Arnold Wilson, PhD - Endometrial Panic: A Psychobiological Phenomenon

Hello, friends, Collins. I'm very delighted to have been invited to speak. I confess that I am impressed, verging on in awe of the research that has been spoken to today. I come with no RCTs. And the closest thing that I have to being a carrier of significant data is that I have spent tens of thousands of hours talking with women who have endometriosis, listening to them, hypothesizing what's going on and trying to help them. You folks are the generals. I'm a foot soldier. I live in the trenches and I am going to try today to bring you with me into the trenches, particularly the young people here, the postdocs, the residents. I'm going to try to convince you that there's such a thing as endometrial panic and that every woman who has endometriosis must be screened for panic.

I'm going to take you at first on a very, very quick and brief passage through what panic disorder looks like circa 2026 in American psychiatry. In the DSM, which is an empire, there is no subtyping of panic disorder. There's just generic panic disorder. But researchers have done a lot of work subtyping panic disorders. It just hasn't made its way into the Bible yet. And perhaps it never will because the Bible is collapsing and we're moving into a new world where neurobiological phenomena, brain behavior relationships are going to be the diagnostic imprimaturs, not the phenomenology of symptoms.

So let's go. I'm going to rifle right through this so that we can get it behind us because this is not really what I want to talk about. One broad category is called respiratory and somatic subtypes of panic disorder. And it's best identified with something called the CO2 challenge, the carbon dioxide challenge. This part will perhaps bring the physicians here back into your psychiatric rotations when you were young and had to go through your psychiatric rotations. So please forgive me if I'm just stirring up old Denvers. A second category of disorders in the research literature in clinical psychology and psychiatry, nocturnal panic disorders. And that's where people just wake up in the middle of the night in state of panic.

Somatic symptom clusters by organ system. And you have cardiac vestibular GI-based panic subtypes that has yielded a great deal of interesting research in panic. There's cognitive versus autonomic, non-fearful panic. And here what you've got is your fears of going crazy, fears of losing control, catastrophic thoughts. I'm sure you've all seen many examples of this. And then there's a bundle of research on clinical progression, and that's where panic is looked at in four stages, stage one, two, three, and four. And in type one, you've got your single isolated panic attack, type two and so on and so forth. You can read the screen, and I'm not so interested in you taking all this information home with you. The treatment strategies by subtype, a lot of the treatment strategies in contemporary psychiatry are primarily pharmacologic. And the type of therapies, the type of talk treatments are primarily cognitive behavioral.

And each of the subtypes of panic has been gussied up and refined according to different ways in which cognitive behavioral strategies can be implemented. I'm going to just keep going. I'm rifling past the clonazepam and the SSRIs and all of that because I presume that you all know about it and have prescribed these things. Most of the prescriptions of SSRIs and SNRIs are pretty much helpful in all kinds of panic. And so you can't really go so wrong with it, but you're not going to write with it either. It's like throwing mud at a wall. Sometimes the mud sticks and sometimes it doesn't. And there's very little precision in terms of the prescription of SNRIs and SSRIs for patients with panic.

I'm going to just skip right through this and I'm going to also skip through the clinical progression and the subtypes. Okay. And that's going to bring us to a researcher and theorist whose name is Yak Panksep. Panksep is an Estonian theorist who has founded the school, which is called affective neuroscience or affective neurobiology. And briefly, Pancept's models are clusters of signs, symptoms, emotions, all of which are subcortical. Now that's important because subcortical psychological phenomena usually can be compared to unconscious processes, but not conscious thought processes. And each one of his seven systems have distinctive brain locations, brain loci, neural pathways. And in particular, I'm going to be concerned with you about two of panccept systems, what he calls the fear system and what he calls the panic system. Okay? Fear and panic. Panic system, he sometimes calls the panic grief system.

Why psychotherapy is biological medicine? Good grief. The panic system is naturally regulated by the brain's own opioids, oxytocin, and prolactin. And in endometriosis, this system often becomes dysregulated. The fear system is very different, involves different brain areas, and effective treatment involves more than just psychopharmacology, but these are discreet systems and both are in play all the time. However, one of them may predominate over the other. This part of my talk is going to be redundant because all of the people who preceded me have already gone through these matters, the psychosocial landscape of panic in endometriosis. Now, what I'm going to be getting at here is that endometrial panic is different, qualitatively different than the panic that we see in panic attacks or panic disorders. It wasn't until after listening to hundreds, hundreds of women with endometriosis that ... I'm slow, you've got to forgive me.

It finally dawned on me that these are not panic attacks, but they're going through. So it got much easier for me to conceptualize my way forward when I realized that there was something entirely different from a panic disorder or a panic attack, although that's the patois that most women who have endometriosis have to live with. They have to be subject to the diagnostics of having panic attacks, and usually their "panic attacks" are anomalous.

Okay, so impact on quality of life, we know that the weight of stress. Did you know that many women with endometriosis who have solved the problem of pelvic pain, the moment they're stressed, re-experience pelvic pain, and then the moment the stress dies down, the pelvic pain goes away again, and many women can learn that I am being stressed when my pelvic pain flares up, and when my pelvic pain is not present, that means things are good. You all know about all the health associations, all the researchers today have gone through them and told you about those, you know about medical traumas, how many women have had untold numbers of surgeries and grief, and have learned to hate doctors, and have felt misdiagnosed, and have felt that they have no ... In the world of medicine, they have no place, because there just doesn't seem to be categories that work for them, and they have to ... It's like a reverse procrustian bed.

