Psychosocial impairment is the gravest consequence of Panic Disorder and of the psychology of anxiety in general. It is a far more distressing reality than an actual panic attack. It may last for a life-time and it is more resistant to treatment than the overt symptoms of Panic Disorder. Psychological impairment lacks the solidity and the transparency of the somatic symptom. It is not an abrupt alteration in the functioning of the patient’s body that produces surprise and fear (such as palpitations or hot flashes). It is a slowly progressive and subtly deteriorating experience that takes time to notice and that affects many areas of the patient’s live (both psychological and social). Modern diagnostic criteria do not categorize the phenomenon of psychosocial impairment as a clinical entity separate from Panic Disorder. The concept of psychosocial impairment refers to a multi-dimensional organization of psychological life that is painful to the patient and that affects his/her social functioning in an undesirable way. In other words, it can be understood as a persistent and repetitive inability to lead life according to one’s own genuine aspirations and real abilities. Its manifestations can take two forms: diagnosis-specific psychosocial impairment and generic psychosocial impairment.
Diagnosis-specific psychosocial impairment
In the diagnosis-specific psychosocial impairment, the areas of the patient’s psychological and social life that are distressing to him/her are affected directly by Panic Disorder. For example, a patient diagnosed with Panic Disorder and Agoraphobia may not be able to perform his/her daily activities outside the city areas within which the sufferer experiences emotional protection from possible panic attacks. Therefore, his/her mobility is progressively decreased and ultimately restricted to a very limited local framework as a direct consequence of the symptoms of the diagnosis. If the patient’s professional responsibilities fall outside the limits of the agoraphobic safety circle, during the active phase of the disorder, s/he may feel forced to change jobs and deplorably accept a less rewarding position, in order to avoid feeling emotionally vulnerable in his/her professional life. Therefore, the patient’s work life has been negatively and undeservedly affected not as a reflection of his/her real abilities and wishes but as a result of the nature of the diagnosis of Panic Disorder. This form of psychosocial impairment is clearly related to the clinical characteristics of the diagnosis and responds well to targeted treatments for panic Disorder: when the diagnosis is removed through therapy, the patient’s mobility slowly increases and eventually returns to normal. After a successful therapeutic intervention, all the domains of the patient’s social life which were previously endangered by the diagnosis are now not exposed to the effects of the disorder.
Generic psychosocial impairment
In the generic psychosocial impairment, the life of the patient with Panic Disorder may also be impaired in areas not directly affected by the clinical characteristics of Panic Disorder. And yet the distress experienced by the patient in these other areas may play a decisive role both in the patient’sability to respond well to therapy for Panic Disorder and in his/her ability to remain well after the end of treatment. For example, a patient may have grown up in a family in which the central parental attitude towards socialization was that new life experiences and novel social environments are inherently dangerous and that real emotional security can be experienced only within the boundaries of the familiar. The patient who has learned to think and view life in this way has also learned to react with almost automatic anxiety, if exposed to novice experiences, irrespectively of how really unsafe these experiences or environments may be. Progressively s/he instinctively avoids novelty and eventually limits himself/herself within a sad circle of psychological and social functioning. This form of avoidance and impairment is not directly associated to the clinical diagnostic criteria of Panic Disorder. It is a generic psychosocial impairment that affects a much larger area of the patient’s life, chronically informs the prodromal phase of Panic Disorder and silently increases the possibility of relapse, if not addressed during therapy. But even during the asymptomatic periods in the patients’ life, it forms the basis for a subtle, persistent and perhaps greater distress than the somatic symptoms of Panic Disorder. A meaningful treatment for Panic Disorder should not focus only on the difficulties associated with the clinical criteria of the diagnosis but should extend to carefully assessing and positively promoting the patient’s general psychosocial functioning.