Panic Disorder

   Panic has always been considered a symptom of larger psychiatric illnesses. Yet, only recently has it come to be considered a disorder of its own. The whole panic story is interesting as an example of how symptoms wax and wane in the history of psychiatry, treated as one among many at one point, and the focus of all nosology at the next. There may be good scientific reasons for the fluctuating historical courses of such symptoms, yet commerce plays a role as well, for if industry needs a symptom for a compound it has developed, one may be sure that entities such as panic will stand in good service. The following subentries represent the major steps in the panic story. (See also Anxiety and Phobias: Westphal’s agoraphobia-panic [1872].)

   Paroxysmic attacks of panic (1873). Maurice Krishaber (1836–1883), a Hungarian physician practicing in Paris, described patients who "are taken out of the blue . . . with a peculiar sensation in the head, ‘like a flush [bouffée] or a rising wave’; instantly there occurs a clouding of the senses, ringing in the ears, and the seeing of sparks at the same time as a sense of anguish in the area of the heart accompanied by palpitations, a sense of nausea. . . . [There follow] vertigo, staggering around [titubation]." Krishaber said the attacks may occur episodically during the months ahead and may or may not be accompanied by insomnia (pp. 158–159). He attributed them to misadventures on the cerebro-cardiac axis and called the disorder, in a book of that title published in 1873, "la névropathie cérébro-cardiaque." This is generally thought the first description in the French literature of paroxysmic anxiety, later called "panic attacks." This priority may hold true for France but not for Germany. In 1872, German psychiatrist Rudolph Gottfried Arndt (1835–1900), associate professor at Greifswald University, gave a paper at a psychiatry meeting in Leipzig on "melancholic anxiety attacks" ("der melancholischer Angstanfall," published in the General Journal of Psychiatry (Allgemeine Zeitschrift für Psychiatrie) in 1874, in which he took for granted that the phenomenon had long been described in the German literature. For Arndt, "melancholic" meant general nervous and mental illness rather than depression. He associated such attacks with disorders of the nerves of the heart.

   Entry of term "panic" into psychiatry as part of melancholia (1879). In his The Pathology of Mind,* Henry Maudsley offered a careful description of panic attacks: "These paroxysms of anguish or panic, which are a notable feature of melancholia— paroxysms of melancholic panic they might be called—deserve careful notice. They often come on quite suddenly; the patient has perhaps been lying down to rest [then] starts up in great agitation, his heart beating tumultuously, his senses distraught, and rushes wildly to the window to throw himself out of it. . . . In some cases the convulsive panic is preceded by an anomalous and alarming sensation of distress about the region of the stomach or of the heart, a sensation which, appearing to rise thence to the head, is accompanied by an indescribable terror and a dreadful feeling of helplessness. . . . The whole affair is suggestive of the onset of mental epilepsy" (p. 365). Yet, Maudsley’s term "panic" was not taken up in the literature.

   * The Pathology of Mind was considered the "third edition," extensively reworked, of his Physiology and Pathology of Mind (1867). Yet, the earlier volume does not use the term "panic."

   Differentiating somatic "anguish" (later "panic") and mental "anxiety" (1890). Édouard Brissaud (1853–1909), a neurologist at St.-Antoine hospital in Paris who had an organicist view of psychiatry, differentiated in an article in the Parisian Medical Weekly (la Semaine médicale) between "anguish" (l’angoisse), and "anxiety" (l’anxiété). Anguish represented the sensation of somatic distress, as for example in precordial (heart–stomach region) pain. Anxiety was "angoisse intellectuelle," a mental phenomenon, the mind’s processing of the somatic sensation of anguish. In heart pain, "anxiety is attached less to the physical sensation of thoracic constriction and a sense of suffocation than to the mental state accompanying this situation. It announces the disturbance, the disquiet and the terror that arise as the immediate consequences of this [chest] oppression." Paroxysmic anxiety, said Brissaud, is found not just in cardiac problems but in hysteria, neurasthenia and hypochondria. "It is common to see anxious melancholia begin with paroxysms of this nature." By contrast, somatic anguish in paroxysmic form would be the core of what was later called panic attacks, though some authorities believed somatic "angoisse" and psychic "anxiété" were so closely intermingled that in attacks they occurred together. (See Francis Heckel, La névrose d’angoisse et les états d’émotivité [1917].)

