Panic Attacks in Halacha

Ki-Tavo 5780

And among those nations you will not be tranquil, there will be no rest for the sole of your foot; there Hashem will give you a trembling heart, longing of eyes, and suffering of soul. Your life will hang in the balance, and you will be frightened night and day, and you will not be sure of your survival. (Devarim 28:65-66)

In this week’s essay, we will examine the Halachic status of “Charada” (panic or fright). In general, the discussions of Hilchos Refua revolve around Refuas haGuf (physical health) and there is far less discussion of Refuas haNefesh (mental health). Although we cannot possibly cover the entire gamut of Halachos pertaining to mental health, we will examine two basic questions:

1. How does the Halacha view an Aveira that was committed during a panic attack?
2. When can one violate Issurim in order to prevent or treat a panic attack?

The first question is easier to answer than the second. The degree to which a person is culpable for his actions depends on whether he was truly in a state of Ones (“coerced” by his feelings of panic) or not. Only Hashem knows whether he truly had no control of his actions or could have handled the situation differently and found another way to deal with his panic.

For example, if a person switches on a light on Shabbos in a fit of panic – if he had been so desperate that it felt like he had no choice but to switch on the light, then it would be an Ones and would not require atonement.

There are a number of sources in Chaza”l that are relevant to this discussion.

The Mishna in Shabbos (29b) states:

If a person extinguishes a lamp because he fears gentiles [who have forbidden people to light candles], bandits [whom he doesn’t want to discover his hiding place], melancholia [for whom the darkness will sooth his feelings of depression], or so that a sick person can fall asleep, he is exempt.

The Gemara (ibid. 30a) explains that when the Mishna exempts a person who extinguished a lamp “so that a sick person can fall asleep”, it refers to somebody who was dangerously ill. Therefore, not only is he exempt for having done so, it was even permitted for him to have done so in the first instance[1].

The majority of Rishonim maintain that the same is true of the other examples in the Mishna – they too are cases of Pikuach Nefesh and extinguishing the lamp is permitted. However, the Rambam (Pirush haMishnayos) holds that in those cases, while the person is exempt for extinguishing the lamp, it was forbidden for him to do in the first instance (“Patur Aval Assur”).

The commentaries ask that the Rambam’s position appears to be contradictory. If the Mishna does not refer to a situation of Pikuach Nefesh then the person who extinguished the lamp should not be exempt. If it is a case of Pikuach Nefesh then he should have been permitted to do so in the first instance. Why should it be Patur Aval Assur?

The simplest approach (see the Harchev Davar, Shemos) is to say that, according to the Rambam, the Mishna is not referring to a true case of Sakana. The person who extinguished the lamp was frightened, mistakenly believing that he was endangered. Therefore, the basic Halacha is that it is forbidden for him to extinguish the lamp. Nevertheless, if he did not overcome his fear and extinguished it, he is exempt his fright created a situation of Ones.

The other Rishonim may well agree that an act performed out of fright is considered an Ones. The reason they did not explain the Mishna like the Rambam is because they found it preferable to explain that all four cases of the Mishna are Patur u’Mutar, whereas, according to the Rambam, the first three cases are Patur Aval Assur and the final case is Patur u’Mutar.[2]

Although we have proven that a person who transgresses a prohibition out of fright is considered Anus, this doesn’t necessarily mean that he should be considered a Shoteh (who is exempt from all of the Mitzvos). In fact, even somebody who regularly suffers from panic attacks is not considered a Shoteh. This can be proven from the Gemara in Chagiga 3b-4a:

The Rabbis taught: Who is a Shoteh? Somebody who goes out [of the city] alone at night, somebody who sleeps overnight in a cemetery, and somebody who tears his clothes.

