Skip to main content
Log in

Summary

In this paper we discuss the theory that agoraphobic avoidances are central and spontaneous panics an epiphenomenon to the development of agoraphobia. Moreover we discuss the theory that posits a fixed cognitive-catastrophizing set as causal for panic. We conclude these theories do not fit the facts. We argue that it is important to distinguish between spontaneous panic and chronic or anticipatory anxiety and avoidance. Such a distinction allows for an understanding of the roles of anti-spontaneous panic medications such as tricyclics and MAOI's, as well as exposure therapy, in the treatment of panic disorder with agoraphobia. The former serves the purpose of blocking panic attacks while the latter undermines phobic avoidance, but only after the panic attacks have ceased through proper medication. We conclude that recognizing the key role of spontaneous panic and its variants in anxiety nosology is a necessary guide for etiological, psychophysiological and therapeutic research in this rapidly developing area.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  • Adler C, Craske MG, Barton DH (1987) Relaxation-induced panic (RIP): When resting isn't peaceful. Integrat Psychiatry 5:94–112

    Google Scholar 

  • American Psychiatric Association (1987) Diagnostic and statistical manual of mental disorders (3rd edn revised)

  • Angst J, Dobler-Mikola A (1985) The Zurich study: Anxiety and phobia in young adults. Eur Arch Psychiatr Neurol Sci 235:171–178

    Google Scholar 

  • Argyle N, Roth M (1986) The relationship of panic attacks to anxiety states and depression. In: Biological psychiatry 1985: Proceedings of the IVth World Congress of Biological Psychiatry. Shagass C, Tosiassen RC, Bridger WH, Weiss KT, Stoff D, Simpson GM. Elsevier, Amsterdam, pp 460–462

    Google Scholar 

  • Aronson TA, Logue CM (1987) On the longitudinal course over of panic disorder: Developmental history and predictors of phobic complications. Compr Psychiatry 28:344–455

    Google Scholar 

  • Bowlby J (1969) Attachment and loss, vol I: Attachment. Basic Books, New York

    Google Scholar 

  • Bowlby J (1973) Attachment and loss, vol II: Separation anxiety and anger. Basic Books, New York

    Google Scholar 

  • Brantigan CO, Brantigan TA, Joseph N (1982) Effect of beta-blockade and beta-stimulation on stage fright. Am J Med 72:88–94

    Google Scholar 

  • Breier A, Charney DS, Heninger GR (1985) The diagnostic validity of anxiety disorders and their relationship to depressive illness. Am J Psychiatry 142:787–797

    Google Scholar 

  • Breier A, Charney DS, Heninger GR (1986) Agoraphobia with panic attacks: Development, diagnostic stability and course of illness. Arch Gen Psychiatry 43:1029–1036

    Google Scholar 

  • Brown FW (1942) Heredity in the psychoneuroses. Proc Soc Med 35:785–790

    Google Scholar 

  • Buigues J, Vallejo J (1987) Therapeutic response to phenelzine in patients with panic disorder and agoraphobia with panic attacks. J Clin Psychiatry 48:55–59

    Google Scholar 

  • Burns LE, Thorpe GL (1977) The epidemiology of fears and phobias. J Int Med Res 5 : [Suppl 107]

  • Carey G, Gottesman II (1981) Twin and family studies of anxiety, phobic and obsessive disorders. In: Klein DF, Rabkin J (eds) Anxiety: new research and changing concepts. Raven Press, New York

    Google Scholar 

  • Charney DS, Woods SW, Goodman WK, Kifkin B, Kinch M, Aiken B, Quadrino LM, Heninger G (1986) Drug treatment of panic disorder: the comparative efficacy of imipramine, alprazolam and trazadone. J Clin Psychiatry 47:580–585

    Google Scholar 

  • Clark DM (1986) A cognitive approach to panic. Behav Res Ther 24:461–470

    Google Scholar 

  • Cloninger RC, Martin RL, Clayton P, Guze SB (1981) A blind follow-up and family study of anxiety neurosis: Preliminary analysis of the St. Louis 500. In: Klein DF, Rabkin J (eds) Anxiety: New research and changing concepts. Raven Press, New York, pp 137–154

    Google Scholar 

  • Cloninger RC (1987) Recent advances in the genetics of anxiety and somatoform disorders. In: Meitzer HY (ed) Psychopharmacology: the third generation of progress. Raven Press, New York

    Google Scholar 

  • Clum GA, Pendrey D (1987) Depression symptomatology as a non-requisite for successful treatment of panic with antidepressant medications. J Anxiety Dis 1:337–344