   Reentry of term "panic" into psychiatry (1932). Oskar Diethelm (1897–1993), then an associate professor of psychiatry at Johns Hopkins University, suggested in an article in 1932 in the A.M.A. Archives of Neurology and Psychiatry that panic represented an independent illness entity, "characterized by fear, extreme insecurity [and] suspiciousness." Making no reference to Henry Maudsley’s previous usage (see above), Diethelm described a patient who, fearing a forthcoming operation, "had to rush out of bed. She felt a tightening in her throat, palpitation, nausea, and . . . fear of ‘mental disease’ " (p. 1154). Diethelm said that another author had described the rather limited case of "homosexual panic," but added, "I also find masturbation panics and panics due to unmanageable heterosexual desires, as well as many other situations that are unbearable to certain make-ups and from which the subjects see no escape either by mastery or flight" (p. 1156). He distinguished panic from anxiety neuroses, which usually lacked the element of fear; also from Wernicke’s anxiety psychoses (see Anxiety: Wernicke . . . [1895]) and from extreme fright reactions, for which the Swissborn Diethelm (who was highly familiar with the German literature) also used the German term "Schreckneurosen."

   Cohen describes precipitating "anxiety" (panic) attacks in patients with anxiety neurosis (1940). Mandel Cohen (1907–2000) and Stanley Cobb (1887–1968), psychiatrists at Harvard University, described in 1940 in the Journal of Clinical Investigation how giving carbon dioxide to patients with anxiety neurosis could precipitate an anxiety attack. (Far fewer controls experienced such attacks in rebreathing CO2.) Cohen is thus seen as the immediate father of the concept of "panic attack," although he himself did not use that term. Cohen later said of this work, "We have shown that a number of things became abnormal during the anxiety attack, such as blood lactate levels, even though nothing appeared to be abnormal at baseline. . . . Since then there has been a whole field of lactogenic anxiety attacks" (Healy interview, in the journal History of Psychiatry, 2002, p. 212).

   Roth’s phobic anxiety-depersonalization syndrome (1959). In the Proceedings of the Royal Society of Medicine in 1959, Martin Roth (1917–), professor of psychiatry in Newcastle-on-Tyne, described a recurring combination of symptoms involving anxiety attacks, phobic avoidance of crowds, and a feeling of depersonalization. "There was a fearful aversion to leaving familiar surroundings, to walking in the street and to entering shops, travelling in vehicles or visiting cinemas or theatres. Waiting or sitting still in such settings was prone to evoke a sense of impending disaster, acute agitation and flight in panic" (p. 590). The patients, typically women in their late twenties, displayed familiar symptoms in this syndrome: "the syncopal attacks with fear of losing consciousness, the anxiety about falling asleep, the terrified starts from slumber. . . . The cases also have in common the transient stage of clouding of consciousness after the impact of stress" (p. 594). Some observers see Roth’s syndrome as an early description of panic attacks.

   Differentiation of panic from anxiety on the basis of drug response (1962, 1964). In 1962, Donald Klein and Max Fink at Hillside Hospital, in a clinical trial of imipramine that was published in the American Journal of Psychiatry, discovered that anxious patients with panic disorders responded to the drug but that anxious patients with phobias did not. Klein then received a grant from the National Institute of Mental Health and did a second, controlled trial on his own. Published in 1964 in Psychopharmacologia, his paper confirmed that imipramine was effective for panic but not for other kinds of anxiety. This set the stage for discriminating panic on a pharmacological basis as a disease separate from anxiety. (For details, see KLEIN, DONALD F.)

   The Research Diagnostic Criteria included panic (1978). Robert Spitzer, Columbia University psychologist Jean Endicott (1936–), and Eli Robins, building on the work of the St. Louis school, proposed in the Archives of General Psychiatry a revised list of diagnoses to be used in research. Called the "Research Diagnostic Criteria," the RDC system included "panic disorder," described as similar to anxiety neurosis.

   Panic in DSM-III (1980). This edition continued the RDC (1978) category of panic disorder, which would become a huge diagnosis in the coming years. "The panic attacks," the Manual explained, "are manifested by the sudden onset of intense apprehension, fear, or terror, often associated with feelings of impending doom" (p. 230). Twelve symptoms were mentioned, such as chest pain, dizziness, feelings of unreality, and fear of "going crazy or doing something uncontrolled during an attack," and to qualify for a diagnosis of panic disorder the patient had to exhibit four of them. There were some kinds of attacks in which the diagnosis agoraphobia with panic would be more suitable, it said.

   DSM-III-R in 1987 introduced the formal distinction between panic with and without agoraphobia. And DSM-IV in 1994 further distinguished among "panic attack," "agoraphobia," and "panic disorder," the latter meaning recurrent panic attacks plus worry about having them.

   Anxiety, panic, and phobic disorders in ICD-10 (1992). The tenth edition of the World Health Organization’s International Classification of Diseases (ICD) distinguished between "phobic anxiety disorders" and "other anxiety disorders" including panic. British psychiatrist Simon Wessely comments, in a personal communication to me, as follows on these international differences: "DSM is not the bible as far as we are concerned. [Shorter] seems to have missed the vital US/Europe difference here, that we regard avoidance/phobia as the prime mover, hence agoraphobia sits at the top of our system, with panic just a symptom of it, while the US, partly because of the success of [Donald] Klein/imipramine, puts it in reverse order."