This document summarizes the relationship between attachment, helplessness, panic, and schizophrenia. It discusses how attachment theory explains the occurrence of panic states due to feelings of helplessness caused by separation from an attachment figure. Feelings of helplessness can disrupt the development of self-consciousness and cause experiences of annihilation, derealization, and depersonalization. Disturbances in self-consciousness are central to schizophrenia and can also cause feelings of panic and helplessness. The document proposes that there is a two-way relationship between panic and imbalanced self-consciousness, with helplessness in between. This may help explain the high rates of panic disorder comorbidity in schizophrenia.

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Attachment and self-consciousness: A dynamic connection between
schizophrenia and panic q
André B. Veras a,⇑
, Antonio E. Nardi a
, Jeffrey P. Kahn b
a
Laboratory of Panic and Respiration (LabPR/UFRJ), National Institute for Translational Medicine (INCT-TM), Brazil
b
Department of Psychiatry, Weill Cornell Medical College, New York, NY, United States
a r t i c l e i n f o
Article history:
Received 21 June 2013
Accepted 22 August 2013
a b s t r a c t
Introduction: Attachment theory offers an evolutionary explanation for the occurrence of panic states.
The distance between a mother and child causes the sensation of fear. The experience of feared annihi-
lation, an intense fear reaction (panic), is presented as a threat to the individual’s cohesiveness, disrupting
the mental representation of self-consciousness, specifically self-unity. Alterations in self-consciousness
in schizophrenia are so important that they are mostly included among Kurt Schneider’s first-ranked
symptoms.
Hypotheses: Based on clinical trials, case reports, and brain imaging and pharmacological studies, a par-
adigm is proposed to explain the relationship between panic anxiety and psychosis.
Conclusion: The psychosis-anxiety pathophysiology explanation needs further investigation into the
brain areas that integrate self-monitoring with fear areas, but it seems possible to note the importance
of the anterior cingulate cortex.
Ó 2013 Elsevier Ltd. All rights reserved.
Introduction
Attachment, helplessness and panic
Attachment theory, developed by John Bowlby in his trilogy
[1–3], is based on concepts from child psychology and on etholog-
ical and observational studies of children. As a fundamental aspect,
this author offers an evolutionary explanation for the behavior of
‘‘looking for comfort and closeness’’, initially with the mother
and later with other members of the species. Such behavior acts
as a biologically instinctive system that was positively selected
for the protection of individuals in the flock. This ‘‘behavioral sys-
tem’’ is gradually developed during childhood and is regulated by
the feeling of fear (or panic). That is, the distance between a
mother and child eventually causes the sensation of fear, which
activates the search and approach system, with a consequent
return to maternal protection and gratification with a sense of
comfort. In situations in which it is impossible to regain proximity
to the mother (as in situations that have been experimentally ob-
served in primates and children left in orphanages), feelings of fear
are perpetuated. This is experienced as anguish caused by the loss
of the caregiver [1]. This loss puts the immature individual in a sit-
uation of vulnerability and a lack of guarantees about life—that is,
in the situation of a person who lacks full adaptive capabilities,
which were provided by the supportive mother. This experience
is characterized as Helplessness.
The panic reaction due to the helplessness can reach varying
intensity levels depending on innate tendencies and on regulation
acquired by living with the mother. An intense fear reaction is
known to generate a series of psychic and physical manifestations,
such as the feeling of imminent death (threat), palpitations, trem-
ors and breathlessness. This reaction is a panic state (or crisis). It is
worth noting that such states occur in panic disorder (PD) as well
as in early childhood separation anxiety (SA). SA is characterized
by the presence of excessive anxiety for the individual’s develop-
ment level involving removal from the home or attachment
figures. This anxiety is related to separation predictions, such as
considering the need to go to school or other environments, and
any other situation that could trigger this parting, such as diseases,
accidents and violence. Anxiety manifestations are also expressed
as dreams with a separation theme and as somatic symptoms
[4]. Given the review so far, it is not surprising that panic attacks
most commonly occur in children, are related to mother-infant
bonding and occur before separation anxiety [5]. Here, the item
that regulates the intensity of anxiety before the separation is
the experience of helplessness or the lack of assurance. That is,
the more the child perceives an absence of guarantee from the
bond with the mother, the greater his anxiety will be before the
separation. This ability to perceive helplessness depends on
0306-9877/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.mehy.2013.08.021
q
Grants: INCT Translational Medicine (CNPq), Brazil.
