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Why Panic Attacks Are Nearly Always Pathological: Page 2 of 3

Why Panic Attacks Are Nearly Always Pathological: Page 2 of 3

The background story: panic on the precipice
Recently, I came across an article that may have been the genesis of my distinguished colleague’s “hanging off the edge of a cliff” scenario. In his 2007 review of the book The Loss of Sadness,2 Dr Kenneth Kendler3 wrote:

If an individual experience[s] a full-blown panic attack when . . . he looses his grip and falls 40 feet before his rope catches him . . . no psychiatrist I know would consider this to be a psychopathological phenomenon. A panic attack is not—in and of itself—psychopathological. It only becomes pathology when it occurs in certain contexts—at times and in places when it should not. Thus the diagnostic status of panic disorder is inherently contextual. It is not a disorder in and of itself but only in certain contexts. . . .

Later in his review, Kendler alludes to what he takes to be a unanimous consensus among psychiatrists, “. . . our all agreeing that the climber dangling from the rope has a clearly ‘understandable’ and hence non-pathological panic attack.” He then contrasts panic attacks with, for example, a bizarre delusion, such as, “A hard drive has been installed in my head by aliens. . . .” He regards the latter as inherently pathological. But, regarding the panic attack, is Kendler correct?

On a purely pragmatic view of psychopathology, I believe he is correct. Undoubtedly, no psychiatrist would say to our mountain climber, after his cliff-hanger panic attack, “You need psychiatric treatment. Please set up an appointment with me right away!” Nor would many competent psychiatrists say, “You are likely to need psychotherapy and perhaps medication, given that you experienced this panic attack.”

So, in terms of clinical praxis, Kendler is right to claim that the panic-on-the-precipice scenario is not an instantiation of psychopathology—at least in the sense that the term “psychopathology” is typically used in the psychoanalytic literature; ie, as a disturbance of internalized objects, unresolved unconscious conflicts, use of primitive ego defenses, etc. Kendler is also technically correct in noting that panic disorder (like its building block, the panic attack) is “inherently contextual,” in the limited sense that DSM-IV and DSM-5 criteria require that panic disorder be characterized by recurrent and unexpected, ie, spontaneous, panic attacks. Unexpected attacks are, in essence, contextless attacks—ones that come on “out of the blue.” The clear implication is that there is such a thing as expected panic attacks. In DSM-IV, “expected” implies that the attack is associated with a situational trigger, such as a cue or reminder of a previous trauma—ie, the attack occurs in an understandable context.

It’s not clear how the framers of DSM-IV or DSM-5 would classify the panic attack in our cliff-hanger scenario. But there are no compelling clinical reasons for viewing a context-based panic attack as non-pathological. Thus, I believe Kendler erred in suggesting that the mountain climber’s panic attack was “. . . ‘understandable’ and hence [a] non-pathological panic attack.” The problem is with the use of the word “hence.” That an event is understandable does not, by itself, render the event non-pathological. (Kendler, of course, is well aware of this with respect to major depressive symptoms in the context of recent bereavement, and has so argued on the DSM-5 Web site.4) Similarly, I believe Jerome Wakefield errs when he comments on the Kendler scenario, arguing that the mountain climber’s panic attack “was normal because that is precisely the context in which such intense anxiety experiences were biologically designed to occur [italics added].”5

I know of no empirical evidence that human beings are biologically “designed” to experience panic attacks in any circumstance or context—precipice or no precipice. Nor am I aware of any evidence that such intense anxiety in objectively dangerous situations is somehow advantageous to the human organism. In my view, panic attacks do not demonstrate biological design, but biology gone awry. We should not confuse anxiety with fear, which is a realistic and adaptive emotion in the face of some objective, external threat—such as a Mack truck heading straight for your car. Unlike ordinary fear, panic attacks do not prepare the endangered person for appropriate defensive action—rather, they usually incapacitate him.

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