Among my concerns of visiting Jon and Philip was how such a trip might affect my disability status. Enduring difficult travel to attend a health conference was one thing, but taking such a trip to "simply visit friends" could easily be misunderstood during a disability review. This troubled me a great deal because, honestly, I'm not sure how I'd survive without disability support. Many people just don't understand the dramatic fluctuations of panic disorder and how unpredictable the windows of brief 'functional' time can be.

I personally knew that visiting Jon and Philip would be more than just a simple visit with friends. The three of us shared panic disorder and we were all well educated in our conditions. Living in different countries, we had somewhat different clinical experiences. Our in-person meeting had potential for gaining new and constructive insights. Besides, the chances of us touring about were essentially nil. Jon rarely went far from his home, Philip warned me that he might never leave his apartment, and we all understood that our panic attacks could cripple any of us at any time. Our time together would be more like informal group therapy than anything resembling a vacation.

A comment I made to Jon and Philip seems almost prophetic in hindsight. On several occasions I wrote to them saying, "If only there was some kind of panic disorder conference in Europe, I would have the perfect excuse to visit you." Such a conference would somewhat allay my fears of such a trip being misunderstood. Eventually, the old adage "Be careful of what you wish for" became a reality. In early March, 2003, I stumbled upon a post in the ASAP group regarding a conference on panic attacks that would take place in London. The post mentioned a web site for the conference which I promptly visited.

The conference web site announced, "The 1st International Conference on Psychophysiology of Panic Attacks." The conference would take place at the University of Westminster, Harrow Campus, London, September 5th through 8th, 2003. The conference organizers were seeking presenters and a web page was set up for on-line submission of abstracts (brief descriptions of presentations) to be reviewed and considered by a committee. However, the overall tone of the site seemed directed towards researchers, clinicians and formal students. As simply a patient, I really wasn't sure if they would accept me as an attendee, to say nothing of being accepted as a presenter.

I had no idea if I would be welcome to the conference in any way. Nonetheless, the opportunity was simply too tempting to neglect. I needed to learn more about my disorder, I wanted to better understand the international perspectives, I had much experience to express and it was hard to imagine a better excuse to visit Jon and Philip. I was very anxious about submitting an abstract, but felt I had nothing to lose by trying. If they accepted my abstract and welcomed me as a speaker, I would be very happy despite massive performance anxiety. If they rejected me, my disappointment would be tempered by relief from performance anxiety and the good knowledge that I had given it a try. Either way, submitting an abstract would be a positive experience for me.

My main concern now was deciding upon a good subject for my abstract. Having no formal academic nor clinical training regarding anxiety disorders, there were limits to what I could speak about with acceptable authority. As with past conferences, I would have to openly acknowledge that I am a patient and focus on patient perspectives of interest to health professionals. Only in this manner could I hope to offer something of unique value that might be seriously appreciated by everyone.

After much thought I submitted an abstract entitled, "A Comparison of Physiological Panic Disorder with Psychological Trauma." This would be a personal "case study" of my own experience confronting both panic disorder and post-traumatic stress disorder (PTSD) at the same time, under the same therapeutic conditions, and with differing responses to therapies. My hope was to show the contrast between the medical and psychological forms of anxiety disorders, their overlap and the need for improved diagnostic methods on the level of the individual patient.

With a frightening degree of irony, I received paperwork for my next disability review the day after submitting my conference abstract (March 5). This disability review came nearly a year before I expected. I'm always terribly anxious about these reviews, but the coincidence with the conference greatly complicated my anxieties. I promptly filled out the disability forms, answering numerous questions about various aspects of my life. I was entirely honest, but I didn't volunteer information about my uncertain future with the conference or hopes to visit distant friends with similar disorders. I mailed the forms back to the Social Security Disability office and hoped for the best.

Following several weeks of uncertainty and insecurity, I finally received an e-mail from the conference committee (March 31). My abstract had been accepted! I had been accepted as a presenter and would speak at the conference! My heart soared, I indulged a brief victory dance, and I spent the rest of the day feeling like the most fortunate person in the world! The next day, however, reality began to sink in and I knew that I had a big task and much responsibility to live up to.

My first priority for speaking at the conference was ensuring that I could actually get myself there. Since the conference was in another country, I needed a valid passport. Having been mostly house-bound for many years, virtually all my forms of identification (ID) were either old or expired (expired driver's license, long expired passport, etc.). I searched desperately for my birth certificate, but couldn't find it anywhere. Fortunately, my old expired passport proved adequate and I was able to successfully apply for my new passport at the main post office.

I also needed to arrange an International Money Order (IMO) to pay my conference fee. Such conference fees were necessary because there was little or no financial support for the conference, so everyone participating needed to chip in to cover facility costs and the like. It seemed a good idea to take care of this IMO while in the process of renewing my passport. I spent several hours walking from bank to bank, but no one was willing to process an IMO for me without a currently valid ID! To make matters worse, I was becoming a sweaty and anxious wreck walking about the city and I'm sure my appearance didn't inspire much confidence after a while. Fortunately, I was able to find one place that would accept my stamped "passport renewal receipt" as valid ID. After a few more hikes to and from the post office, my IMO was safely on it's way to London.

My next step was to actually write my conference paper. Writing this paper would, of course, be the most time consuming aspect of my preparations. However, I was deeply familiar with the material and seemed to have a full five months before the conference. I felt very little pressure at first, yet I also knew how such things could easily drag on and I couldn't predict anxiety related cognitive complications. I also wasn't exactly sure when the conference committee might want my paper; a month or more before the conference, or sometime after the actual event? From early April onward, I intensely devoted my functional time to writing my paper.

