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Some thoughts on the validity of the concept of panic disorder
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Symposia S.01 Panic and depression IS.01
.Ol 1Some thoughts on the validity of the concept of panic disorder
D.F. Klein. Nat York State Psychiatric Institute and the Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York, LISA This was supported, in part, by MH-30906. To validate the concept of panic disorder requires that it makes a difference in our tindings. As Bertrand Russell says, “A difference that makes no difference is no difference”. There arc several levels of concern about the validity of a nosological concept. First, the concept must be sufficiently well defined that it allows reliable diagnosis. This is reliability rather than validity, but without reliability there can be no validity. Numerous suggested nosological concepts have failed this elementary test. However, that is not the case for panic attack and disorder. The five phases of the validation of psychiatric disorders proposed by Robins and Guze are, clinical description, laboratory studies, delimitation from other disorders, followup study, family study. Under “delimitation from other disorders” should be included the pattern of psychotropic drug response. At a more sophisticated level of validation, the nosological concept is embedded in a testable theory concerning etiology and pathophysiology. The importance of this theoretical embedding is that a useful theory should predict aspects of the condition that have gone unnoticed. These risky predictions are among the most important validators of scientific theory. It is sometimes stated that scientific theories can only be disconfirmed and that piling up confirmations failed to verify a theory. I find this overdrawn. Confirmed startling deductions lend credibility to a theory and help to validate the nosological construct the theory attempts to explain. Panic Terminology. The term panic, like many of the terms in psychiatry, e.g., depression and anxiety, is an ordinary word and therefore carries a host of surplus associations irrelevant to its use in a psychopathological context. Further, the term panic attack is really synonymous with the venerable term anxiety attack. Why then did I feel called upon to coin this term and thus break with tradition? What difference required emphasis‘? The basic discovery was that imipramine blocked the spontaneous attack characteristics of patients who developed agoraphobia, severe enough to require hospitalization, but that the level of chronic anticipatory anxiety and phobic avoidances remained high for some time. Freud noted a marked resemblance between the anxiety that occurred in “neurotics” and the fear that occurred when danger confronted normal people. However, what was puzzling about “anxiety neurosis” was the absence of manifest danger. Freud affirmed the identity of psychoneurotic anxiety and fear by asserting there was an internal danger, that of the return of the repressed. Due to the growing failure of repression in patients with anxiety neurosis, anxiety mounted until the ego was overwhelmed causing panic and flight. The phobic avoidances were interpreted as the avoidance of temptations that stimulate repressed drives. What was problematic was that imipramine completely blocked the panic attack, but had no immediate effect upon the high levels of chronic anxiety and avoidance. It seemed illogical that if the panic attack was simply a quantitative extreme, that the most severe form of anxiety should be ablated, while the chronic anxiety was maintained. Detailed histories showed that the onset of agoraphobia indeed occurred regularly after the onset of spontaneous panic attacks, as Freud
had indicated. These attacks often occurred during a period of unusual stress, such as a divorce or death in the family, but were not anteceded by a state of mounting anxiety. Many occurred out of the blue. After recurrent attacks the chronic anxiety and phobic avoidances developed and grew, rather than the opposite sequence. This also contradicted the belief that panic was simply the extreme of neurotic anxiety. Further, it was clinically obvious that imipramine had no effect upon ordinary fear, so the idea that it was acting, in some non-specific way, to reduce fearf4 reactions was clearly wrong. Therefore, I coined the term “panic attack” to draw a terminological distinction from anxiety so as to reflect the lack of continuity with ordinary anxiety and fear. Is Fear Central to the Definition of Panic? Katon et al (1987) point out that panic disorder patients may selectively focus on one symptom such as tachycardia, chest pain or dizziness and minimize symptoms of nervousness. In 195 primary care patients, a spectrum of panic complaints was