Anxiety: The urge to disappear

This text is a powerful illustration of the "integrative" approach you champion—balancing the immediate crisis of a panic attack with the slow, deep work of psychoanalytic exploration.

It was 5:00 a.m. on a Monday when I woke up. I usually try not to reach for my phone the moment I open my eyes, but addiction and temptation often win. When I lit up the screen, I found seven messages from Oscar (a pseudonym). Honestly, I was startled. He had never messaged me before; he was always punctual for our weekly appointments, maintaining that respectful distance that characterizes him—and the strict clinical frame that characterizes me.

Seeing that the messages were sent between 1:45 a.m. and 4:00 a.m., it was clear he was in a state of absolute desperation. They were short phrases, almost telegrams for help: “Sorry to bother you, I can’t breathe,” “I’m so embarrassed, but it’s happening again, my heart is racing,” “I’m soaked in sweat,” “Doctor, what do I do?”

Oscar is 27 years old, a systems engineer. His story is one of those carried in silence: he lost his mother at 15, a rupture that marked the end of his adolescence. His father lives with his older sister, Susana, and her family. In therapy, we have navigated the unelaborated grief for his mother and his complex relationship with Susana, who assumed a maternal role that he appreciates but simultaneously feels as a stifling, "plastic" shadow that evaluates and suffocates him. We also spoke of his father's passivity—a man Oscar feels he lost when the father sank into melancholic mourning and drowned himself in a bottle of rum. The central theme—his reason for seeking consultation a year and a half ago—was the possibility of meeting a woman, something that had remained suspended in fantasy until Emilia appeared.

Over the last month, Oscar worked through the emotions of this real connection. He questioned his identity and his masculinity; he said he wasn't afraid of discovering he was gay, but he was afraid of feeling at a disadvantage. He wondered which psychiatric pathology he might "belong" to, feeling that his lack of experience with women was a "highly negative and pathological sign." He expressed intense feelings that oscillated between envy toward "successful" others and the idealization of a "perfect woman" who would validate him—an ideal that kept him paralyzed. It was clear that beneath this lay unconscious motivations pulling him away from his own desire.

When he arrived at the session that Monday, after spending the early hours in the ER, he was broken. He arrived with immense shame and guilt for having "lost his cool," but above all, he was terrified: “Why me? I almost died; it’s the worst thing that’s ever happened to me.”

My priority was containment. Anyone who has felt a panic attack knows it isn't "just nerves"; it is the imminent certainty of death, a traumatic experience. We did basic psychoeducation: his body was on maximum alert against an unnameable threat. We used tools from Cognitive Behavioral Therapy (CBT) to give him back some ground: when we overestimate danger and underestimate our resources, the alarm system triggers. These strategies don't cure the origin, but they restore the power to keep walking. And the technical recommendation that never hurts: a glass of water is imminent.

However, to go deeper, my gaze inevitably becomes clinical and diverse. I apologize to the "psychoanalytic or scientist police," but I believe authentically and naturally that my approach is integrative. As always, I turn to Freud, seeing anxiety as the Ego’s alert signal in the face of a repressed desire pushing to emerge (the drives, "the animal within") or a punishment from the Superego (the internalized law)—that eternal conflict between "I want" and "I must."

But it is in the Kleinian perspective where I find the most meaning for his crisis. From this stance, we do not seek to eliminate anxiety immediately. Anxiety emerges from very primitive places, acting as defenses of the soul responding to objective or subjective threats. Therefore, on the contrary: the goal is to hold it so we can work through it. A symptom that is eliminated—with or without medication—without being analyzed is a lost opportunity for growth and will return like a boomerang.

Those who have read my work know it is worth returning to Bion to explain, quite beautifully, that my labor here becomes almost artisanal: it is about taking those "Beta-elements" (the choking sensation, the surprise effect, the nameless fears, the sweat, the tachycardia) and, through the word in session, transforming them into "Alpha-elements"—something that can be thought and digested. It is giving order to chaos, giving words to what was once only physical impact. As Nancy McWilliams points out, anxiety tells us much about personality structure; in Oscar, we were navigating between the anxiety of disintegration and the moral weight of guilt.

That Monday session was unforgettable. Exhausted and scared, Oscar lowered his defenses. Authentically and spontaneously, he allowed himself a raw honesty about Susana for the first time. He began by saying how much he needed her during that night of terror and how much he resisted calling her, even though she was the one he wanted by his side at the hospital. But the mere thought of the mixture of accusations and having her "on top of him" more than ever made him choose not to tell her. He spoke of his love for her and his admiration for the strength with which she assumed care for their father and himself when she was barely 20... but he also admitted to feeling a great aversion, hatred, and anger. On one hand, he felt she made him feel small by blaming her for his feelings of being "weak and useless," creating a dependency he didn't want and didn't find necessary.

In this process, the office is a stage. At a transferential level, Oscar began to deposit in me that lost maternal figure and the persecutory sister. I became the receptacle for his fears.

And here enters my countertransference: what Oscar makes me feel. I feel a genuine affection for him mixed with a responsibility that sometimes feels heavy. I find myself wanting to "push" him out of his comfort zone, or even feeling the urge to scold him for his passivity—reactions that speak more to his dynamic with his sister than to myself. Recognizing this is my compass for understanding how he relates to the world outside.

It was the beginning of a puzzle that is still in progress, but it has shed light on what it means for him to make room for a new woman: facing love, dependency, and the terror of a loss he already knows all too well.

Today, months later, he has had other episodes. He has returned to the ER, but he no longer arrives as the victim of a strange phenomenon; he arrives as someone beginning to understand the language of his anguish. He has managed to set aside the guilt and shame that anxiety attacks bring, turning down the volume to make room for growth. That anxiety attack was an unparalleled link. Because sometimes, only when the body stops us in our tracks do we finally allow ourselves to begin piecing together the story of who we are and what we have struggled so hard to name.