Panic has been with us for very a long time. The very first known work of literature, The Epic of Gilgamesh, about four thousand years old, recounts King Gilgamesh’s struggle with panic and fear of dying, which then triggers his quest for immortality (spoiler alert: he fails at this) and also for the meaning of life (he has success on this front). My quest is more modest - to walk you, the reader through the evolutions of conceptualizing the panic experience.

The language, terminology and theoretical conceptualizations have evolved over time from the 18th century conceptualization of panic due to toxic vapors emanating from the uterus, to panic stemming from psychological neuroses, to more recent cognitive-behavioral theoretical models of panic (see my write up). Modern descriptions of panic symptoms from the Diagnostic and Statistical Manual Version 5 include:

intense fears of losing control or going crazy

intense fear of dying

palpitations, pounding heart or rapid heart rate

chest pain

feeling short of breath

nausea or stomach distress

dizziness

sweating

trembling

chills

numbness or tingling

derealization

How Panic got it’s name

Panic disorder wasn’’t conceptualized until the third version of the Diagnostic and Statistical Manual (DSM-III) in 1980. But to get to that more modern conceptualization, let’s first go to 1771. French physician Boissier de Sauvages wrote the Nosologie Methodique, a comprehensive catalogue of all the known diseases of the time in Europe (Weckowicz, & Liebel-Weckowicz 1990). One set of disorders he describes is something he called “panophobias”. By combining pan with phobia, he coined the term panophobia, literally meaning a “fear of terror”, or “a fear of fear”.

Why “pan” and “phobia”? Where do these terms come from? Pan was a Greek forest deity with goat legs and a human body who screamed loudly and wildly at humans whenever they wandered through his territory. Pan is a curious choice to name panic after. Personally, I don’t get it. He may have freaked people out with his screaming, but he also played the flute really well (“the Pan flute”) and rather than looking fearsome, in some depictions Pan looks downright handsome, like a sexy Sasquatch.

The term phobia comes from Phobos, another Greek god, this one being who the son of the war god Ares (also known as Mars). Phobos used lightening and thunder to paralyze people with fear, especially soldiers before a battle. Asaph Hall was a cheeky astronomer who discovered two moons revolving around Mars and decided to name one of them Phobos. So when you gaze up at the red planet named after the god of war, look for a tiny little moon named after the god of fear. Sadly Martian Phobos doesn’t look as beautiful as our own moon, and in my humble opinion it resembles a Russet potato.

Let’s get back to our good French doctor. In his book Boissier de Sauvages identified a sequence of different panophobias, but one resembles what we’d call modern day panic: panophobia hysterica. This was a disorder whose typical symptoms involved intense fright, dramatically increased heart rate, and clamminess. But strangely, Boissier de Sauvages as well as a number of physicians at that time believed that panophobia hysterica was caused by “vapors”. They were not referring to the famous rock band from the early 1980’s, but to vapors that escape from a person’s uterus and toxify other parts of the body. Boissier de Sauvages provided one of our earliest modern definitions of panic, but his explanation as to why they occurred was off the mark.

In Europe in the 1800’s there was a explosive growth in the sciences - arguably culminating with the works of Darwin and Wallace. Robert Koch published works on infectious diseases and spurred on scientists to look for biological and microbiological causative agents of disease. In the psychological sciences, research psychologists like William James were just getting cooking in America. In Germany, psychiatrist Emil Kraepelin, considered one of the founding fathers of modern psychiatry, put forth the idea that mental illness is biologically and genetically driven. Kraepelin did not describe panic as a separate disorder, but he did describe symptoms of panic that were embedded into a variety of diagnoses, especially bipolar disorder (at the time called manic depression). Contemporaries of Kraepelin, like Freud and Janet also started describing anxiety in newer ways, leaving the vapors idea behind. Freud tried to separate anxiety from an “anxiety attack” that he described as having a stronger physical presentation. After the vapor induced panic of the 1700’s, the panic of the 1800s integrated biological and psychosocial pathways but panic itself still did not get much attention on its own, but as part of other diagnoses.

Panic as an “anxiety neurosis”

Now, we come to America, specifically New York and 1917. The National Committee for Mental Hygiene and the American Medico-Psychological Association (which would eventually become the American Psychiatric Association) came up with the Statistical Manual for the Use of Institutions for the Insane. The steering committee that worked on the book was chaired by Albert Barrett, a psychiatrist who trained in Heidelberg with Kraepelin. The book was for physicians who worked in asylums and so it emphasized severe mental illnesses that necessitated hospitalization. The book was also a precursor for the DSM that would be published in 1952.

The book primarily focused on psychotic symptoms, but under the term “psychoneuroses”, they did describe four types of neuroses, the last of which was called anxiety neurosis. This included “morbid fear as the most prominent feature…as well as numerous physical symptoms which may be regarded as the bodily accompaniments of fear, particularly cardiac and vasomotor disturbances: the heart’s action is increased, often there is irregularity and palpitation; there may be sweating, nausea, vomiting, diarrhea, suffocative feelings, dizziness, trembling etc”.

At this point, you might be asking where is the science? Lots of very wise clinical judgment at work in conceptualizing things, but we need the science. After all, we are in the early 20th Century at this point in our journey. Looking at other disciplines, by the 1950’s infectious disease scientists were expanding the basic concepts of the scientific method to develop and test vaccines - so much so that by 1954, double-blind clinical trials were being done with 1.8 million children to test the effectiveness of the polio vaccine. What were psychologists and psychiatrists up to? Well, just a little more patience.

In 1952, the American Psychiatric Association published the first Diagnostic and Statistical Manual, Version 1 (DSM-I) but STILL no formal diagnosis of panic existed in it, instead they used the term psychoneurotic disorder to describe panic-like symptoms. This first version of the DSM was heavily influenced by ideas presented by Freud, Kraepelin and others.

Panic as an official disorder

In 1972 Feighner, Robins and colleagues published “Diagnostic Criteria for Use in Psychiatric Research” which substantially altered the way in which we diagnose psychological disorders (it has been cited over 7000 times in other scientists’ papers). Feighner and his coauthors argued for information from clinical studies to be included in how we conceptualize each disorder. They emphasized statistical concepts like validity and reliability as guide for diagnostic criteria. This reflected a shifting perspective away from relying exclusively on clinical observation and judgement to including results from empirical studies. This might seem obvious in today’s world, but it wasn't back in the day.

Finally, it wasn’t until 1980 (the year the 80’s band the Vapors had their biggest album - remember them?) that the DSM-III was published and debuted the diagnosis of panic disorder. The DSM-III formally separated the terms anxiety and panic into separate diagnoses. Before the 80’s were over, Behavioral scientists would publish comprehensive conceptualizations of how panic disorder may develop and present itself as well as treatment approaches that are still used to this day.

References

Craddock N, Owen MJ. The Kraepelinian dichotomy - going, going… but still not gone. Br J Psychiatry. 2010 Feb;196(2):92-5.

Kawa & Giordano, 2012. A brief historicity of the Diagnostic and Statistical Manual of Mental Disorders: Issues and implications for the future of psychiatric canon and practice

Nardi, 2006. Some notes on the historical perspective of panic disorder.

The Vapors They are still touring. Get their merch and tour info here at www.thevapors.co.uk

Weckowicz & Liebel-Weckowicz. A History of Great Ideas in Abnormal Psychology

A History of Panic Disorder