⇑ Corresponding author. Address: Panic and Respiration Laboratory, Institute of
Psychiatry, Federal University of Rio de Janeiro, INCT Translational Medicine
(CNPq), 190, Campo Grande, MS 79032-300, Brazil. Tel.: +55 67 33057371; fax: +55
67 30281008.
E-mail address: barcielaveras@hotmail.com (A.B. Veras).
Medical Hypotheses 81 (2013) 792–796
Contents lists available at ScienceDirect
Medical Hypotheses
journal homepage: www.elsevier.com/locate/mehy

3. Author's personal copy
previous linking experiences. If the mother is able to promote a
stable and comforting link with a proper balance between encour-
agement to explore and protection, the sensitivity to helplessness
is reduced. Otherwise, it is increased [1].
Thus, the relationship between attachment and panic is
established by means of helplessness through the regulation of
sensitivity to helplessness by innate and acquired factors (the
mother–child bond) (Fig. 1).
The development of self-consciousness and its changes in schizophrenia:
Kurt Schneider’s first-ranked symptoms
The consciousness of one’s self has been didactically divided in
the literature into body-consciousness and self-consciousness [6].
Despite the need for body consciousness, self-consciousness has
a connotation of wholeness, suggesting integration between the
body and the psychic life. The construction of self-consciousness
by an individual begins as soon as the individual comes into con-
tact with the outside world (i.e., at birth). This is because the fetus
not only experiences integration with the maternal body during
pregnancy but is also physically connected to it. Psychology richly
describes the development of infants’ individuation [7]. The indi-
vidual gradually passes through stages that begin with the gradual
perception of external objects: the mother’s breast, followed by the
gradual perception of one’s own body, satisfaction with this body,
manipulation of objects, identification of people who are neither
the baby nor the mother, acquisition of motor skills that allow
environment exploration, the perception of one’s own feelings,
observing the environment even in absence of the mother and
the gradual awareness of one’s own mental universe. This gradual
awareness of an autonomous mental universe cannot be consid-
ered merely a phase of child development; once the process begins,
it continues throughout an individual’s lifetime.
The development of self-consciousness is also modulated by in-
nate neurological factors and by acquired experiences arising from
the parental relationship, environmental stimulation and psycho-
logical, physical, chemical and biological aggression. The actions
of these factors on the various conscious maturation stages and
their effect on these stages are the focus of attempts to explain
the etiology of psychopathological self-consciousness phenomena.
Interference with the stages of development of self-consciousness
produces more severe psychopathologic alterations when this
damage is persistent, as in schizophrenia, or less severe alterations
when development is just delayed, as in anxiety disorders.
Alterations in self-consciousness in schizophrenia are so impor-
tant that they are included in Kurt Schneider’s first-ranked symp-
toms [8]. These symptoms include audible thoughts, hearing
voices that interfere with one’s activity, somatic passivity experi-
ences, thought withdrawal and effects that appear in the realm
of feelings and will that are created or imposed by others.
Additional symptoms, such as hearing voices in dialogue form
and delusional perceptions, although not classified as impaired
self-consciousness, show some involvement of this sphere. Even
simple auditory hallucinations, a common symptom in schizophre-
nia, arise from a disturbance in self-consciousness. The voices
heard by patients are their own thoughts ‘‘localized’’ (or projected)
into the external world. In such an experience, the patient cannot
recognize a psychic phenomenon due to the patient’s reduced
capability to be aware of what is internal and what is external.