found, associated with phobias, depression and emotional discomfort. These authors emphasize that detection of panic disorder should emphasize autonomic symptoms rather than feelings of fear. Beitman et al (1992) also have emphasized non-fearful panic. It seems probable that such features as sudden fear of dying are quite specific indicators of a panic attack but are related to the occasional severe attack and therefore are insensitive as compared to the regular, sudden, time limited, crescendo of physical symptoms. Spontaneity and Course. Neither psychoanalysis nor learning theory places any particular emphasis on panic, which is viewed as simply the quantitative extreme of the anxious state. The baffling spontaneity is explained by symbolic displacement, or covert or enteroceptive conditioning, etc., without any clear evidence that these processes would suffice to cause panic. During imipramine treatment, after about 4-6 weeks, spontaneous fullblown panics no longer occur. However, patients often feel as if a panic is starting and helplessly observe their increasing distress which suddenly, surprisingly, stops and does not peak into terror. (This is inconsistent with the hypothesis that panic is a vicious circle, psychological overreaction to threatening endogenous stimuli. If that were true. all panics should accelerate to a maximum.) Such episodes also occur when not on medication. Freud refers to “larval” anxiety attacks which probably contribute to inter-panic chronic anxiety. Illness course is quite variable. Some develop panics but do not develop high chronic inter-panic anxiety. This is surprising if conditioning and sensitization sufficed to account for chronic inter-panic anxiety. This paper will address other aspects of the Robins and Guze validational program. References [I] B&man, BD, Thomas, AM. Kushner, MG. Panic disorder in the families of patients with normal coronary arteries and non-fear panic disorder. Brhawour Research & Therapy I992;30(4):403-406. [2] Katon W. Vitaliano PP, Russo J, Jones M, Anderson, K: Panic disorder. Spectrum of severity and somatization. J NEW Ment Ilk 1987: 175: 12- 19.
Is.01.021 Basic
mechanisms they separate?
of panic and depression:
Are
H.G.M. Westenberg. Anxiety Research Unit. Unioersity Hospital Utrecht, The Netherlands Introduction: Since the beginning of this century, psychiatrists have debated whether anxiety and depression represent different aspects of the same disorder or embody distinct, although partly overlapping,
Symposia S.01 Panic and depression IS.01
.Ol 1Some thoughts on the validity of the concept of panic disorder
D.F. Klein. Nat York State Psychiatric Institute and the Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York, LISA This was supported, in part, by MH-30906. To validate the concept of panic disorder requires that it makes a difference in our tindings. As Bertrand Russell says, “A difference that makes no difference is no difference”. There arc several levels of concern about the validity of a nosological concept. First, the concept must be sufficiently well defined that it allows reliable diagnosis. This is reliability rather than validity, but without reliability there can be no validity. Numerous suggested nosological concepts have failed this elementary test. However, that is not the case for panic attack and disorder. The five phases of the validation of psychiatric disorders proposed by Robins and Guze are, clinical description, laboratory studies, delimitation from other disorders, followup study, family study. Under “delimitation from other disorders” should be included the pattern of psychotropic drug response. At a more sophisticated level of validation, the nosological concept is embedded in a testable theory concerning etiology and pathophysiology. The importance of this theoretical embedding is that a useful theory should predict aspects of the condition that have gone unnoticed. These risky predictions are among the most important validators of scientific theory. It is sometimes stated that scientific theories can only be disconfirmed and that piling up confirmations failed to verify a theory. I find this overdrawn. Confirmed startling deductions lend credibility to a theory and help to validate the nosological construct the theory attempts to explain. Panic Terminology. The term panic, like many of the terms in psychiatry, e.g., depression and anxiety, is an ordinary word and therefore carries a host of surplus associations irrelevant to its use in a psychopathological context. Further, the term panic attack is really synonymous with the venerable term anxiety attack. Why then did I feel called upon to coin this term and thus break with tradition? What difference required emphasis‘? The basic discovery was that imipramine blocked the spontaneous attack characteristics of patients