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

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

Richard Maddock has pointed out that it is theoretically possible for a patient to meet DSM-IV panic attack criteria with only 4 of 13 possible symptoms (eg, tachycardia, sweating, sensations associated with increased respirations, and a fear of dying). In theory, under some threatening circumstances, these particular fear-related symptoms might be adaptive—but patients with such limited panic symptoms are almost never seen in clinical practice. Maddock notes: “Although the simple DSM-IV definition of a panic attack can capture some adaptive fear or stress responses, I believe this has no bearing on clinical practice” (personal communication, November 25, 2012).

It is erroneous to claim that labeling a panic attack as “pathological” or “disordered” represents a “false positive,” if the attack occurs in an understandable context.5 Indeed, the entire notion of a false positive in psychiatry rests on an unproved ontological assumption—ie, that there exist natural types of disease entities (taxons) defined by necessary and sufficient criteria, against which diagnostic claims may be deemed false.6 Lilienfeld notes, “Such terms as ‘false positives’ and ‘overdiagnosis’ carry no ontological meaning in the absence of a taxon [a genuine category that exists in nature], as they presume the existence of at least some true breaking point in nature.”7

One possible reason for confusion among contextualists is the overlap in DSM criteria for panic attack with what traditionally has been called the fight or flight response, or the general adaptation syndrome (GAS), first characterized by Selye.8 Most physiologists would indeed regard the GAS as an evolution-based adaptation to acute stress. But despite some overlapping features with panic attacks (eg, adrenergic activation, tachycardia, increased respiratory rate, sweating), the GAS is a fundamentally different process. For example, the GAS usually lacks such panic-specific features as a feeling of choking, chest pain, nausea, dizziness, fear of going crazy, derealization, or paresthesias—none of which appears adaptive.

Although research is still incomplete, there is reason to believe that the physiology of a panic attack differs from that of the prototypical fight or flight response. Maddock, one of the foremost researchers in the area of panic disorder, notes:

. . . panic attacks are dysfunctional, while ordinary fight or flight responses are generally adaptive. From the perspective of physiological data supporting this distinction, one difference immediately comes to mind. In the GAS response, elevated [serum] cortisol is the norm. However, elevated cortisol is distinctly the exception during panic attacks (personal communication, November 16, 2012).

Indeed, panic attacks appear to share more features with acute coronary syndrome—basically, myocardial ischemia—than with the GAS.9 Moreover—unlike the GAS—panic attacks predict onset and severity of psychopathology beyond anxiety disorders.10 Whereas the GAS is adaptive—at least, in its earliest stages—it is far from clear that any panic attack, under any circumstances, is ever normal or adaptive. Insofar as it is experienced as terrifying, crippling, death-dealing, or debilitating, a panic attack is always pathological (from pathos, meaning “suffering”) and disordered. That said, a single panic attack does not qualify as a discrete disorder, nor does it merit diagnosis of a specific disease entity. Thus, to diagnose panic disorder, DSM-5 requires additional features, such as recurrent attacks and maladaptive changes in behavior.

The second part of this article further explores the role of context in psychiatric diagnosis.

Acknowledgments—My sincere appreciation to Dr Richard Maddock and Dr Sidney Zisook for their helpful comments and suggestions on early drafts or portions of this essay.



1. Zisook S, Corruble E, Duan N, et al. The bereavement exclusion and DSM-5 [published correction appears in Depress Anxiety. 2012;29:665]. Depress Anxiety. 2012;29:425-443.
2. Horwitz AV, Wakefield JC. The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. New York: Oxford University Press; 2007.
3. Kendler KS. Review of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=1595220. Accessed January 4, 2013.
4. Kendler KS. American Psychiatric Association, 2010. http://www.dsm5.org/about/Documents/grief%20exclusion_Kendler.pdf. Accessed November 23, 2012.
5. Wakefield JC. Misdiagnosing normality: psychiatry’s failure to address the problem of false positive diagnoses of mental disorder in a changing professional environment. J Ment Health. 2010;19:337-351.
6. Lilienfeld SO, Marino L. Essentialism revisited: evolutionary theory and the concept of mental disorder. J Abnorm Psychol. 1999;108:400-411.
7. Lilienfeld SO. Book review of: Horwitz AV, Wakefield JC. The Loss of Sadness. Soc Serv Rev. 2009;83:473-477.
8. Selye H. Forty years of stress research: principal remaining problems and misconceptions. CMAJ. 1976;115:53-56.
9. Soh KC, Lee C. Panic attack and its correlation with acute coronary syndrome—more than just a diagnosis of exclusion. Ann Acad Med Singapore. 2010;39:197-202.
10. Craske MG, Kircanski K, Epstein A, et al; DSM V Anxiety; OC Spectrum; Posttraumatic and Dissociative Disorder Work Group. Panic disorder: a review of DSM-IV panic disorder and proposals for DSM-V. Depress Anxiety. 2010;27:93-112.



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