History of Panic Attacks

History of Panic Attacks. Introduction

Anxiety is a universal human experience, and as such has been dealt with in many different ways in literature, philosophy, religion, and, of course, psychology and medicine.

The first written records describing anxiety are mentioned in the Epic of Gilgamesh in about 2000 B.C. Even the origin of the word “panic” has ancient roots. The Greeks called groundless fear “panikos.” On the other hand, the term “panic attack” or “panic disorder” are relatively young and only entered psychiatry as a diagnostic entity in the late seventies.

Panic attacks, characterized by sudden bouts of overwhelming anxiety, serve as symptomatic manifestations within various psychiatric disorders. Meanwhile, Panic Disorder emerges as a distinct diagnostic category, marked by the recurrent occurrence of panic attacks with defined frequency. Often, this disorder intertwines with agoraphobia, further complicating the clinical picture.

In essence, the evolution of the term “panic” and its psychiatric connotations reflects the continuous refinement of our understanding of anxiety and its manifestations. From its mythological origins to its contemporary clinical usage, “panic” serves as a linguistic bridge connecting ancient fears to modern psychiatric insights, elucidating the intricate interplay between language, culture, and mental health.

The aim of this article is to illuminate the history of panic attacks, tracing the evolution of our comprehension of the intriguing nature of this disorder.

Research on Panic Attacks in the 19th and 20th Century

Historically, the technical usage of “panic” diverges from its colloquial counterpart, denoting both abnormal group behaviour and acute individual states of high anxiety. This conceptual framework, formalized for the first time in the diagnostic manual, the DSM-III, underscores the evolving understanding of anxiety disorders, panic attacks and generalized anxiety, and their classification.

Sigmund Freud and the Concept of “Anxiety Neurosis”

The first description of anxiety disorders derives from Sigmund Freud. He created the first historical description of disorders that we call today “panic attacks” and “generalized anxiety disorder”. Freud described these disorders using the term: “anxiety neurosis” (German: “Angstneurose”). As he wasn’t able to identify in both conditions any visible triggers, he called them “neurosis without conflict”.

Emil Kraepelin Research on Anxiety

Kraepelin, a prominent figure in clinical psychiatry, documented cases of panic attacks and severe agoraphobia. He categorized various anxiety disorders delineating generalized anxiety characterized by pervasive worry, obsessive thoughts and compulsions. He also identified phobias, including insect phobias, agoraphobia, specific social phobia, and generalized social phobia, contributing significantly to the classification of contemporary anxiety disorders.

Walter Canon. Fight-or-Flight Response

Walter Cannon, a physiologist and the intellectual descendant of Darwin, emphasized in 1919 the crucial roles of anger and fear as a survival strategy. His work on the secretion of epinephrine from the adrenal medulla led to the development of the concept of the fight-or-flight response. Despite some misconceptions about chemical transmission, Cannon’s research legacy remains influential in contemporary research on stress.

DSM III. Differentiating Panic Disorder from Generalized Anxiety Disorder

DSM-III introduced in 1980 split anxiety disorders in two categories, Panic Disorder and Generalized Anxiety Disorder (GAD). It was the official birth date of GAD as a diagnostic category. 

One major argument for the separation of spontaneous panic disorder from generalized anxiety was the assumption that they could be identified based of response to medication. The approach was termed “pharmacological dissection.” 

A double-blind placebo-controlled study conducted by Klein had shown that patients treated with imipramine got fewer panic attacks even though their levels of generalized anticipatory anxiety remained high. However, more recent studies conducted by Kahn and colleagues have disproved that Panic Disorder is a specific indication for antidepressant therapy, whereas GAD is not responsive. Contradicting Klein’s observations, Kahn proved that antidepressants are also effective in the treatment of GAD.

Freud on Panic Attacks

Freud interpreted anxiety attacks as exacerbations of an underlying basic anxiety.

The core symptom of “anxiety neurosis,” as Freud termed the condition, because “all its components can be grouped around the main symptom of anxiety,” is called “anxious expectation.” It is based on a “usually latent but constantly lurking anxiety,” which can suddenly “break into consciousness” and “trigger an anxiety attack.” This “consists either solely of the feeling of anxiety without any associated idea or with the immediate interpretation of impending death, ‘blow,’ or impending madness…”.

Based on chronic anxiety… two groups of typical phobias develop… The first group includes the fear of snakes, thunderstorms, darkness, vermin… The other group contains agoraphobia…”.