Considering the relatively coarse self-consciousness distur-
bances observed in schizophrenia, it is natural to think that
psychic-cerebral damage occurs during the early phases of the
development of this complex mental function. Although self-con-
sciousness is predominantly developed and matured in early child-
hood, the most subtle aspects continue to evolve over an
individual’s life. The ability to distinguish between one’s own emo-
tional experience and environmental states is achieved gradually
and may prove to be ‘‘deficient’’ even among people without a
mental disorder. For example, appropriate discrimination between
an individual’s feelings exclusion and actual rejection by a group,
which is an inner experience and an external reality, is difficult
even for mature people. For some schizophrenia patients, notably
for schizophrenia of early onset which has a severe progression,
it could even be said that the complete and unequivocal distinction
between internal and external is never acquired over the lifetime.
Helplessness, panic, annihilation experience and imbalanced self-
consciousness
At the same time that helplessness makes the body respond
with fear reactions, as described in the previous discussion, a psy-
chological perspective makes an individual see himself or herself in
terms of an undeniable inefficiency and inability to address a
threatening situation. Such an experience is central to the feelings
of impending death and madness found in panic. This is the expe-
rience of one’s own imminent mental and physical annihilation by
threat of death [9]. This annihilation experience is presented as a
threat to the individual’s entirety at that moment. The annihilation
experience breaks the mental representation of the self, and the
relationship between the annihilation experience and an imbal-
ance in self-consciousness, specifically self-unity, becomes evident.
Furthermore, the experiences of loneliness, fragility and absolute
helplessness are so unbearable to an individual that he must use
the attachment resource in such a desperate and disorganized
mode to search for guarantees for the psyche and the completeness
of his own mental universe with the other, what is outside and the
environment. The panicked patient asks for help from people and
seeks a hospital, but also has an experience of strangeness about
himself and about his own body (depersonalization), which often
seems to float or to be affected by vertigo, and about other
people and the environment (derealization) [10]. Derealization
and depersonalization are psychopathological manifestations of
Attachment
Bound
Separation
Unbound
Comfort Panic
Helplessness
Innate
Tendencies
Acquired
Experiences
External Factors
Fig. 1. Schematic explanation of the relationship between attachment, helplessness and panic.
A.B. Veras et al. / Medical Hypotheses 81 (2013) 792–796 793

4. Author's personal copy
consciousness arising from the experience of the annihilation of
self-unity [9,11] (Fig. 2).
In contrast to what was described above, there is also a contri-
bution of psychopathological experiences of self-consciousness to
the occurrence of panic. The maturation of self-awareness allows
the individual to more clearly identify an internal event and an
external event. This notion is fundamental to an individual’s rela-
tionship with the environment. Based on protective self-delinea-
tion (self-sufficiency), the encouragement of exploitation
becomes possible. When an individual is faced with his or her
insufficiency and incompleteness, these senses emerge in a fear
sensation. In the case of psychopathological experiences of self-
consciousness, which are central to schizophrenia [8], this experi-
ence of insufficiency and incompleteness is presented as impera-
tive and spontaneous. Becoming aware of one’s lack of control
over the body (self-activity disturbance), the thoughts (self-world
opposition disturbance) or the unit itself naturally arouses feelings
of fear and failure as well as a lack of definition and a lack of guar-
antees (helplessness). For these reasons, psychopathologic self-
consciousness disturbances are experienced with such anxiety by
patients that they often become panic [12]. Furthermore, patients
resort to defense resources to address this anguish, placing their
thoughts (hallucinations) or the fear of threat and annihilation
(delusion) on the external world.
Given the above, a two-way path is identified between panic
and imbalanced self-consciousness, with helplessness located be-
tween these two experiences. This evidence does not propose a
continuum or spectrum between panic disorder and schizophrenia.