    Google Scholar 

  • Cohen ME (1951) The high familial prevalence of neurocirculatory asthenia (anxiety neurosis, effort syndrome). Am J Hum Genet 3:126–158

    Google Scholar 

  • Crowe RR (1985) The genetics of panic disorder and agoraphobia. Psychiatr Dev 2:171–186

    Google Scholar 

  • Crowe RR, Noyes R, Pauls DL, Slymen D (1983) A family study of panic disorder. Arch Gen Psychiatry 40:1065–1069

    Google Scholar 

  • Crowe RR, Noyes R, Wilson AF, Elston RC, Ward LJ (1987) A linkage study of panic disorder. Arch Gen Psychiatry 44:933–937

    Google Scholar 

  • Freud S (1895) Obsessions and phobias; their psychical mechanisms and their aetiology. Collected papers, vol 1. (Translated by Riviere J) Hogarth Press, London 1924

    Google Scholar 

  • Fyer AJ (1988) Discontinuation of antipanic medication. In: Hand I, Wittchen HV (eds) Panic and Phobia II. Springer, Berlin Heidelberg New York

    Google Scholar 

  • Garakani H, Zitrin CM, Klein DF (1984) Treatment of panic disorder with imipramine alone. Am J Psychiatry 141:446–448

    Google Scholar 

  • Garvey MJ, Tuason VB (1984) The relationship of panic disorder to agoraphobia. Compr Psychiatry 25:529–531

    Google Scholar 

  • Gloger S, Grunhaus L, Pirmacher B, Troudart T (1981) Treatment of spontaneous panic attacks with chlomipramine. Am J Psychiatry 138:1215–1217

    Google Scholar 

  • Gorman J, Levy GF, Liebowitz MR, McGrath P, Appleby IL, Dillon DJ, Davies SO, Klein DF (1983) The effect of acute beta-adrenergic blockade on lactate induced panic. Arch Gen Psychiatry 40:1079–1083

    Google Scholar 

  • Gorman J, Askanazi J, Liebowitz MR, Fyer AJ, Stein J, Kinney JM, Klein DF (1984) Response to hyperventilation in a group of patients with panic disorder. Am J Psychiatry 141:857–861

    Google Scholar 

  • Gorman JM, Fyer MR, Goetz R, Askanazi J, Liebowitz MR, Fyer AJ, Kinney J, Klein DF (1988) Ventilatory physiology of patients with panic disorder. Arch Gen Psychiatry 45:31–42

    Google Scholar 

  • Grunhaus L, Gloger S, Branacker B, Palmer C, Ben-David M (1983) Prolactin response to the cold pressor test in patients with panic attacks. Psychiatr Res 8:171–177

    Google Scholar 

  • Gurney C, Roth M, Garside RF, Kerr TA, Schapira K (1972) Studies in the classification of affective disorders. The relationship between anxiety states and depressive illness — II. Br J Psychiatry 121:162–166

    Google Scholar 

  • Hafner J, Milton F (1977) The influence of propranolol on the exposure in vivo of agoraphobics. Psychol Med 7:419–425

    Google Scholar 

  • Harris EL, Noyes R, Crower RR, Chaudhry DR (1983) Family study of agoraphobia. Arch Gen Psychiatry 40:1061–1064

    Google Scholar 

  • Hartley LR, Ungapen S, Davie I, Spencer DJ (1983) The effect of beta-adrenergic blocking drugs on speakers' performance and memory. Br J Psychiatry 142:512–517

    Google Scholar 

  • Hoehn-Saric R, McLeod DR (1985) Generalized anxiety disorder. Psychiatr Clin North Am 8:73–88

    Google Scholar 

  • Johnstone EC, Owens Cunningham DG, Frith CD, MiPherson K, Dowie C, Riley G, Gold A (1980) Neurotic illness and it response to anxiolytic and antidepressant treatment. Psychol Med 10:321–328

    Google Scholar 

  • Kahn RJ, McNair DM, Covi L, Downing RW, Fisher S, Lipman RS, Kickels K, Smith V (1981) Affects of psychotropic agents on high anxiety subjects. Psychopharmacol Bull 17:97–100

    Google Scholar 

  • Kahn RJ, McNair DM, Lipman RS, Covi L, Rickels K, Douning R, Fisher S, Frankenthaler LM (1986) Imipramine and chloridiazepoxide in depressive and anxiety disorders: 2. Efficacy in anxious outpatients. Arch Gen Psychiatry 43:79–85

    Google Scholar 

  • Katon W (1984) Panic disorder and somatization. Am J Med 77:101–106

    Google Scholar 

  • Katon W, Vitaliano PP, Anduson K, Jones M, Russo J (1987) Panic Disorder: Residual symptoms after the acute attacks abate. Compr Psychiatry 28:151–158