Freud created the connection between the panic attacks without any obvious reason and phobic panic attacks triggered by certain objects or situations.

In his clinical observation Freud emphasized the relevance of unconscious conflicts and the role of psychoanalysis to uncover its source.

The Aetiology of Panic Attacks

In 1895, Sigmund Freud published a paper entitled “On the Grounds for Detaching a Particular Syndrome from Neurasthenia Under the Description ‘Anxiety Neurosis’”. In this paper he wrote:

“In some cases of anxiety neurosis, no aetiology (root cause) at all is to be discovered. It is worth noting that in such cases there is seldom any difficulty in establishing evidence of a grave hereditary taint. But where there are grounds for regarding the neurosis as an acquired one, careful enquiry directed to that end reveals that a set of noxae and influences from sexual life are the operative etiological factors”.

Freud paid attention to the fact that there is a higher occurrence of anxiety symptoms running in the members of the same family. For the cases without a family history, he related the origin of anxiety to sexual suppression.

Typical for his psychoanalytical theory Freud overestimated the role of sexuality as an etiological factor. From today’s perspective (and author’s own clinical experience) we can conclude that the Freudian link to suppressed sexuality is valid only in a very low percentage of the anxiety disorders.

Freud’s Description of Panic Attacks

On the symptomatic level Freud’s description of the anxiety neurosis correlates astonishingly well with the current description of panic attacks. In his paper on “anxiety neurosis” he wrote:

“I append here a list which includes only those forms of anxiety attack which are known to me:

(a) Anxiety attacks accompanied by disturbances of the heart action, such as palpitation.

(b) Anxiety attacks accompanied by disturbances of respiration, several forms of nervous dyspnoea, attacks resembling asthma, and the like.

(c) Attacks of sweating, often at night.

(d) Attacks of tremor and shivering which are easily confused with hysterical attacks.

(e) Attacks of ravenous hunger, often accompanied by vertigo.

(f) Diarrhoea coming on in attacks.

(g) Attacks of locomotor vertigo.

(h) Attacks of what are known as congestions, including everything that has been termed vasomotor neurasthenia.

(i) Attacks of paraesthesia (numbness). (But these seldom occur without anxiety or a similar feeling of discomfort.)”

When comparing the above presentation with the criteria in the DSM classification, the level of agreement may be quite surprising. 

From Neurosis to Disorder

Looking back on the history of panic attacks and generalized anxiety, we will find old fashioned psychoanalytical terms such as “neurosis”, “neurasthenia” or “hysteria”. Over time these words “infiltrated” common language gradually acquiring a negative overtone. In the current psychiatric nomenclature psychiatrists have replaced the terms “neurosis” or “hysteria” with the more “politically correct” word “disorder”.

History of Panic Attacks. Conclusion

In Panic attacks the sudden bouts of overwhelming anxiety appears without any obvious triggers. Panic Disorder is a distinct diagnostic category, marked by the recurrent occurrence of panic attacks with defined frequency.

In psychology, there are various theories and approaches explaining anxiety. The study of anxiety has its origins in the late 19th century. It was Sigmund Freud’s who investigated anxiety and in particular the panic attacks. Considering today’s criteria he presented the most detailed description of panic symptoms.

Freud also created the theoretical foundation of this disorder. He recognized the importance of environmental factors without neglecting the hereditary predisposition. Despite his pioneering research he was quite mistaken on the aetiology of panic attacks by overestimating the impact of sexuality.

Sources:

Freud S. The Standard Edition of the Complete Psychological Works of Sigmund Freud: (1893-1899) Early psycho-analytic publications. Strachey J, trans. London, UK: The Hogarth Press; 1962:90ff. The Standard Edition of the Complete Psychological Works of Sigmund Freud; vol 3

Freud S. Obsessions et phobies. Rev Neurol. 1895;3(2):33–38

Klein DF. Delineation of two drug-responsive anxiety syndromes. Psychopharmacologia. 1964;5:397–408. 

Kahn RJ., McNair DM., Lipman RS., et al Imipramine and chlordiazepoxide in depressive and anxiety disorders. II. Efficacy in anxious outpatients. Arch Gen Psychiatry. 1986;43(1):79–85. 

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Washington DC: American Psychiatric Association; 1980

Anderson DJ., Noyes R. Jr, Crowe RR. A comparison of panic disorder and generalized anxiety disorder. Am J Psychiatry. 1984;141(4):572–575.