https://doi.org/10.4081/ripppo.2020.421

Panic disorder: attack of fear or acute attack of solitude? Convergences between affective neuroscience and phenomenological-Gestalt perspective

Vol. 23 No. 1 (2020)
Submitted: July 18, 2019
Accepted: February 19, 2020
Published: May 21, 2020
Panic Disorder, Affective Neuroscience, Phenomenological-Gestalt perspective, Gestalt therapy
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Authors

Gianni Francesetti
International Institute for Gestalt Therapy and Psychopathology - IPsiG, Italy.
Antonio Alcaro
Santa Lucia Foundation, European Centre for Brain Research, Italy.
Michele Settanni
michele.settanni@unito.it
Department of Psychology, University of Turin, Italy.

There is consensus among scientists in considering Panic Attack (PA) as an exaggerated fear response triggered by intense activation of the amygdala and related Fear brain network. Current guidelines for treatment (e.g. National Institute for Clinical Excellence, NICE, 2011), that are based on this view, do not achieve satisfactory results: one-third of all treated patients report persistent PAs and other Panic Disorder (PD) symptoms, and several meta-analyses report the high likelihood of relapse. Here we review findings from Affective Neuroscience and clinical insights from a phenomenological-Gestalt perspective, putting into question the link between PD and activation of the Fear brain network. We propose an alternative hypothesis about PD etiology: PD is mainly connected to the Panic system, that is activated in situations of separation from affective support and overexposure to the environment. In our view, PA can be understood as an acute attack of solitude which is not adequately recognized by the patient due to the intervention of a dissociative component that makes it impossible to integrate all neuro-physiological responses activated by the Panic/Separation brain system within a coherent emotional feeling. This perspective can explain many evidences that otherwise remain isolated elements without a comprehensive frame: i.e., the association with agoraphobia, the onset of PD during adolescence and young adult life, the need to be accompanied, the connection with air hunger and other respiratory anomalies, the efficacy of antidepressants and the lack of activation of the Hypothalamic-Pituitary-Adrenal (HPA) axe. We discuss future steps to test this hypothesis and the consequences for psychotherapeutic treatment.

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Europe PMC
Adolphs R. (2017). How should neuroscience study emotions? by distinguishing emotion states, concepts, and experiences. Social cognitive and affective neuroscience, 12(1), 24–31. doi:10.1093/scan/nsw153 DOI: https://doi.org/10.1093/scan/nsw153
Alcaro A., Carta S., Panksepp J. (2017). The affective core of the self: a neuro-archetypical perspective on the foundations of human (and animal) subjectivity. Front Psychol. 8: 1424. doi: 10.3389/fpsyg.2017. 01424.
American Psychiatric Association (APA) (2009). Practice guidelines for the treatment of patients with panic disorder. American Psychiatric Association. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/panicdisorder.pdf
Arciero G, Bondolfi G (2009). Selfhood, Identity and Personality Styles. Wiley-Blackwell, Chichester UK DOI: https://doi.org/10.1002/9780470749357
Barlow D.H., Gorman J.M., Shear M.K., Woods S.W. (2000). Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. JAMA. 283(19): 2529-36.
Batelaan N.M., Bosman R.C., Muntingh A., Scholten W.D., Huijbregts K.M., van Balkom A.J. (2017). Risk of relapse after antidepressant discontinuation in anxiety disorders, obsessive-compulsive disorder, and post-traumatic stress disorder: systematic review and meta-analysis of relapse prevention trials. British Medical Journal. 358: j3927.
Battaglia M. (2015). Separation anxiety: at the neurobiological crossroads of adaptation and illness. Dialogues Clin Neurosci. 17(3): 277-85.
Bauman Z. (2002). Liquid Modernity. Cambridge, UK: Polity Press.
Beck J.G., Shipherd J.C., Read J. (1999). Response patterns to repeated CO2 inhalation in individuals with high anxiety sensitivity. Behav Res Ther. 37(11): 1073-89.
Beck J.G., Shipherd J.C., Ohtake P. (2000). Do panic symptom profiles influence response to a hypoxic challenge in patients with panic disorder? A preliminary report. Psychosom Med. 62(5): 678-83.
Binswanger L. (1963). Being in the World. New York: Basic Books.
Bloom D. (2009). The Phenomenological Method of Gestalt Therapy: Revisiting Husserl to Discover the Essence of Gestalt Therapy. Gestalt Review. 13(3): 277-295.