    Google Scholar 

  • Kelly D, Gvirquis W, Frommer E, Mitchell-Heggs N, Sargant W (1970) Treatment of phobic states with antidepressants: A retrospective study of 246 patients. Br J Psychiatry 116:387–398

    Google Scholar 

  • Kelly D, Mitchell-Heggs N, Sherman D (1971) Anxiety and the effects of sodium lactate assessed clinically and physiologically. Br J Psychiatry 119:129–141

    Google Scholar 

  • Kendler K, Heath A, Martin NG, Eaves LJ (1986) Symptoms of anxiety and depression in a volunteer twin population: the etiologic role of genetic and environmental factors. Arch Gen Psychiatry 43:213–221

    Google Scholar 

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

    Google Scholar 

  • Klein DF (1967) Importance of psychiatric diagnosis in prediction of clinical drug effects. Arch Gen Psychiatry 16:118–126

    Google Scholar 

  • Klein DF (1973) Drug therapy as a means of syndromal identification and nosological revision. In: Cole JO, Freedman AM, Friedhof AJ (eds) Psychopathology and psychopharmacology. The John Hopkins Press, Baltimore, pp 143–160

    Google Scholar 

  • Klein DF (1978) A proposed definition of mental illness. In: Spitzer R, Klein DF (eds) Critical issues in psychiatric diagnosis. Raven Press, New York, pp 41–71

    Google Scholar 

  • Klein DF (1983) Is the antipanic acitvity of antidepressant medication a reflection of antidepressant effects? Integrat Psychiatry 1:26–27

    Google Scholar 

  • Klein DF (1987) Anxiety reconceptualized. Gleaning from pharmacological dissection — early experience with imipramine and anxiety. In: Klein DF (ed) Anxiety. Karger, Basel

    Google Scholar 

  • Klein DF, Fink M (1962) Psychiatric reaction patterns to imipramine. Am J Psychiatry 119:432–438

    Google Scholar 

  • Klein DF, Ross DC, Cohen D (1987) Panic and avoidance in agoraphobia: Application of path analysis to treatment studies. Arch Gen Psychiatry 44:377–385

    Google Scholar 

  • Klein DF, Mein HM (1988) The definition and psychopharmacology of spontaneous panic and phobia: A critical review I. In: Tyrer P (ed) Psychopharmacology of anxiety. Oxford University Press

  • Kleiner L, Marshall WL (1987) The role of interpersonal problems in the development of agoraphobia with panic attacks. J Anxiety Dis 1:313–323

    Google Scholar 

  • Koenigsberg HW, Pollack C, Sullivan T (1987) The sleep lactate infusion. Arousal and the panic mechanism. Biol Psychiatry 22:789–791

    Google Scholar 

  • Leckman JS, Weissman MM, Merikangas KR, Paulo DL, Prusoff BA (1983) Panic disorder and major depression: increased risk of major depression, alcoholism, panic and phobic disorders in families of depressed probands with panic disorder. Arch Gen Psychiatry 40:1055–1060

    Google Scholar 

  • Liebowitz MR, Gorman JM, Fyer AJ, Levitt M, Dillon D, Levy G, Appleby IL, Anderson S, Palij M, Davies SO, Klein DF (1985) Lactate provocation of panic attacks: II. Biochemical and physiological findings. Arch Gen Psychiatry 42:709–719

    Google Scholar 

  • Lipman RS, Covi L, Rickels K, McNair OM, Downing R, Kahn RJ, Lasseter VK, Faden V (1986) Imipramine and chlordiazepoxide in depressive and anxiety disorders: I. Efficacy in depressed outpatients. Arch Gen Psychiatry 43:68–77

    Google Scholar 

  • Lydiard BR (1987) Emergence of depressive symptoms in patients receiving alprazolam for panic disorder. Am J Psychiatry 144:664–665

    Google Scholar 

  • Mann JJ, Aarons SF, Frames AJ, Brown RD (1984) Studies of selective and reversible monoamine oxidase inhibitors. J Clin Psychiatry 45:62–66

    Google Scholar 

  • Marks IM (1983) Are there anticompulsive or antiphobic drugs? Review of the evidence. Br J Psychiatry 143:338–347

    Google Scholar 

  • Marks IM (1987) Fears, phobias and rituals: Panic, anxiety and their disorders. Oxford University Press, Oxford

    Google Scholar 

  • Mavissakalian M, Michelson L, Dealy RS (1983) Pharmacological treatment of agoraphobia: Imipramine vs. imipramine with programmed practice. Br J Psychiatry 143:348–355