At present, the etiologies of each of these disorders are considered
quite distinct unless we consider a psychotic version of panic dis-
order using an evolutionary theory, where schizophrenia is severe
panic in combination with reduced frontal lobe consciousness [13].
The element to be extracted from the exposition of this relation-
ship is the succession of mental events, or the understanding of
the psychodynamics. These disorders may share the symptoms’
pathological dynamics, which in both cases lead to a downward
spiral of illness (Fig. 3). In the case of panic disorder, the spiral be-
gins with the experience of helplessness, whereas in the case of
schizophrenia, it begins with the imbalance of self-consciousness.
Schizophrenia and panic
The relationship between anxiety and psychosis has not been
discussed widely in the literature compared to other themes, such
as the relationship between psychosis and mood disorders. Among
patients with schizophrenia, studies have observed a prevalence of
20–30% with comorbid panic [14–16]. This anxious event is related
to the disease’s onset in the prodromal phase of schizophrenia
when vague anxiety, somatic and cognitive symptoms are predom-
inant [17–21]. However, another relationship to the occurrence of
panic after the course of the disease has been established and
involves the existence of paroxysmal anxiety concomitant with
auditory hallucinations and delusions [20]. A recent meta-analysis
identified a 9.8% average prevalence of panic disorder co-occur-
rence in individuals with established schizophrenia [22], whereas
in the general population, the prevalence is 1.2% [23]. An interest-
ing relationship involves the increased risk of panic disorder in
schizophrenic patients’ first-degree relatives [18]. Studies that
characterize schizophrenia into a ‘‘panic-psychosis’’ subtype are
of particular interest. Kahn et al. [17] examined patients with
schizophrenia who had current panic disorder [24–26]. In seven
such patients, panic and psychotic symptoms (both positive and
negative) all improved in response to the addition of alprazolam
[17]. Eight subjects with schizophrenia and auditory hallucinations
(without previously assessed panic or anxiety history) had panic
triggered by the 35% CO2 challenge test [27]. All of these patients
also had panic anxiety as determined by the specialized Panic
and Schizophrenia Interview (PaSI). Schizophrenia with panic is
associated with a less impaired cognitive profile, possibly because
less impaired patients are more able to report panic symptoms
[28]. Because panic may be concurrent with psychotic symptoms
in ‘‘panic-psychosis’’, conventional assessments of panic in schizo-
phrenia may considerably underestimate its true prevalence.
Among these patients’ most relevant clinical aspects are panic
attacks with paroxysmal occurrence accompanied by the abrupt
onset of auditory hallucinations or delusions as well as more fre-
quent occurrence of positive symptoms and a greater preservation
of cognition and morbidity awareness. That is, the detection of
these clinical features shows that some patients who are in posses-
sion of greater global cognitive ability are able to perceive their
own involvement with a disease and to identify and name their
psychopathological changes. The questionnaires present a higher
score for positive symptoms that are only identified when they
are reported by patients, resulting in greater distress at the time
of the symptom’s occurrence (Fig. 3).
Ulas et al. used the PANSS and observed a higher intensity of
positive symptoms among patients with schizophrenia with panic
attacks in 2007 [24] and an insignificant difference in the intensity
of positive symptoms in a similar group in 2010 [29]. Higuchi et al.
[30] also found no relationship between panic attacks and positive
symptoms of PANSS using quantitative analysis only. The authors
who came closest to a qualitative analysis using the PANSS were
Lysaker and Salyers [25]. These authors found a positive correla-
tion between hallucinations and panic symptoms (0.27), social
anxiety (0.29) and frightening concerns (0.25) and a greater occur-
rence of hallucinations in the group of patients with schizophrenia
with severe anxiety. However, neither the type of hallucination nor
the quality of other psychotic symptoms, such as delusions, were
specified. Despite small sample sizes and a lack of comparison
groups, other authors have observed a relationship between audi-
tory hallucinations and panic attacks [20,27]. The relationship be-
tween the quality of delusions and panic attacks were found in
Panic
ANS Activation Annihilation
Experience
Self-Unity
Breaking
Imminent Death
Madness
Depersonalizatin
Derealization
Fig. 2. Schematic explanation of the damages to self-consciousness in a panic crisis.