Bloom D. (2019). Afterword. Neither from the “Inside” Looking “Out” nor from the “Outside” Looking “In”. In: Francesetti G., Griffero T., eds. Psychopathology and Atmospheres. Neither Inside not Outside. Newcastle upon Tyne: Cambridge Scholars Publishing.
Bollas C. (2018). Meaning and Melancholia. Life in the Age of Bewilderment. London: Routledge. DOI: https://doi.org/10.4324/9781351018500
Borgna E. (1988). I conflitti del conoscere. Milan: Feltrinelli.
Bowlby J. (1969). Attachment. Attachment and Loss (vol. 1) (2nd ed.). New York: Basic Books.
Busch F.N., Sandberg L.S. (2014). Unmentalized aspects of panic and anxiety disorders. Psychodynamic Psychiatry. 42(2): 175-95. doi: 10.1521/pdps.2014.42.2.175. DOI: https://doi.org/10.1521/pdps.2014.42.2.175
Cacioppo J.T. and Patrick W. (2008). Loneliness: Human Nature and the Need for Social Connection. New York: W.W. Norton & Co.
Cannon W.B. (1920). Bodily Changes in Pain, Fear, Anger and Rage. New York: Appleton and Co.
Casey L.M., Oei T.P., Newcombe P.A. (2004). An integrated cognitive model of panic disorder: the role of positive and negative cognitions. Clin Psychol Rev. 24(5): 529-55.
Clark D.M. (1986). A cognitive approach to panic. Behav Res Ther. 24(4): 461-70.
Cox B.J., Swinson R.P., Shulman I.D., Bourdeau D. (1995). Alexithymia in panic disorder and social phobia. Compr Psychiatry. 36(3): 195-8.
Craig AD (2003). Interoception: the sense of the physiological condition of the body. Current Opinion in Neurobiology. 13, 500 DOI: https://doi.org/10.1016/S0959-4388(03)00090-4
Cucchi M., Cavadini D., Bottelli V., Riccia L., Conca V., Ronchi P., Smeraldi E. (2012). Alexithymia and anxiety sensitivity in populations at high risk for panic disorder. Compr Psychiatry. 53(6): 868-74. doi: 10.1016/j.comppsych.2012.01.005. DOI: https://doi.org/10.1016/j.comppsych.2012.01.005
Davis K.L., Panksepp J. (2011). The brain’s emotional foundations of human personality and the affective neuroscience personality scales. Neurosci. Biobehav. Rev. 35: 1946–1958. doi:10.1016/j.neubiorev.2011.04.004. DOI: https://doi.org/10.1016/j.neubiorev.2011.04.004
de Jonge P., Roest A.M., Lim C.C., Florescu S.E., Bromet E.J., Stein D.J., Scott K.M. (2016). Cross-national epidemiology of panic disorder and panic attacks in the world mental health surveys. Depression and anxiety. 33(12): 1155–1177. doi:10.1002/da.22572. DOI: https://doi.org/10.1002/da.22572
Esquivel G., Schruers K.R., Maddock R.J., Colasanti A., Griez E.J. (2010). Acids in the brain: a factor in panic? J Psychopharmacol. 24(5): 639–47.
Faravelli C., Pallanti S. (1989) Recent life events and panic disorder. Am J Psychiatry. 146:622-6. DOI: https://doi.org/10.1176/ajp.146.5.622
Feinstein J.S., Buzza C., Hurlemann R., Follmer R.L., Dahdaleh N.S., Coryell W.H., Welsh M.J., Tranel D., Wemmie J.A. (2013). Fear and panic in humans with bilateral amygdala damage. Nat Neurosci. 16(3): 270–2.
Fonagy P. and Target M. (1997). Attachment and Reflective Function: Their Role in Self-organization. Development and Psychopathology, 9(4): 679-700.
Francesetti G. (2007). Panic Attacks and Postmodernity: Gestalt Therapy Between Clinical and Social Perspectives. Milan: FrancoAngeli, 2013.
Francesetti G. (2015). From Individual Symptoms to Psychopathological Fields. Towards a Field Perspective on Clinical Human Suffering. British Gestalt Journal. 24,1: 5-19.
Francesetti G. (2019a). The Field Perspective in Clinical Practice. Towards a Theory of Therapeutic Phronesis. In: Brownell P., ed. Handbook for Theory, Research and Practice in Gestalt Therapy (2nd ed.). Newcastle upon Tyne: Cambridge Scholars Publishing.
