Panic attacks, hypochondriasis, and agoraphobia: a self-psychology formulation

The clinical and theoretical material presented points to the value of looking at the syndrome of panic attacks, hypochondriasis, and agoraphobia from a self-psychology perspective. From this vantage, the nature of the constellation of symptoms and its relationship to premorbid personality characteristics can be understood and a coherent view of the syndrome can be constructed. Phenomenologically and pathogenetically, panic attacks, hypochondriasis, and agoraphobia are related to states of self-fragmentation. Despite longstanding faulty anxiety-regulatory mechanisms, from which arises the vulnerability to self-fragmentation, a cohesive self may be formed in childhood through compensatory and defensive structures. If these structures are undermined, cohesion is lost and as the self experiences fragmentation, panic ensues. The panic state has far-reaching consequences by setting in motion a regression to a precohesive state and evoking powerful feelings as well as the need for selfobjects appropriate to that early troubled developmental period. Hypochondriasis and agoraphobia arise out of this regressed matrix: hypochondriasis as a somatic representation and elaboration on the state of self-fragmentation, and agoraphobia as a defense against and an attempt to repair self-fragmentation. Transference phenomena during the treatment of patients with the syndrome can best be understood in the light of this formulation.