It was stated: R’ Huna said: [He is not considered a Shoteh] unless he does each of these three acts. R’ Yochanan said: Even one of them [on one occasion] is sufficient. What are the circumstances? If he did these acts in a manner of a Shoteh [i.e. there is no rational explanation for them] then even one of them [should be sufficient to render him a Shoteh if he does it three times[3]]. And if he did not do these acts in the manner of a Shoteh [i.e. there is a rational explanation for them], then even if he did all of them he should not [be considered a Shoteh]!

[The Gemara answers]: In fact we are discussing a case where he did act in the manner of a Shoteh. [Nevertheless, Rav Huna still held that he cannot be considered a Shoteh unless he does each of the three acts because each of them, in isolation, can be justified:] Somebody who sleeps in a cemetery – one could say that he intends for an evil spirit to rest upon him. Somebody who goes out alone at night – one could say that he has been seized by Gandrifas [see below]. Somebody who tears his clothes – one could say that he is a person of [deep] thoughts [and he tore his clothes absentmindedly]. However, once he performs each of the three acts he is akin to an ox that gores another ox, a donkey and camel. [The Halacha is that the ox] becomes a “Mu’ad” for all of these species[4].

What is Gandrifas? Rashi explains that it is an illness that is caused by worrying or anxiety (”De’aga”). This may be the cause of this person wandering alone at night.

We may infer from this Gemara (see Tosfos ad. loc.) that if a person is beset by worry (which may well be similar to a panic attack) and wanders alone at night, he is not considered a Shoteh according to R’ Huna, even if it is a recurrent behavior. We see that a senseless act performed out of panic does not confer the status of Shoteh. When a person behaves irrationally (e.g. out of panic or fright), his behavior cannot be attributed to an absolute lack of intellectual capacity but to a temporary disability which causes him to lose control of himself and the ability to act rationally. Overall, however, he retains his status of Bar Da’as (person of intellect). [5]

Turning to the second, more challenging question: When can one violate Issurim in order to prevent or treat a panic attack? For instance, can a psychologist or psychiatrist answer a telephone call on Shabbos from a patient known to experience frequent panic attacks?

Interestingly, Halacha appears to consider Charada as a greater danger to life than the conventional medical view. From a medical perspective, a panic attack does not endanger a person’s health[6] unless he has other medical or mental health conditions that may be exacerbated. However, there are sources in Halacha that imply that panic or fear can lead to death.[7]

Patients whose lives are in danger due to existing conditions are certainly considered to be at risk if they are startled or frightened. This is clearly referenced in the Gemara in Shabbos 128b and Shulchan Aruch O.C. 330:1 that permit lighting a candle on Shabbos to assuage the fear of a Yoledes (woman giving birth) who fears that her treatment will be compromised due to the darkness. One may do so even if her fears have no medical basis and even if she is blind! Moreover, one needn’t even consult a medical expert, which is quite unlike the Halacha of a person who is sick on Yom Kippur which dictates that we consult a doctor to decide whether the patient should be permitted to eat. Tosfos (ad. loc.) explain that this is because “a Yoledes is more likely to be endangered by fear… than a sick person will be endangered by hunger.”

This is also explicitly stated by the Bi‘ur Halacha (328) who discusses desecrating Shabbos on account of a patient who claims that it is necessary when his physician disagrees. The Halacha is that that one pays no heed to the patient “unless there is a concern that he will lose his mind when he sees that they are paying no attention to him.”

Clearly, fear can be a cause of death for those who are dangerously ill. However, this is not necessarily true of somebody who is physically well.

The Gemara in Yoma (84b) cites a Beraisa:

The Rabbis taught: One may engage in Pikuach Nefesh on Shabbos, and somebody who does so with alacrity is praiseworthy, and he needn’t seek permission from Beis Din. How so? … If he sees that a child is locked behind a door, he may break it down to extricate the child.

Rashi adds: “If a door is locked – and the child is startled” – in other words, if the child is frightened or startled, it is a matter of Pikuach Nefesh to extricate him from the locked room. Many Acharonim contend that according to Rashi one may only desecrate Shabbos and break the door down if the child is frightened. If the child is calm at that moment, there is no basis for desecrating Shabbos, even if one fears that the child will suddenly become frightened.