Francesetti G. (2019b). Fundamentos de psicopatología fenomenológico-gestáltica: una introducción ligera. Madrid: Los libros del CTP.
Francesetti G. (2019c). A Clinical exploration of Atmospheres: Towards a Field-based Clinical Practice. In: Francesetti G., Griffero T., eds. Psychopathology and Atmospheres. Neither Inside not Outside. Newcastle upon Tyne: Cambridge Scholars Publishing
Francesetti G., Gecele M. and Roubal J. (2013). Gestalt Therapy in Clinical Practice. From Psychopathology to the Aesthetics of Contact. Milan: FrancoAngeli; Siracuse: Istituto di Gestalt HCC Italy Publ. Co.
Francesetti G., Griffero T., eds. (2019). Psychopathology and Atmospheres. Neither Inside not Outside. Newcastle upon Tyne: Cambridge Scholars Publishing.
Furukawa T., Watanabe N., Churchill, R. (2006). Psychotherapy plus antidepressant for panic disorder with or without agoraphobia: Systematic review. British Journal of Psychiatry. 188(4): 305-312. doi:10.1192/bjp.188.4.305. DOI: https://doi.org/10.1192/bjp.188.4.305
Gallagher M.W., Payne L.A., White K.S., Shear K.M., Woods S.W., Gorman J.M., Barlow D.H. (2013). Mechanisms of change in cognitive behavioral therapy for panic disorder: the unique effects of self-efficacy and anxiety sensitivity. Behav Res Ther. 51(11):767-77. doi: 10.1016/j.brat.2013.09.001. DOI: https://doi.org/10.1016/j.brat.2013.09.001
Giorgi A. (2009). The Descriptive Phenomenological Method in Psychology. Pittsburgh, PA Duquesne University Press.
Gorman J.M., Askanazi J., Liebowitz M.R., Fyer A.J., Stein J., Kinney J.M., Klein D.F. (1984). Response to hyperventilation in a group of patients with panic disorder. American Journal of Psychiatry. 141: 857–861.
Gorman J.M., Kent J.M., Sullivan G.M., Coplan J.D. (2000). Neuroanatomical hypothesis of panic disorder, revised. American Journal of Psychiatry. 157(4): 493-505.
Graeff F.G. (2012). New perspective on the pathophysiology of panic: merging serotonin and opioids in the periaqueductal gray. Braz J Med Biol Res. 45(4): 366–75.
Griez E.J., Colasanti A., van Diest R., Salamon E., Schruers K. (2007). Carbon dioxide inhalation induces dose-dependent and age-related negative affectivity. PLoS One. 2(10):e987.
Guidano V.F. (1991). The Self in Process. Guilford, New York
Hamm A.O., Richter J., Pané‐Farré C., Westphal D., Wittchen H.U., Vossbeck‐Elsebusch A.N., Kircher T. (2016). Panic disorder with agoraphobia from a behavioral neuroscience perspective: Applying the research principles formulated by the Research Domain Criteria (RDoC) initiative. Psychophysiology. 53(3): 312-322.
Heim E., Wegmann I., Maercker A. (2017). Cultural values and the prevalence of mental disorders in 25 countries: A secondary data analysis. Social Science & Medicine. 189: 96-104.
Iancu I., Dannon P.N., Poreh A., Lepkifker E., Grunhaus L. (2001). Alexithymia and suicidality in panic disorder. Compr Psychiatry. 42(6): 477-81.
Izci F., Gültekin B.K., Saglam S., Koc M.I., Zincir S.B., Atmaca M. (2014). Temperament, character traits, and alexithymia in patients with panic disorder. Neuropsychiatr Dis Treat. 16; 10:879-85. doi: 10.2147/NDT.S62647. DOI: https://doi.org/10.2147/NDT.S62647
Jacobs L., Hycner R., eds. (2009). Relational Approaches in Gestalt Therapy. New York: Gestalt Press.
Jaspers K. (1963). General Psychopathology (trans. from German by J. Hoenig and M.W. Hamilton). Manchester: Manchester University Press.