    Google Scholar 

  • McInnes RG (1937) Observations on heredity and neurosis. Proc R Acad Med 30:895–904

    Google Scholar 

  • McNair DM, Kahn RJ (1981) Imipramine compared with a benzodiazepine for agoraphobia. In: Klein DF, Rabkin J (eds) Anxiety: New research and changing concepts. Raven Press, New York

    Google Scholar 

  • Mendel JGC, Klein DF (1969) Anxiety attacks with subsequent agoraphobia. Compr Psychiatry 10:190–195

    Google Scholar 

  • Modigh K (1987) Antidepressant drugs in anxiety disorders. Acta Psychiatr Scand 76[Suppl 335]:57–73

    Google Scholar 

  • Mountjoy CQ, Roth M, Garside RF, Leitch IM (1977) A clinical trial of phenelzine in anxiety depressive and phobic neuroses. Br J Psychiatry 131:486–492

    Google Scholar 

  • Munjack DJ, Rebal R, Shaner R, Staples F, Braun R, Leonard M (1985) Imipramine vs propranolol for the treatment of panic attacks: A pilot study. Compr Psychiatry 26:80–89

    Google Scholar 

  • Muskin PR, Fyer AJ (1981) Treatment of panic disorder. J Clin Psychopharmacol 1:81–90

    Google Scholar 

  • Neftel KA, Adler RH, Kappeli L, Rossi M, Dolder M, Käser HE, Bryggesser HH, Vorkauf H (1982) Stage fright in musicians: A model illustrating the effect of beta-blockers. Psychosom Med 44:461–469

    Google Scholar 

  • Norton GR, Hamson B, Hauch J, Khodes L (1985) Characteristics of people with infrequent panic attacks. J Abnorm Psychol 94:216–221

    Google Scholar 

  • Noyes R, Clancy J, Crowe R, Hoenk PR, Slymen DJ (1978) The familial prevalence of anxiety neurosis. Arch Gen Psychiatry 35:1057–1059

    Google Scholar 

  • Noyes R (1984) Diazepam and propranololin panic disorder and agoraphobia. Arch Gen Psychiatry 41:287–292

    Google Scholar 

  • Noyes R, Crowe RR, Harris EL, Haura BJ, McChesney CM, Chandhry DR (1986) Relationship between panic disorder and agoraphobia: a family study. Arch Gen Psychiatry 43:227–232

    Google Scholar 

  • Noyes R, Clarkson C, Crowe RR, Yates WR, McChesney CM (1987a) A family study of generalized anxiety disorder. Am J Psychiatry 144:1019–1024

    Google Scholar 

  • Nurnberg HG, Coccaro EF (1982) Response of panic disorder and resistance of depression to imipramine. Am J Psychiatry 139:1060–1062

    Google Scholar 

  • Nutt DJ (1986) Increased central alpha2-adrenoceptor sensitivity in panic disorder. Psychopharmacology 90:268–269

    Google Scholar 

  • Pauls DF, Bucher KD, Crowe RR, Noyes R (1980) A genetic study of panic disorder pedigrees. Am J Hum Genet 32:639–644

    Google Scholar 

  • Pitts FN, Allen RE (1979) Biochemical induction of anxiety. In: Fann WE (ed) Phenomenology and treatment of anxiety. Medical and Scientific Books, New York, pp 125–140

    Google Scholar 

  • Roth M, Gurney C, Garside RF, Kerr TA (1972) Studies in the classification of affective disorders. The relatioship between anxiety states and depressive illnesses. Br J Psychiatry 121:147–161

    Google Scholar 

  • Roy-Byrne P, Uhde TW, Post RM, King AC, Buchsbaum MS (1985) Normal pain sensitivity in patients with panic, disorder. Psychiatry Res 14:75–82

    Google Scholar 

  • Roy-Byrne P, Uhde TW, Post RM (1986) Effect of one night's sleep deprivation on mood and behavior in panic disorder. Arch Gen Psychiatry 43:895–899

    Google Scholar 

  • Schweizer E et al., Winokur A, Rickels K (1986) Insulin-induced hypoglycemia and panic attacks. Am J Psychiatry 143:654–655

    Google Scholar 

  • Sheehan DV, Ballenser J, Jacobsen G (1980) Treatment of endogenous anxiety with phobic, hysterical and hypochondriacal symptoms. Arch Gen Psychiatry 37:51–59

    Google Scholar 

  • Sheehan DV, Davidson J, Manschreck T, Van Wyck Fleet J (1983) Lack of efficacy of new antidepressant (bupropion) in the treatment of panic disorder with phobias. J Clin Psychopharmacol 3:28–31