They bend for the categories rather than the categories bending for them.

You've heard all of this today about the pathophysiologies, the inflammation you know about hormonal imbalances, neurotransmitters. We've heard a lot about that today. The gut-brain axis. Now, what's important about all of these things is that they're all different in women who have panic, endometrial panic, than people who have panic disorders. People of panic disorders don't have any of these things. So if endometriosis is, as many of the researchers today have suggested, a multifactorial phenomena, and it represents the intersection of many different and converging lines of psychological, physiological dysfunction, then it's important to keep all of those things in mind. These are all impacting the panic system of pancreat.

Genetics you know about. Okay. What you don't know about is what women have told me about, and these are factors that are in ... I'm calling them depth psychological factors. And parenthetically, we haven't really tackled them today. There's been illusions to them all day, but they have not really been tackled and I'm now going to try to brainwash you, particularly all those magnificent young postdocs and residents and the future of our field. I want to brainwash you to believe in the hegemony of the depth psychological factors and make sure that as you move on in the field, you have these in your mind. And that's for both researchers as well as clinicians.

Can I go back? Okay. Yeah. To be understood or not understood. Most women who have endometriosis are tremendously agitated about the fact that nobody has ever really understood them. They have been told that their mutants, they've been told that they are people carrying factitious disorders. They've been told that all you've got to do is grit your teeth and gut it out. There's nothing worse if you're a patient, nothing worse than being told all you have to do is grit your teeth and gut it out. I see what I'm calling depression pain cycles, where the presence of depression increases the amount of pain, the amount of pain increases the depression, and it's very, very difficult for a woman with endometriosis to pull herself out of those cycles. And it's the job of everybody who has hands-on exposure to these women to learn how to do that.

There is a phenomena in clinical psychology, which is called dissociation. You've probably heard about it. You may not know it when you see it, but dissociation is when your mind basically shuts down and rather than having a vertical split, as is the case with repression, you have a horizontal split in which your mind takes shards of the world and just pushes them to the side, but they're not repressed. They're still there. And so you have a fracturing of your lived experience and many women survive, particularly that horrific week before the onset of the menstrual flow, survive by retreating into what I've called the psychic dead zone, where they just shut down and retreat.

There's enormous amounts of guilt and depression that are present. How many women have told me they feel responsible for their illness? How many women have said that it's their fault and how important is it for us to be able to convey to them that there is no fault, there is no blame, there is a medical illness with psychological sequelae, and this is one of the psychological sequelae that is drawing on an unconscious factor. Now, this is one that is most important in terms of depth psychological factors. Women who have endometriosis have enormous transferences to their physicians.

Many women sleep, dream, think about, fantasize about their surgeons, their gynecological surgeons. The gynecological surgeons can range anywhere from being heroes, coming down from Mount Olympus to save them, to being devils who are trying to insert themselves into their bodies. That has to be explored with ... It has an enormous impact on recovery, and it's not a healthy medical state to immunize oneself against the patient's fantasies about you. And it's very easy to exploit a patient's, an endometriosis woman's transference to you as a godlike figure. And with the idea that somehow, if you accompany them on this journey through this terrible disease, that you will both end up in a place that is wonderful and beautiful, it's not like that. The place that most women end up with, women who have endometriosis is not usually so wonderful and beautiful. Oh, and the other thing too, and again, this is for the youngsters here, is you have to be aware of your own countertransferences to your patient, the way in which you like them, dislike them, resent them.

Okay. And then of course, there's the whole issue of sexuality. Women who have endometriosis, if you don't know by now that they have enormous conflicts about their sexuality and that this disease just paralyzes these things, and they live in a state of panic about what's going to happen to them. The last factor that I'm going to discuss is what it really means to recover. There seems to be an assumption, and the assumption is that if you can perform an endometriosis surgery properly and get someone out of the hell of endometriosis, then everything is going to be okay. It's not like that.

People don't work like that. When I was a postdoc about half a century ago, we used to discuss whether or not masochism is a universal phenomena in all people, an unconscious phenomena in all people, and that went on for months and months. And of course, we were just twiddling our thumbs, but there is a very real attachment to pain and recovering from endometriosis is not an uncomplicated business. At Sloan Kettering, where I was an attending for years, services were provided to survivors of cancer, people who had survived cancer surgery. We need to adopt a model that's something like that, that when a woman is recovering from endometriosis, we need to be able to have some place that we can refer them to and help them with all the conflicts and all the difficulties around realizing their dreams of reaching the promised land and finding out that it's not everything they had hoped.

Okay, this is my last slide. So it's an excerpt from the abstract of a manuscript by Wilson and ... Who's that other guy? Seshkind that is published 2026. The American Psychological Association was kind enough to make this manuscript part of what they call their online program, which means it is a free download for over 100,000 practicing psychologists in the United States. So that's not bad, folks. We're doing pretty good getting the word out. I'm going to read this quick excerpt. "The optimal treatment of endometriosis requires a dual focus on biological excision and deep psychological repair. The collaborative model advanced here offers a vital exportable framework for integrated care, ensuring that recovery encompasses both physical health and psychological wellbeing. "I'm going to stop here before someone tells me I have to stop. I