Joukamaa, M., Kokkonen, P., Veijola, J., Läksy, K., Karvonen, J. T., Jokelainen, J., & Järvelin, M. R. (2003). Social situation of expectant mothers and alexithymia 31 years later in their offspring: a prospective study. Psychosomatic Medicine, 65(2), 307-312. DOI: https://doi.org/10.1097/01.PSY.0000030389.53353.BC
Kaunonen M., Paivi A.K., Paunonen M., Erjanti H. (2000). Death in the Finnish family: experiences of spousal bereavement. Int J Nurs Pract. 6: 127–34.
Kessler R.C., Angermeyer M., Anthony J.C., De Graaf R.O.N., Demyttenaere K., Gasquet I., Kawakami N. (2007). Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization's World Mental Health Survey Initiative. World Psychiatry. 6(3): 168.
Klauke B., Deckert J., Reif A., Pauli P., Domschke K. (2010). Life events in panic disorder—an update on “candidate stressors”. Depression and anxiety. 27(8): 716-730.
Klein D.F, Fink M. (1962). Psychiatric reaction patterns to imipramine. American Journal of Psychiatry. 119: 432–438.
Klein D.F. (1993). False suffocation alarms, spontaneous panics, and related conditions. An integrative hypothesis. Archives of General Psychiatry. 50: 306–17.
Klein R.G. (1995). Is Panic Disorder Associated with Childhood Separation Anxiety Disorder? Clinical Neuropsychopharmacology. 18(Suppl 2): 7–14.
Kossowsky J., Pfaltz M.C., Schneider S., Taeymans J., Locher C., Gaab J. (2013). The separation anxiety hypothesis of panic disorder revisited: a metaanalysis. American Journal of Psychiatry. 170: 768-781.
Lasch C. (1978). The Culture of Narcissism: American Life in an Age of Diminishing Expectations. New York: Norton.
LeDoux J.E. (2015). Anxious: Using the Brain to Understand and Treat Fear and Anxiety. New York, NY: Viking.
Leibold N.K., Viechtbauer W., Goossens L., De Cort K., Griez E.J., Myin-Germeys I., Steinbusch H.W., van den Hove D.L., Schruers K.R. (2013). Carbon dioxide inhalation as a human experimental model of panic: the relationship between emotions and cardiovascular physiology. Biol Psychol. 94(2): 331–40.
Liebowitz M.R., Fyer A.J., Gorman J.M., Dillon D., Appleby I.L., Levy G., Anderson S., Levitt M., Palij M., Davies S.O., Klein D.F. (1984). Lactate provocation of panic attacks. I. Clinical and behavioral findings. Archives of General Psychiatry. 41: 764–770.
Lorenzini R., Sassaroli S. (1987). La paura della paura. NIS, Roma
Macaurelle R. (2003). Marital relationship and the treatment of panic disorder with agoraphobia: A critical review. Clinical Psychology Review, 2003, DOI: 10.1016/S0272-7358(02)00207-6 MacLean P.D. (1985). Brain evolution relating to family, play, and the separation call. Archives of General Psychiatry. 42: 405-417.
Majohr K.L., Leenen K., Grabe H.J., Jenewein J., Nuñez D.G., Rufer M. (2011). Alexithymia and its relationship to dissociation in patients with panic disorder. Journal of Nervous and Mental Diseases. 199(10): 773-7. doi: 10.1097/NMD.0b013e31822fcbfb. DOI: https://doi.org/10.1097/NMD.0b013e31822fcbfb
Marchesi C., Fontò S., Balista C., Cimmino C., Maggini C. (2005). Relationship between alexithymia and panic disorder: a longitudinal study to answer an open question. Psychother Psychosom. 74(1): 56-60.
Markowitz J.S., Weissman M.M., Ouellette R., Lish J.D., Klerman G.L. (1989). Quality of life in panic disorder. Archives of General Psychiatry. 46(11): 984-992.
McNally R.J., Otto M.W., Yap L., Pollack M.H., Hornig C.D. (1999). Is panic disorder linked to cognitive avoidance of threatening information? J Anxiety Disord. 13(4):335-48.
Meltzer H., Bebbington P., Dennis M.S. et al. (2013). Feelings of loneliness among adults with mental disorder. Social Psychiatry and Psychiatric Epidemiology. 48(1): 5-13. https://doi.org/10.1007/s00127-012-0515-816.
Milrod B., Leon A.C., Shear M.K. (2004). Can interpersonal loss precipitate panic disorder? American Journal of Psychiatry. 161: 758–9.
Minkowski E. (1927). Le temps vécu. Etudes phénoménologiques et psychopathologiques. Paris: Collection de l’évolution psychiatrique; Paris: PUF, 2013.