The Gemara explains that the Chidush of the Beraisa is that one is not obliged to attempt to calm the child by other means and may break down the door immediately. This also supports the conclusion that one may only desecrate Shabbos if the child is already frightened, for otherwise the Gemara should have said that the Beraisa conveys a much greater Chidush[8] that one may even break the door down if the child is calm at that moment!

Other Rishonim[9] who cite this Halacha also imply that one may only break the door if the child is frightened. They write, “A child who is crying inside a house – one may break down the door and extricate him” which implies that the child is already fearful. However, the Rambam (Hilchos Shabbos 2:17, quoted by the Magen Avraham and Mishna Berura 328:13) appears to differ:

If a door is locked in front of a child, one may break the door and extricate him, lest the child be startled and die.

According to the Rambam, one is justified in breaking down the door in case the child becomes fearful. The same is implied by other Rishonim.

Does this ruling only apply to a small child? R’ Yaakov Emden (Mor u’Ketzia on the Shulchan Aruch ibid.) rules that it applies to any child who “needs his mother”, which is below the age of six[10]. However, if there is any concern that a child of an older age will be extremely frightened, “One should be lenient in [these] matters that may be a matter of Pikuach Nefesh”.

Rav Wosner zt”l (Shevet haLevi 8:75) maintains that this Halacha also applies to older children:

Nevertheless there is some doubt if this only applies to Tinokos, which is the example of the Gemara, in other words, very young children, or even to older children. There is room to make a distinction in this regard and require that they [older children] actually feel frightened, as Rashi holds, and not [extricate them due to the concern] that they may become frightened if they are not yet frightened.

According to Rav Wosner, even if this Halacha is applicable to older children, we do not desecrate Shabbos unless the child is frightened. Although he notes (earlier in the Teshuva) that the Magen Avraham and Mishna Berura quote the Rambam who does not require that the child must actually be frightened in order to justify desecrating Shabbos, we are still only lenient to that degree for very young children.

Rav Wosner continues:

We learn from this Halacha that feeling greatly frightened may be a matter of Pikuach Nefesh. It is obvious that this is also true of adults. We find a number of accounts in Chaza”l which portray how abrupt emotional reactions can cause a person’s death. Therefore, although a locked door is not a cause of fright for adults, in other cases where there are the signs that an adult is greatly frightened, it is a Mitzva to desecrate Shabbos on his account.

Rav Shlomo Zalman Auerbach zt”l (Minchas Shlomo 1:7) appears to differ:

If a person is enormously wealthy and a fire breaks out in his estate, though extinguishing it would only be a Melacha she’Eina Tzricha leGufa, it is nevertheless forbidden. Though his distress at seeing the fire devour his estate is profound, for in one instant he goes from enormous wealth to abject poverty, and there is now a concern that debtors will pursue him and unlawfully embarrass him, and perhaps he will even take ill and die from the terrible distress…

See also the Kuntrus Over Orei’ach 334 by the Aderes zt”l who discusses rescuing Kisvei Yad (handwritten manuscripts of Divrei Torah and Chidushim) [from a fire on Shabbos] who writes: “It could be said that it may be a matter of Pikuach Nefesh if a person invested enormous effort in them [his Kisvei Yad] all of his life – for the grief may cause him to take ill, God forbid. I heard this about the Gaon R’ Avraham Charlap, the Av Beis Din of Bialystok, whose holy writings were accidentally destroyed, and he did not live for long afterwards due to the terrible grief.

[In spite of all of the above] it is still forbidden to extinguish the fire… on account of an enormous loss of money. Though the pain and distress is enormous, and he would gladly cut off his arm if doing so could save his wealth, it is nevertheless forbidden to extinguish the fire. This is because physical pain is different…[but] a person who has taken these events to heart and is in great distress – we cannot take that into account as it is considered as if he is killing himself, not the fire.

