Sarosh Motivala, PhD 9/23/22 Sarosh Motivala, PhD 9/23/22

A History of Panic Disorder

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

Sarosh Motivala, PhD 2/21/20 Sarosh Motivala, PhD 2/21/20

Lost in the Wild

In his excellent book Deep Survival, Laurence Gonzalez writes about his studies on the experience of being lost in the wild. Hikers who lose their way experience something called woods shock; Gonzalez writes “everyone who dies (in the woods) dies of confusion. There is a destructive synergy...including exhaustion, dehydration, hypothermia, anxiety, hunger, injury.” Woods shock is a useful experience to learn about in order to better understand the very common and troubling experience of panic (click here for a more basic run down on panic disorder).

Woods shock is the catastrophic reaction people can have when they grapple with being lost. When their mental maps of their location do not match with their physical environment and when the internal tussle between reason and emotion no longer work in accord, but instead “become like two swimmers, dragging each other down.” In its worst cases, Woods shock can lead to death. I have heard time and time again that when my clients panic, it is like they are drowning and that their emotions are swirling around them with incredible ferocity.

Gonzales recounts stories of experienced hikers doing inexplicable things like not making a fire, misreading landmarks, discarding backpacks when lost. Why? Why when our reasoning faculties are needed most, do they sometime abandon us?

Disorientation

The roots of woods shock start with becoming disoriented; you lose the connection between your surroundings and your internal, mental map of your location. But plenty can happen between this disorientation and full blown woods shock. “Being lost is not a location, but a transformation” Gonzalez writes. He outlines it as follows a few poor mental strategies we use to handle being lost. A perversion in the “call to action” drives a series of mental strategies that transform being lost into being injured, making poor decisions, being hopeless. Initially a refusal to admit you are lost and a tendency to act out “convincing oneself that you are ok” leads to urgently forging onward. This denial can help us cope with the rising panic, but it eventually peters out and may even make us more disoriented. So we move on to another approach - a massive action strategy. The emergency is realized, but the response is frenetic massive action (running, fast walking). This keeps the rising panic at bay, providing a sense that “I’m on this”, but it burns precious energy and can make you vulnerable to fast but poor decision making and even physical injury (slipping, falling). After burning up your physical energy, you might switch to a cognitive strategy. Gonzalez describes it as frenetic orienting. A panicked attempt to mentally figure out where you are. The mental velocity of this state does not lend itself to accuracy, insights and realizations about where you are and what you need to do. If anything, it promotes poor decision making. It is important in these moments, to work your way to a place of acceptance/resignation AND determination. It’s a delicate balance. But important to survive.

The Split

When a person realizes they are stuck, Gonzales describes “the split”. In example after example of mountain climbers, sailors, fighter pilots lost in the wild, and I would add those that struggle with panic attacks, Gonzales writes that a person starts to split into two people - one that perceives reality and is coldly rational, and another that is having “waves of hot emotion”. This is a common experience in panic attacks - one part of my mind is freaking out, the other is rational. Understanding this split, accepting it, and working to maintain a balance between these two subjective experiences - is vital. Gonzales writes about climber Joe Simpson and his partner Simon Yates as they were descending the summer of Siula Grande, a 21,000 foot peak in the Peruvian Andes. Simpson broke his leg on the climb down. Simpson and Yates worked together to help Simpson, but both men knew that Simpson was in ALOT of trouble. Regarding the balance of his split mind, the balance between rational and emotional, Simpson writes in his book Touching the Void, “It felt as if I was holding something terrifyingly fragile and precious.”

Gonzales quotes from the diary of a sailor, Steve Callahan, who was on a solo sailing trip across the Atlantic when his boat collided with a whale and began to sink. Callahan wrote “a myriad of conversations and debates flash through my mind, as if a group of men are chattering with my skull. Some joke…others stoke the furnace of fear…I must be careful. I fight blind panic: I do not want the power from my pumping adrenaline to lead to confused and counterproductive activity. I do not want to sit frozen in fear until the end comes. Focus, I tell myself.”

Gonzales then writes that Callahan handled the split with self-talk - enacting a sense of discipline. Callahan later wrote, “When I am in danger or injured, my emotional self feels fear and my physical self feels pain. I instinctively rely on my rational self to take command over the fear and pain.” This to me is, is a vital, beautiful statement to remind ourselves of when the panic storm is raging.