Montag C., Hahn E., Reuter M., Spinath F.M., Davis K., Panksepp J. (2016). The role of nature and nurture for individual differences in primary emotional systems: evidence from a twin study. PLoS ONE. 11:e0151405. doi:10.1371/journal.pone.0151405. DOI: https://doi.org/10.1371/journal.pone.0151405
Moreira F.A., Gobira P.H., Viana T.G., Vicente M.A., Zangrossi H., Graeff F.G. (2013). Modeling panic disorder in rodents. Cell Tissue Res. 354(1): 119-25.
Nardi A., Amrein R., Cardoso A., Dias G., Freire R., Machado S. (2016). PS247. High relapse rate after efficacious ultra-long term treatment of panic disorder with clonazepam or paroxetine. International Journal of Neuropsychopharmacology. 19(1): 90. doi:10.1093/ijnp/pyw043.247. DOI: https://doi.org/10.1093/ijnp/pyw043.247
National Institute for Health and Care Excellence (NICE) (2011). Generalised anxiety disorder and panic disorder in adults: Management. https://www.nice.org.uk/guidance/CG113.
Nelson E.E., Panksepp J. (1998). Brain substrates of infant-mother attachment: contributions of opioids, oxytocin, and norepinephrine. Neurosci Biobehav Rev. 22(3): 437-52.
Panksepp J. (1998). Affective Neuroscience: The Foundations of Human and Animal Emotions. NewYork, NY: Oxford University Press.
Panksepp J. (2004). Textbook of Biological Psychiatry. New York: Wiley.
Panksepp J., Biven L. (2012). The Archaeology of Mind: Neuroevolutionary Origins of Human Emotion. New York, NY: W.W. Norton and Company.
Papp L.A., Klein D.F., Gorman J.M. (1993). Carbon dioxide hypersensitivity, hyperventilation, and panic disorder. American Journal of Psychiatry. 150: 1149-1157.
Perls F., Hefferline R., Goodman P. (1951). Gestalt Therapy. Excitement and Growth in the Human Personality. Highland, NY: Gestalt Journal Press.
Philippson P. (2009). The Emergent Self. An Existential-Gestalt Approach. London: Karnac Books.
Pini S., Abelli M., Troisi A., Siracusano A., Cassano G.B., Shear K.M., Baldwin D. (2014). The relationships among separation anxiety disorder, adult attachment style and agoraphobia in patients with panic disorder. J Anxiety Disord. 28(8): 741-6. doi: 10.1016/j.janxdis.2014.06.010. DOI: https://doi.org/10.1016/j.janxdis.2014.06.010
Porges S.W. (2007). The polyvagal perspective. Biol Psychol. 74(2):116-43.
Porges S.W. (2011). The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication and Self-regulation. New York, NY: W.W. Norton.
Preter M., Klein D.F. (1998). Panic disorder and the suffocation false alarm theory: current state of knowledge and further implications for neurobiologic theory testing. In: Bellodi L., Perna G., eds. The Panic Respiration Connection. Milan: MDM Medical Media.
Preter M., Klein D.F. (2008). Panic, suffocation false alarms, separation anxiety and endogenous opioids. Prog Neuropsychopharmacol Biol Psychiatry. 32(3):603–12.
Preter M., Lee S.H., Petkova E., Vannucci M., Kim S., Klein D.F. (2011). Controlled cross-over study in normal subjects of naloxone-preceding-lactate infusions;respiratory and subjective responses: relationship to endogenous opioid system,suffocation false alarm theory and childhood parental loss. Psychol Med. Feb. 41(2): 385–93.
Raskin M., Peeke H.V., Dickman W., Pinsker H. (1982). Panic and generalized anxiety disorders: Developmental antecedents and precipitants. Archives of General Psychiatry. 39(6): 687-689.
Rizq R. (2002). Is there anybody there? A psychodynamic view of panic attack. British Journal of Guidance and Counselling. 30(1): 81-92. doi: 10.1080/030698880220106537. DOI: https://doi.org/10.1080/030698880220106537
Roberson-Nay R., Eaves L.J., Hettema J.M., Kendler K.S., Silberg J.L. (2012). Childhood separation anxiety disorder and adult onset panic attacks share a common genetic diathesis. Depression and Anxiety. 29(4): 320–7.
