Consensus statement: panic disorder

A historical inquiry into the appropriateness of the term "panic disorder"

Panic disorder was introduced in the standard psychiatric nosology with the publication of the DSM-III in 1980. The myriad of earlier medical and psychiatric names describing anxiety attacks and related conditions were all abandoned, being housed under the term "panic attack and panic disorder". In this paper, the rationale and the appropriateness of this term are critically examined from a historical perspective. First, a brief historical account of anxiety that comes in the episodic form, and the medical and psychiatric terminology that emerged during the last two centuries regarding this condition, are presented. Next, the origins of the concept of panic as a collective or individual fear reaction are traced from a mythological and historical standpoint, up to its current, almost accidental, introduction into the official psychiatric diagnostic systems. Since the word "panic" has its roots in the Greek god Pan and the unpleasant states inflicted by him, this god is described, as well as St Gilles - also known as St Aegidios, the Athenian - the healing saint for those suffering from panic, honor and phobias. Finally, the current diagnostic features of panic disorder are systematically compared with the corresponding troubles inflicted on people by the mythical god Pan. It is concluded that the introduced term "panic" appropriately and successfully replaced the old ones.

The psychobiology of anxiolytic drugs. Part 1: Basic neurobiology

The authors provide an overview of the current state of knowledge with regards to the neurobiological mechanisms involved in normal and pathological anxiety. A brief review of the classification and cognitive psychology of anxiety is followed by a more in-depth look at the neuroanatomical and neurochemical processes and their relevance to our understanding of the modes of action of anxiolytic drugs. The serotonergic, noradrenergic, and gamma-aminobutyric acidergic systems are reviewed. The numerous physiological and pharmacological methods of anxiety provocation and the increasing importance of functional neuroimaging are also examined. The review provides an overview of the biology and basic pharmacology of anxiolytic drugs, and compliments the more clinically oriented companion review.

Panic disorder: clinical perspectives

The evolution of the concept of panic disorder is described and its utility in identifying treatment strategies outlined. Some data are provided which may account for the female preponderance in diagnosed cases. In discussing the continuing role of benzodiazepines the curious history of their progressive restriction in Britain is described. Component and cluster analysis of the phenomena associated with panic attacks provides unexpected support for Klein's theory linking the disorder with an evolved alarm mechanism for suffocation. Current concepts on treatment are briefly reviewed.

Drug treatment of panic disorder. Comparative efficacy of alprazolam, imipramine, and placebo. Cross-National Collaborative Panic Study, Second Phase Investigators

The Cross-National Collaborative Panic Study, Phase Two, compared alprazolam with imipramine and with placebo in a sample of 1168 randomly assigned subjects. The study, conducted at 12 centres, assessed clinical change over eight weeks of double-blind drug treatment. Improvement occurred with alprazolam by week 1 and 2, and with imipramine by week 4. By the end of week 8, however, the effects of the two active drugs were similar to each other, and both were superior to placebo for most outcome measures.

The pharmacology of human anxiety

The human pharmacology of anxiety disorders, including panic disorder, is detailed. The major theories center around the role of benzodiazepine receptor, noradrenergic and serotonergic dysfunction. The contribution that challenge tests with lactate, hyper- and hypocapnia, beta- and alpha-2-adrenoceptor agonists, peptides, pentylenetetrazol, and caffeine make to our understanding of the biological basis of anxiety and these major theories are described and discussed.

The neurochemistry of anxiety: an update

1. Recent neurochemical investigations have enhanced our understanding of the anxiety disorders. Emphasis has been placed on dysfunction in central benzodiazepine, serotonergic and noradrenergic systems. 2. Changes in activity of endogenous ligands for the benzodiazepine receptor or in benzodiazepine receptor sensitivity appear to modulate anxiety. 3. There is evidence of serotonergic involvement in anxiety, in that serotonin agonists may increase anxiety, whilst drugs that reduce serotonin function are anxiolytic. 4. Noradrenergic dysfunction, especially that of alpha-2-adrenoceptors, provides the strongest etiological evidence in the development of anxiety. 5. A number of testable hypotheses can be generated from our present knowledge. As a result, new and more specific treatments may become apparent for the anxiety disorders.

Working with general practitioners

Psychiatrists and general practitioners have found new ways of working together in the last ten years, but there have also been separate activities which could develop into rivalry. These opportunities and dangers are the central theme of this paper. Ways are considered in which the psychiatry of general practice differs from the experience of psychiatrists. Forms of help are suggested which general practitioners need from psychiatrists, whether in clinical practice or education.