ANS: autonomic nervous system.
Helplessness
Panic
Self -
consciousness
Fig. 3. Spiral of succession of symptoms linking panic and psychosis.
794 A.B. Veras et al. / Medical Hypotheses 81 (2013) 792–796

5. Author's personal copy
only one case report by Bermanzohn et al. [31]. In that case, the pa-
tient presented delusional perceptions, which are included among
the Schneiderian first-ranked symptoms, including the delusion
that his sexual organs would be cut, thus experiencing a threat
to body integrity. Although Bayle et al. [26] did not specify the
delusions and hallucinations observed, these authors identified
the occurrence of panic attacks in 19 out of a sample of 40 patients.
In 7 patients, the panic attacks were spontaneous, and the other 12
cases were triggered by positive symptoms, thereby distinguishing
two clinical situations. In this last study, the quality of psychotic
symptoms was not evaluated.
There is a gap in the literature on the relationship between po-
sitive symptoms in schizophrenia and panic attacks. This relation-
ship has not been identified in studies that have gone beyond a
simplistic evaluation of delusions or auditory hallucinations. Fur-
ther characterization of these experiences is necessary because
some types of delusions or hallucinations may present more in-
tense anxiogenic potential, especially experiences in which there
is a greater effect on self-awareness.
First-ranked symptoms and brain activity
In healthy subjects, the unconscious self-monitoring function
depends on the integrated action of certain brain areas. Imaging
studies using PET and fMRI identified the importance of speech
areas (Broca and Wernicke) and the cingulate cortex, particularly
the anterior region (anterior cingulate cortex), for monitoring one’s
thoughts and the importance of the cerebellar areas and the right
inferior parietal lobe on the perceptions of one’s actions [32–36].
Patients with schizophrenia with the Schneiderian first-ranked
symptoms have higher parietal and cingulate cortex activity com-
pared to normal controls or patients with schizophrenia without
delusions of passivity experiences [37]. This cortical hyperactivity
decreases after psychopharmacotherapy accompanied by an
improvement in first-ranked symptoms. This finding was not ob-
served among patients with schizophrenia without first-ranked
symptoms in the group that also received antipsychotic treatment
[37]. From an anatomical perspective, another study found reduced
gray matter volume in areas such as the cingulate cortex and
amygdala and established a correlation between a higher intensity
of Schneiderian symptoms and reduced cortical volume in the right
posterior cingulate and left parahippocampal regions [38]. In a
study combining psychological testing for speech recognition and
fMRI, hyperactivity directly proportional to the intensity of symp-
toms in the lower region of the right parietal lobe was observed
among patients with schizophrenia with positive symptoms, sug-
gesting overactivity in this area as a marker for symptom intensity
and hyperactivity in the anterior cingulate cortex as a trait marker
of the disease [36].
In short, patients with schizophrenia, especially those with
more symptoms related to the breakdown of self-consciousness,
exhibit diminished neurodevelopment of some structures [38]
resulting in neuronal activity non-differentiation in the evaluation
of situations of internal or external stimuli [36,37]. That is, patients
maintain hyperactive self-monitoring areas regardless of the origin
of the stimulus, which leads to a loss of the ability to distinguish an
internal experience from an external stimulus. This occurs because
the brain activation pattern is similar in both situations [39].