Rav Shlomo Zalman did not permit desecrating Shabbos to save a person from the trauma of seeing his wealth go up in smoke before his eyes[11]. Though this level of distress is likely equivalent to that considered by the Poskim to be Pikuach Nefesh (and therefore a justifiable reason to desecrate Shabbos), in this case this it would not be justified as he should have had strengthened his Bitachon and not allowed himself to be so traumatized. As such, the mental anguish is not due to the fire, but is considered his own fault.

Rav Avigdor Nebenzahl Shlit”a (Yerushalayim b’Mo’adeha, Shabbos 2, p356) notes that he found this ruling of Rav Shlomo Zalman immensely surprising. Even though this person should have had more faith in Hashem, ultimately his life is endangered, and Shabbos prohibitions should be set aside in order to save him. He attests that Rav Shlomo Zalman retracted this ruling in his later years. (See also Shemiras Shabbos Kehilchasa 41, footnote 8 & Shulchan Shlomo 334:25, footnote 33)[12].

            There are two Teshuvos that are commonly cited in regard to Chilul Shabbos for the treatment of panic attacks:

The Tzafnas Paneach (39) discusses a case where a great tumult is taking place in a town due to the proximity of a dangerous army or group of bandits. The group do not present an actual danger to life and so Chilul Shabbos is not permitted in order to flee. Nevertheless, if any individuals are frightened of the perceived danger and wish to desecrate Shabbos and flee, they are permitted to do so (though nobody else may desecrate Shabbos on their behalf).

This appears to indicate that a person may violate Issurim if he is beset by panic or fright. However, there is a clear distinction between this case and that of a person suffering from a panic attack. In this case there is an objective danger, and although it doesn’t reach the level of Pikuach Nefesh that would warrant Chilul Shabbos, nevertheless, if somebody is frightened, he is allowed to be concerned for his life and to consider it a matter of Pikuach Nefesh. This is quite unlike a panic attack where the “danger” that is feared is usually a product of the person’s imagination. Perhaps that would not be considered a matter of Pikuach Nefesh for there is no actual danger.

Rav Moshe Feinstein zt”l (Igros Moshe O.C. 1:227) discusses a fascinating ruling of the Magen Avraham (248) regarding a “Yotzei b’Shayara l’Midbar” – somebody who wishes to join a group setting out on a journey through the desert. The Shulchan Aruch rules that if it is certain that the group will need to continue traveling on Shabbos (as it is dangerous to remain in one place in the desert), one may not join them on Wednesday, Thursday, or Friday relying on the fact that Pikuach Nefesh overrides Shabbos. However, it is permitted to depart with them during the first half of the week (i.e. Sunday, Monday, or Tuesday), and he may then desecrate Shabbos on account of Pikuach Nefesh when it arrives.

The Magen Avraham cites the Maharival who disagrees. He holds that if the Shayara is certain to have to desecrate Shabbos then it is forbidden to join them on any day of the week. Therefore, the only way that a person can possibly join the group is if he decides that in spite of the danger, he will not desecrate Shabbos and will remain in one place for the entire day. The Magen Avraham says that this ruling is the basis for those who risk their lives in order to avoid Chilul Shabbos.

Rav Moshe explains that the Magen Avraham was certainly not referring to a situation of actual Sakana as a person who places himself in real danger in order to keep Shabbos is “Mischayev b’Nafsho” (culpable for any consequences). He must have been referring to a case where the danger that is present is perceived differently by different sorts of people. Those who are generally courageous and unafraid would not consider the danger that faces the Shayara as being much of a Sakana. Others of a more fearful nature would consider it a Sakana and would be permitted to desecrate Shabbos if they found themselves in those circumstances.

Therefore, since according to the Maharival it is forbidden to join the Shayara if they will definitely need to desecrate Shabbos (in other words, if they have an anxious or apprehensive nature and would consider it a Sakana to remain in place over Shabbos), the only way to join them is if they decide, in spite of their fears, to remain in place and not desecrate Shabbos.

