Anxiety/panic attacks

[Antoine Mulpas]

Hello everyone,

I got a difficult case in the clinic today, and I would like to have another opinions on the subject.
I saw a patient today, 59, with severe anxiety and occasional panic attacks. He has thoracic oppression, sweating, feeling of passing out. He came to consult because he cannot sleep at all. He had the issue beginning few years ago, but worsening this year and since the beginning of the month it has worsen to the point he had taken a break from work.
He is under heavy medication, antidepressants etc.. But he doesn’t take sleeping pills.
Several trauma had happened to him the past few years, he lost his mother, had a big deception at work which has been processed as a failure of his professional career (last November). But the worst was a car accident in which his son was involved as the driver. His son is miraculously alive, but a passenger was killed during the crash.. The patient felt an immense fear which he has not yet accepted or managed, especially because his son had been sued for unintentional homicide and undergone a trial.
The other symptoms are gastric issues (appetite is variable, acid reflux, often he has loose stools, bloating..). He has these issues since childhood. He also sweats at night. He also has shaking of the legs and arms, especially at night.
He has no confidence in himself, completely controlled by his fear and anxiety. He doesn’t understand how he ended up there (he works at the local hospital). He is also able to cry, so he is not holding up his emotions. According to him he has no anger, sadness is present however.

I found the pulse (not really good at it) to be deep on the left side, the KI pulse was deep and thin. The LV pulse was not felt on the superficial level, and a bit deeper than the moderate level. It was tight and full. The HT pulse was very close to the radial side, not dispersing and deep. The Chi position on the right side was deep and tight, the Guan position on the right was full, tight on the superficial level. He didn’t weakened going deep. The Cun position was weak, not really getting strong when pressing down nor diffusing well.

It was after I took the pulse that something occurred. I retired to my desk to ponder about how to conduct the treatment and when I came back to the table he told me that he didn’t feel me confident and therefore he felt not comfortable. I could see that he had a panic attack on the table. I said to him that if he is not confident with me, we can end the session there without needling. As trust between us is important to work together and let him rest for a while. I didn’t needle him in the end. We discussed after for a while and he left. He told me that I am roughly the same age than his son, and it is something that is difficult for him. He also knows very well my mother for working with her and feels not conformable about it.

For the treatment part, I was thinking about Luo treatment. Bleed the BL or KI to release the fear. I was thinking bleeding BL-58 and moxa KI-3. But I didn’t see any blood vessels at the luo point, and as I am not really familiar with luo treatment, and as he was really stressed I was thinking more about a primary channel treatment. My choice would have been to work on the descending pathway of the LU channel (LU-5, LU-2, 25E, maybe KI-7) to help to accept what happened (which is very difficult for him) and help the internalisation of Qi. And maybe work on the Taiyin Sinews to help working on the same idea and work on the same time on the digestive system and release grief/sadness trapped in the Lungs.

If you have any insights on this case, it would be very helpful. He told me that he may come back when he’ll ready, and I told him that even just to talk (no needles) he can come.
Thank you!
Antoine

[Lois Nethery]

Dear Armin

Thank you for sharing this case. From my perspective, you have been exemplary as a practitioner in your listening, pondering before you act, your treatment ideas and your respect for this patient’s wellbeing. Maybe you were feeling less than confident – the Luos would have been perfect in this instance and you felt unsure to use them. The patient could feel this clearly and felt safe to communicate this to you. You are a clear channel and you can have confidence in this. Knowledge can be gained easily, don’t worry that you’re not “all there yet” with the knowledge (I say this simultaneously to myself!).

I have been doing a lot of study, practice, learning, networking and exploration around trauma these past couple of years. The body of work emerging from Western medicine is profound and works perfectly with our approach (if interested you can read/ watch Bessel van der Kolk, Peter Levine, Pat Ogden, James Gordon etc). The one piece of feedback I will give you is that talking about trauma ignites the fight-flight arousal pathway. Trauma is a repeat of stuck fear, so talking about it brings the level of arousal up, without the ability for completion and release. The talk therapy industry is just beginning to acknowledge this (neuroscience has shown it clearly). They are turning to body work for answers. We are perfectly placed to help people.

Kind regards
Lois

[Armin]

Hi Antoine,

Thanks for sharing this case and your openness about the details of your first encounter with this client. I have been in that position many times and it can certainly be frustrating because we know we can help only if they let us and get passed that initial anxiety of trusting someone with their most intimate existential challenges.

I know from personal experience that every time a client could not trust me or didn’t come back, it was really down to my own anxiety at the time of our meeting. They always sense if we feel confident about working with them or not. Over the years, I have found that especially with the anxious type clients, the simpler my approach in the first session or two, the more success I would have in seeing them again. So, something as simple as the four gates with ear Shen Men as an example, without analyzing their pathology too much in my head. Something just to relax them a bit and get them out of the fight/flight mode. Then when I see them again, which means trust has been built, I get a bit more adventurous and go a bit more in depth to address what’s going on. Later on, it could be something as simple as Pc6 and Kd 9 of yin Wei mai if that fits.

Also, I have also found that anxious people are not the best to try new things that I am learning at the time unless I can be confident about it and feel it in myself first. For instance, if I have a first time client now, I probably would not try sinew channels (it can hurt) or divergents (I don’t know enough about it). I would stick to what I would feel confident with while I practice the advanced acupuncture with my more long term clients.

Generally, I also don’t work on family, friends, neighbours that I know well, acquaintances, or friends of parents that are close. I have found that there is a bit of an awkwardness and boundary issues that it’s hard to get over, perhaps on my part or both parties. Of course, there is always exceptions and each practitioner would have to see what they are comfortable with.

Again, thanks for sharing.

[Antoine Mulpas]

Hello Lois and Armin,

Thank you both for your answers. Lois, it makes totally sense for the fight and flight answer when talking about it with the patient. I am currently reading ‘Heart Shock’ by Ross Rosen, and it talks about it very well. Also quoting Peter Levine in his book. But I’ll dig more informations about the authors you wrote about. Thanks for the references. As you said, the patient can feel when we are not sure about what to do, especially when we’re not yet accustomed to a form of treatment (such as bleeding the luos). I think it is something more prevalent with anxious people, as they have a tendency to see the world from their perspective, in which everything is uncertain. Sometimes it can be hard to not be attracted in their anxiety, at least it takes a good rooting from the practitioner to stay calm and confident!
Thanks Armin for you feedback, going for the easiest type of treatment (or at least the ones we are used to do) is a good advice. It is what I usually tend to do, but in this case my mind was really focus on the KI/BL Luos. Guess it would have be better to not overthink as you said and do for the first one something simple.
Cheers,
Antoine

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