First-ranked symptoms and the fear circuit
It seems that the common neuroanatomical structure between
first-ranked symptoms in schizophrenia and panic is the anterior
cingulate cortex (ACC). The ACC is part of the limbic system and
participates in affective reactions, but the ACC has also been impli-
cated in cognitive functions, such as behavioral self-monitoring
[40,41]. Although the dorsal region of the ACC performs cognitive
functions, its ventral portion is involved in the regulation of emo-
tional responses [40]. The dorsal ACC has interconnections with the
lateral prefrontal cortex, the superior parietal cortex (spatial loca-
tion function) and the frontal premotor areas [40]. The ventral ACC
maintains interconnections with the amygdala, periaqueductal
gray matter, nucleus accumbens, hypothalamus, anterior insula,
hippocampus and orbitofrontal cortex and sends projections to
the autonomic and endocrine systems [40]. Most of these struc-
tures are directly linked to the fear circuit [42], particularly the
amygdala, hypothalamus and periaqueductal gray matter [41]. Be-
cause patients with schizophrenia with first-ranked symptoms
have a tendency to exhibit ACC hyperactivity, it is not surprising
that there is a greater tendency to activate the fight or flight re-
sponses in the early stages of the disease or among patients char-
acterized as having ‘‘panic-psychosis’’.
Marijuana, panic and schizophrenia
The use of marijuana is related to the precipitation of acute
panic attacks [42] as well as an increased risk of panic disorder on-
set [43,44]. Likewise, the effects of cannabis can cause psychotic
symptoms [45], and early exposure to the substance anticipates
the onset of schizophrenia [45,46].
Except for cannabidiol, cannabinoids act as agonists at specific
receptors (CB). The receptor CB1 is present in high concentrations
in nervous structures such as the basal ganglia, the prefrontal cor-
tex, the hippocampus and the ACC [47]. This distribution causes in-
creased resting activity in the prefrontal, insular and ACC cortex
among individuals who are acutely exposed to marijuana or THC
[48]. In investigations that combine functional imaging studies
with cognitive tests, greater activity has been observed in the brain
areas that are necessary to perform a given task among individuals
under the influence of cannabinoids [49]. This suggests an in-
creased need for the brain to compensate for the lower quality of
processing in the affected structures [50]. The use of marijuana
by patients who have a deficiency in ACC development, requiring
greater ACC excitation to compensate for their qualititative deficit,
generates an intense hyperexcitability of a structure that is associ-
ated with first-ranked symptoms and with the occurrence of panic
attacks. This may be why the use of cannabis in schizophrenia is
associated with an increased occurrence of psychotic symptoms
and a greater number of relapses [51,52]. For panic disorder, there
is a temporal link between marijuana use and the occurrence of a
first attack [53]. This link is not observed in studies that have
examined the impact of continued use of marijuana on the evolu-
tion and prognosis of panic disorder.
Conclusion
The relationship between first-ranked symptoms of schizophre-
nia and panic attacks is evidenced by both psychopathological
observations and neurobiological evidence. The proximity between
the psychological functions of self-consciousness and affectivity
narrows in anxiety cases, especially for panic attacks. This is be-
cause anxiety attacks affect self-consciousness and because patho-
logical changes in the psyche are particularly anxiety producing.
Between panic and psychosis is the annihilation experience, and
between psychosis and panic is the helplessness experience. The
importance of identifying these relationships is explained by the
existence of the common co-occurrence of psychosis and anxiety
and by the significant increase in the severity of such conditions.
A proper understanding of the psychic phenomena involved allows
for a well-structured psychotherapeutic strategy. Additionally,
A.B. Veras et al. / Medical Hypotheses 81 (2013) 792–796 795

6. Author's personal copy
understanding of the pathophysiology of psychosis-anxiety allows
for a more comprehensive and effective biological approach. This
exploitation of pathophysiology requires further investigation of
the brain areas that integrate self-monitoring and fear, but it seems
possible to identify the importance of the ACC. Through the analy-
sis of this structure, the intense association between mood regula-
tion and cognitive self-consciousness function can be observed in a
concrete way rather than only in a metaphysical way.
Limitations
This is not a systematic review. The methodology did not allow
for the review of all of the studies in the field. Studies of panic,
first-ranked symptoms and cannabis using functional imaging are
scarce in the literature. Only the initial findings on the topic were
presented in this article.
Conflict of interest statement
None.
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