoughtful and reflective in such relationships, as well as effective at communicating her needs in less dysfunctional ways. I also recommend that she attend a Dialectical Behavior Therapy skills group in addition which can give her the education about how to use some of these skills, which she can then "practice using" in her therapy relationship.

For starters, you might discuss with her therapist whether it would be helpful for your daughter to have sessions at a frequency of twice a week with a focus on her emotional reactions to the therapist within the sessions. I would also recommend that you learn some "mentalization skills" which can help you teach your daughter to communicate in words as opposed to actions and to think about which feelings are causing her to act the way she does. And, as her parents, it is also important for you to look at whether you might be reacting to your daughter based on experiences you had with your own parents in a way that is out of your awareness but that your daughter may be picking up on subconsciously. For example, did you have a needy parent who did things for attention and does your daughter's behavior remind you of how that used to feel?

Good luck with it all! More information about "mentalization" and "Dialectical Behavior Therapy" is available on my website: www.goldsteintherapy.com

Mirel Goldstein, M.S., M.A., LPC
Professional Individual and Marital Counseling

3 Harding Court

Passaic, NJ 07055

303-204-7039

NJ License 37PC00391500

www.goldsteintherapy.com

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Dear Concerned Father:

It is obvious that you and your wife are suffering deeply both from seeing your daughter in this (at least currently) hopeless situation and your frustration and disappointment at, so far, being unable to help her. Your caring and concern are quite evident.

There seems to be some suspicion, not entirely unfounded, based on the fact that numerous evaluations at hospitals have yielded no diagnosis, that these attacks your daughter suffers have no medical bases and that they are attention getting "ploys". What's important to keep in mind, however, is that even if the objective of these attacks is to gain attention, there are psychological/emotional needs that are the causation. Whatever is the basis is for these behaviors, it is leading to a severely debilitating existence for your daughter and needs to be worked with in order to get her on a different path.

There is a saying, "if you keep doing what you've always done, you'll keep getting what you've always gotten". In spite of great effort, seeing the individual psychiatrists with the accompanying medications has not helped, so the goal now should be to consider other methods of treatment. There are a number of options.

The most drastic would be to consider residential treatment which would "envelope" your daughter in an entirely different environment and provide substantial therapy, something that, hopefully, would "jolt" her out of her current state. (I want you to understand, I am not particularly suggesting this, just listing it as part of the option possibilities).

Another option is family therapy. Nobody exists in a vacuum and we are all part of a "system". It is often the particular dynamic that is occurring within the system that leads to "break-down" (for lack of a better term), in one or more of the members of that system. An objective professional (family therapist) can work with all the members of the system, identifying and alleviating the dynamics that are creating the factors that are working poorly for one or more of the members.

It would also probably be very beneficial for your daughter to participate in group psychotherapy which is often a more dynamic way of creating positive changes in someone's life. Again, because we all exist within groups, the interpersonal relationships in the group help, in a sense, re-orient the individual, leading to changes within one's own life. Often, a person combines group with individual therapy making it, so to speak, the best of all possible worlds.

Finally, there is a theory that all behavior is saying something. The challenge is to discover what a behavior is saying. I'm not a proponent of long distance therapy but when one thinks of the word "panic", the connection is usually a response to something frightening. I am proposing that there are some unconscious fears that your daughter is experiencing and when those fears threaten to become conscious, there is a self protective (defensive) psychic mechanism that creates the "panic attack" so that her brain focuses on that rather than the fear that would be so completely, intolerably, threatening and frightening. What may be significant is the statement "I realize that she may suffer from separation anxiety resulting from her youth", with no further explanation. Obviously, there was some apparently traumatic event or events that may be the root of the fear or a number of experiences or anticipated experiences that are leading to these attacks.

It's also important that you understand the phrase that you used: "it's only in the last year that she really began acting out" . The phrase "acting out" is really only part of a sentence, the entire sentence is "acting out her feelings". Meaning, again, that your daughter's actions are saying something, something she is unable, at this time, to express in words. Once she is able to express her feelings in words rather than actions, the panic attacks will lessen and eventually stop and she will get on with life.

It is almost a certainty that with the correct therapy, support and guidance, together with her parents' love and concern, your daughter will once again resume a functional, productive, and, hopefully, happy and fulfilling life.

Sincerely,
Nancy Silberman Zwiebach
Paramus, NJ
201-843-1373
Individual, Couple, Family, and Group Therapy