    Google Scholar 

  • Sheehan DV, Ballenger J, Jacobsen G (1980) Treatment of endogenous anxiety with phobic, hysterical and hypochondriacal symptoms. Arch Gen Psychiatry 37:51–59

    Google Scholar 

  • Slater E, Shields J (1969) Genetical aspects of anxiety. Br J Psychiatry (special publication) 3:62–71

    Google Scholar 

  • Teasdale J (1988) Cognitive models and treatments for panic: A critical evaluation. In: Rachmann S, Maser JD (eds) Panic: Psychological Perspectives. Hillsdale, N. J.: Lawrence Erlbaum Assoc

    Google Scholar 

  • Telch MJ, Agras WS, Taylor CB, Roth WT, Gallen CC (1985) Combined pharmacological and behavioral treatment for agoraphobia. Behav Res Ther 23:325–335

    Google Scholar 

  • Thyer BA, Himle J (1985) Temporal relationship between panic attack onset and phobic avoidance in agoraphobia. Behav Res Ther 23:607–608

    Google Scholar 

  • Thyer BA, Himle J (1987) Phobic anxiety and panic anxiety: How do they differ? J Anx Dis 1:59–67

    Google Scholar 

  • Thyer BA, Himle J, Curtis GC, Cameron OG, Nesse RM (1985) A comparison of panic disorder an agoraphobia with panic attacks. Compr Psychiatry 26:208–214

    Google Scholar 

  • Torgersen S (1983) Genetic factors in anxiety disorders. Arch Gen Psychiatry 40:1085–1089

    Google Scholar 

  • Torgersen S (1985) Hereditary differentiation of anxiety and affective neuroses. Br J Psychiatry 146:530–534

    Google Scholar 

  • Tyrer P (1973) A study of the clinical effects of phenelzine and placebo in the treatment of phobic anxiety. Psychopharmacologia (Berl) 32:237–254

    Google Scholar 

  • Tyrer P, Gardner M, Lambourn J, Whitford M (1980) Clinical and pharmacokinetic factors affecting response to phenelzine. Br J Psychiatry 136:359–365

    Google Scholar 

  • Tyrer P (1986) Classification of anxiety disorders: A critique of DSM-III. J Affective Dis 11:99–104

    Google Scholar 

  • Uhde T, Boulenger JP, Roy-Byrne PP, Geraci MF, Vittone BJ, Post RM (1985) Longitudinal course of panic disorder. Prog Neuropsychopharmacol Biol Psychiatry 9:39–51

    Google Scholar 

  • Uhde T, Vittone BJ, Post RM (1984) Glucose tolerance testing in panic disorder. Am J Psychiatry 141:1461–1463

    Google Scholar 

  • Weissman MM, Leaf BJ, Blazer DG, Boyd JH, Florio L (1986) Panic disorder: clinical, characteristics, epidemiology and treatment. Psychopharmacol Bull 22:787–791

    Google Scholar 

  • Woods SW, Charney DS, McPherson GA, Gradman AH, Heninger GR (1987) Situational panic attacks: Behavioral; physiologic and biochemical characterization. Arch Gen Psychiatry 44:365–375

    Google Scholar 

  • World Health Organization, ICD-10, Draft of Chapter V. Categories F00-1799: Mental, behavioural and developmental disorders, clinical descriptions and diagnostic guidelines (June 1987 draft for field trials), Geneva, 1987

  • Zitrin CM, Klein DF, Woerner MG (1978) Behavior therapy, supportive psychotherapy, imipramine, and phobias. Arch Gen Psychiatry 35:307–316

    Google Scholar 

  • Zitrin CM, Klein DF, Woerner MG (1980) Treatment of agoraphobia with group exposure in vivo and imipramine. Arch Gen Psychiatry 37:63–72

    Google Scholar 

  • Zitrin CM, Klein DF, Woerner MG, Ross DC (1983) Treatment of phobias. 1. Comparison of imipramine hydrochloride and placebo. Arch Gen Psychiatry 40:125–138

    Google Scholar 

  • Zajonc RB (1984) On the primacy of affect. Am Psychol 39:117–123

    Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Additional information

Parts of this article were presented on the occasion of the inauguration ceremony of the Department of Psychiatry of the University of Mainz on April 2 and 3, 1987

Rights and permissions

Reprints and permissions

About this article

Cite this article

Klein, D.F., Klein, H.M. The utility of the panic disorder concept. Eur Arch Psychiatr Neurol Sci 238, 268–279 (1989). https://doi.org/10.1007/BF00449808

Download citation

  • Received:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF00449808

Key words

Navigation