Based on these excerpts from Igros Moshe there are those who conclude that Rav Moshe permits a person to desecrate Shabbos if he is feeling fearful, even if he is not in any real Sakana (although others who do not consider the situation a Sakana may not desecrate Shabbos). Therefore, we may similarly permit a person who is having a panic attack to desecrate Shabbos.

However, a careful reading of Rav Moshe’s words reveals otherwise. If anything, his is similar to that of the Tzafnas Paneach given that he only permits Chilul Shabbos where there is a genuine element of danger. In such circumstances, Rav Moshe held that the decision is left to each individual – those who are fearful may desecrate Shabbos, but those who are not, may not set aside Shabbos prohibitions. However, one cannot adduce any proof that one may commit Issurim due to a purely subjective fear that isn’t grounded in reality at all. 

In summary, there are cases where Halacha considers fright and panic as a matter of Pikuach Nefesh and it is important to correctly evaluate each case. As noted above, a panic attack can closely resemble a heart attack and medical attention should be sought immediately if there is concern that the patient is experiencing an acute cardiac event, even on Shabbos. In an acute trauma or other situation that leads to a panic attack (i.e. even though it is definitely not a heart attack), it might also be permissible to desecrate Shabbos to treat him for his life may be endangered.

If a person experiences recurrent severe panic attacks but is capable of stabilizing himself through medication or self-calming behavioral interventions, he should do so and should not desecrate Shabbos unnecessarily. If he is unable to calm himself and urgently needs to speak to his psychiatrist he may well be permitted to call him and the psychiatrist may answer the call.

This essay does not seek to offer Halachic rulings but only to present a discussion of the topic l’Hagdil Torah u’l’Ha’adira. All practical questions should be addressed to a Rav.

[1] Usually when a Mishna rules that somebody is “Patur” it means “Patur Aval Assur” – the person is exempt but the act was still forbidden in the first instance. Here the Mishna means “Patur u’Mutar” – he is exempt and it was permitted in the first instance.

[2] According to the Rambam, the distinction is indicated by the different phrasing of the Mishna in the first three cases (“Mipnei sheHu Misyarei” – “because he was fearful…”) than in the final case (“Mipnei haCholeh” – “for the [needs of] the sick patient”).

[3] Maharsha ad. loc.

[4] In other words, although each of the acts of goring could be individually justified as a unique occurrence, the weight of evidence points to the fact that this is a dangerous ox. The same is true in this case. Though each of his unusual acts could be rationally explained, the weight of evidence points to the fact that he is a Shoteh.

[5] This proof was adduced by R’ Zev Litke Shlit”a.

[6] We should note that the symptoms of a panic attack resemble those of a heart attack. Therefore, if a person has never experienced a panic attack before, he must seek emergency medical attention. However, if he is accustomed to panic attacks and is under the care of a mental health professional, he needn’t be concerned that they place his life in danger. On the contrary, an important element of his treatment is the recognition that he is not actually in danger at all.

[7] The author is grateful to Dr. Yaakov Friedman for his elucidation of this point.

[8] If the Gemara considers it a Chidush that one needn’t attempt to calm the child by other means it would certainly be a Chidush to say that one needn’t wait to see whether a calm child will remain calm.

[9] Halachos Ketzuvos Shabbos 18 & Piskey Rabbenu Yosef miBamburg 120.

[10] This is the case in Hilchos Eiruvin where a child up until the age of six may be included in the Eruv of his mother and one needn’t set aside an amount of “two Seudos” for him separately (Shulchan Aruch O.C. 414:2).

[11] He does not appear to be discussing the long-term impact on his mental health, only his immediate distress.

[12] In 5774, during a difficult security period in Yerushalayim, Rav Nebenzahl was asked whether it was permissible to desecrate Shabbos to treat anxiety and panic attacks on Shabbos. He replied that it was permissible if there was any risk that without treatment it would progress to psychosis, and that this applied to people of any age.