Robine J.-M., ed. (2016). Self. A Polyphony of Contemporary Gestalt Therapists. St. Romain-La-Virvée: L’Exprimerie.
Rosa H. (2010). Acceleration and Alienation. Towards a Critical Theory of Late-Modern Temporality. Aarhus: Aarhus University Press.
Roubal J. (2019). Surrender to Hope: the Therapist in the Depressed Situation. In: Francesetti G., Griffero T., eds. (2019). Psychopathology and Atmospheres. Neither Inside not Outside. Newcastle upon Tyne: Cambridge Scholars Publishing.
Rovetto F. (2003). Panico. Milan: McGraw-Hill.
Seyle H. (1956). The Stress of Life. New York: McGraw-Hill.
Shore A. N. (2003), Affect Regulation and Repair of the Self, Northon & C.
Sinha S.S., Goetz R.R., Klein D.F. (2007). Physiological and behavioral effects of naloxone and lactate in normal volunteers with relevance to the pathophysiology of panic disorder. Psychiatry Res. 15; 149(1-3): 309-14.
Schimitel F.G., De Almeida G.M., Pitol D.N., Armini R.S., Tufik S., Schenberg L.C. (2012). Evidence Of A Suffocation Alarm System Within The Periaqueductal Gray Matter Of The Rat. Neuroscience. 200: 59–73.
Spagnuolo Lobb M. (2013). The Now-for-Next in Psychotherapy. Gestalt Therapy Recounted in Post-Modern Society. Milan: FrancoAngeli.
Stern D.N. (2015). Relational Freedom. Emergent Properties of the Interpersonal Field. London and New York: Routledge. DOI: https://doi.org/10.4324/9781315765570
Strubbe G., Vanheule S. (2014). The subject in an uproar: a Lacanian perspective on panic disorder. J Am Psychoanal Assoc. 62(2): 237-66. doi: 10.1177/0003065114527616. DOI: https://doi.org/10.1177/0003065114527616
Venturello S., Barzega G., Maina G., Bogetto F. (2002). Premorbid conditions and precipitating events in early-onset panic disorder. Compr Psychiatry. 43(1): 28-36.
Roy-Byrne P.P., Geraci M., Uhde T.W. (1986). Life events and the onset of panic disorder. American Journal of Psychiatry. 143: 1424–1427.
Troisi, A., D’Argenio, A., Peracchio, F., & Petti, P. (2001). Insecure attachment and alexithymia in young men with mood symptoms. The Journal of nervous and mental disease, 189(5), 311-316. DOI: https://doi.org/10.1097/00005053-200105000-00007
Jacobs S., Hansen F., Kasl S., Ostfeld A., Berkman L., Kim K. (1990). Anxiety disorders during acute bereavement: risk and risk factors. J Clin Psychiatry. 51: 269–274.
Yang Y., Kircher T., Straube B. (2014). The neural correlates of cognitive behavioral therapy: recent progress in the investigation of patients with panic disorder. Behav Res Ther. 62: 88-96.
Wachleski C., Salum G.A., Blaya C., Kipper L., Paludo A., Salgado A.P., Manfro G.G. (2008). Harm avoidance and self-directedness as essential features of panic disorder patients. Compr Psychiatry. 49(5): 476-81. doi: 10.1016/j.comppsych.2008.03.003. DOI: https://doi.org/10.1016/j.comppsych.2008.03.003
Windmann S. (1998). Panic disorder from a monistic perspective: integrating neurobiological and psychological approaches. J Anxiety Disord. 12(5): 485-507.
Zahavi D. (2018). The Oxford Handbook of the History of Phenomenology. Oxford: Oxford University Press. DOI: https://doi.org/10.1093/oxfordhb/9780198755340.001.0001
Zou Z., Huang Y., Wang J., He Y., Min W., Chen X., Wang J., Zhou B. (2016). Association of childhood trauma and panic symptom severity in panic disorder: Exploring the mediating role of alexithymia. Journal of Affective Disorders. 206: 133-139. doi: 10.1016/j.jad.2016.07.027. DOI: https://doi.org/10.1016/j.jad.2016.07.027

How to Cite

Francesetti, G., Alcaro, A., & Settanni, M. (2020). Panic disorder: attack of fear or acute attack of solitude? Convergences between affective neuroscience and phenomenological-Gestalt perspective. Research in Psychotherapy: Psychopathology, Process and Outcome, 23(1). https://doi.org/10.4081/ripppo.2020.421

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