who developed agoraphobia, severe enough to require hospitalization, but that the level of chronic anticipatory anxiety and phobic avoidances remained high for some time. Freud noted a marked resemblance between the anxiety that occurred in “neurotics” and the fear that occurred when danger confronted normal people. However, what was puzzling about “anxiety neurosis” was the absence of manifest danger. Freud affirmed the identity of psychoneurotic anxiety and fear by asserting there was an internal danger, that of the return of the repressed. Due to the growing failure of repression in patients with anxiety neurosis, anxiety mounted until the ego was overwhelmed causing panic and flight. The phobic avoidances were interpreted as the avoidance of temptations that stimulate repressed drives. What was problematic was that imipramine completely blocked the panic attack, but had no immediate effect upon the high levels of chronic anxiety and avoidance. It seemed illogical that if the panic attack was simply a quantitative extreme, that the most severe form of anxiety should be ablated, while the chronic anxiety was maintained. Detailed histories showed that the onset of agoraphobia indeed occurred regularly after the onset of spontaneous panic attacks, as Freud
had indicated. These attacks often occurred during a period of unusual stress, such as a divorce or death in the family, but were not anteceded by a state of mounting anxiety. Many occurred out of the blue. After recurrent attacks the chronic anxiety and phobic avoidances developed and grew, rather than the opposite sequence. This also contradicted the belief that panic was simply the extreme of neurotic anxiety. Further, it was clinically obvious that imipramine had no effect upon ordinary fear, so the idea that it was acting, in some non-specific way, to reduce fearf4 reactions was clearly wrong. Therefore, I coined the term “panic attack” to draw a terminological distinction from anxiety so as to reflect the lack of continuity with ordinary anxiety and fear. Is Fear Central to the Definition of Panic? Katon et al (1987) point out that panic disorder patients may selectively focus on one symptom such as tachycardia, chest pain or dizziness and minimize symptoms of nervousness. In 195 primary care patients, a spectrum of panic complaints was found, associated with phobias, depression and emotional discomfort. These authors emphasize that detection of panic disorder should emphasize autonomic symptoms rather than feelings of fear. Beitman et al (1992) also have emphasized non-fearful panic. It seems probable that such features as sudden fear of dying are quite specific indicators of a panic attack but are related to the occasional severe attack and therefore are insensitive as compared to the regular, sudden, time limited, crescendo of physical symptoms. Spontaneity and Course. Neither psychoanalysis nor learning theory places any particular emphasis on panic, which is viewed as simply the quantitative extreme of the anxious state. The baffling spontaneity is explained by symbolic displacement, or covert or enteroceptive conditioning, etc., without any clear evidence that these processes would suffice to cause panic. During imipramine treatment, after about 4-6 weeks, spontaneous fullblown panics no longer occur. However, patients often feel as if a panic is starting and helplessly observe their increasing distress which suddenly, surprisingly, stops and does not peak into terror. (This is inconsistent with the hypothesis that panic is a vicious circle, psychological overreaction to threatening endogenous stimuli. If that were true. all panics should accelerate to a maximum.) Such episodes also occur when not on medication. Freud refers to “larval” anxiety attacks which probably contribute to inter-panic chronic anxiety. Illness course is quite variable. Some develop panics but do not develop high chronic inter-panic anxiety. This is surprising if conditioning and sensitization sufficed to account for chronic inter-panic anxiety. This paper will address other aspects of the Robins and Guze validational program. References [I] B&man, BD, Thomas, AM. Kushner, MG. Panic disorder in the families of patients with normal coronary arteries and non-fear panic disorder. Brhawour Research & Therapy I992;30(4):403-406. [2] Katon W. Vitaliano PP, Russo J, Jones M, Anderson, K: Panic disorder. Spectrum of severity and somatization. J NEW Ment Ilk 1987: 175: 12- 19.
Is.01.021 Basic
mechanisms they separate?
of panic and depression:
Are
H.G.M. Westenberg. Anxiety Research Unit. Unioersity Hospital Utrecht, The Netherlands Introduction: Since the beginning of this century, psychiatrists have debated whether anxiety and depression represent different aspects of the same disorder or embody distinct, although partly overlapping,