Part 2 - Clinical Diversions

On May 2nd I received notice of my disability review "examination!" As with previous disability reviews, having filled out the questionnaire and mailed it back a while ago would not be adequate. I was required to meet with a state assigned doctor who would then interview me and submit a report on my case. Despite having been through such exams twice before over the years, they always made me a nervous wreck. I was all too familiar with how often panic disorder had been misunderstood in the past, so the notion of an unfamiliar doctor evaluating my case was always a great source of anxiety to me. More so now as I was in the midst of preparing a trip overseas to speak at an international conference. I was terribly worried that my efforts to seek information on my condition had turned into a kind of bureaucratic minefield that might explode on me at any moment. Nonetheless, this exam was scheduled for May 30th (four weeks away) and I tried to stay focused on writing my paper.

The day of my disability exam eventually arrived. Naturally, I was very nervous. As with my earlier paperwork I would be honest, yet I didn't want to volunteer any information that might complicate perceptions of my case. The doctor I met was a very nice man. The questions he asked me were similar to questions that my many previous doctors and therapists had asked. We focused mainly on the symptomology of my disorder and how it affected my routine tasks. Fortunately, no questions directly addressed issues relating to the conference. Had I been asked such questions, I certainly would have responded honestly and explained the conference's importance to my health situation. After about 45-minutes, the exam concluded pleasantly and I felt some relief afterwards. Still, I knew this doctor didn't make the actual decision on my case, so I would remain somewhat anxious until receiving a formal letter from Social Security Disability sometime in the near future.

During this time, and for years prior, I had enjoyed a good relationship with my primary care physician. Even though he didn't specialize in psychiatry or neurology, he respected my perspectives of panic disorder and had been very supportive. However, he did work within a huge and growing university hospital with a complex and changing infrastructure that was bound to cause problems eventually. Without going into tedious detail, my case had fallen into a state of outrageous neglect within the last year. This really wasn't my doctor's fault, but rather a collection of communication errors between staff, labs and various departments. Once I confronted my doctor with my case's recent neglect, he instantly took action to resolve these issues. As I relentlessly paced his office in a state of obvious anxiety, he quickly rescheduled lab tests and promptly arranged a review of my case at the university's "Outpatient Psychiatry Clinic."

In the month of June, I had three appointments with the Outpatient Psychiatry Clinic. The first two appointments addressed both medication and psychotherapy issues. To their credit, they encouraged a combination of medication and Cognitive Behavioral Therapy (CBT) for my panic disorder. They first suggested I try some serotonin related medications, but I rejected this because of past bad reactions to similar medication. They also suggested regular, rather than PRN (as needed), use of benzodiazepine medications, but I rejected this based on the very episodic nature of my panic attacks (regularly dosing an episodic disorder seemed like over-medicating to me). They tried to be very persuasive saying, "These approaches generally worked best for our panic disorder patients." However, I really felt that they were ignoring important aspects of my own case history in favor of general treatment statistics. Despite having much CBT experience, I was willing to embrace more CBT without changes to my medication. Yet, because I rejected their pharmaceutical suggestions, they surprisingly dismissed the option of further CBT. I would simply continue my PRN use of Xanax and explore further psychotherapy options.

My third appointment at the clinic was strictly psychological. I had one consultation (initial session) with a psychologist who had a special interest in panic disorder. For a while, we had a very interesting conversation. He was a bright person and I would have enjoyed regular sessions with him. Yet he increasingly leaned towards the theory that my panic attacks were based on some mysterious repressed trauma. I explained that I had spent many years with therapists trying to uncover such a supposed trauma, but never found anything (even with regression hypnosis). His offer of further sessions at $50 (at least half the usual rate) was very tempting, but I didn't feel his approach was going in the right direction for my case. He gave me his card and said that I could make an appointment should I change my mind.

In the absence of any perceived progress with the clinic, I came to see the conference as my next best hope for further clinical insight. After all, presenting my personal case to an international group of panic disorder experts seemed an excellent way to collect valuable suggestions. Of course, I wouldn't act on any suggestions without first consulting my doctor after the conference. Before the conference, however, I did decide to keep the conference a secret from my primary physician and the clinic doctors; as with my disability review, I was simply too worried about misunderstandings and any consequent complications. My presentation was now more than an academic effort, it had also become a covert project to seek further options for my personal case. I simply wanted nothing to interfere with this promising opportunity and I fully intended to reveal everything to my personal physician after the conference. I'm sure that any patient who has endured a decade of clinical frustrations would understand my motives.

On June 13th (a Friday the 13th) I finally received a formal letter regarding my disability status. I had been approved for continuing disability assistance. Obviously, I breathed a great sigh of relief.

All these diversions helped to fuel the writing of my conference paper. The inescapable uncertainties of my disability review and clinical treatment were potent reminders of issues I wanted to address. Though research was illuminating much about anxiety disorders on a general level, individual patients like myself remained in a murky world of inadequate diagnostics and treatments based on trial-and-error. Such general issues would not be the main focus of my paper, yet a detailed presentation of my case study would need to prominently address them.

Part 3 - Difficulties & Compromises

During the past several months, I had planned to attend the conference and then visit Jon and Philip before returning home. This seemed a simple enough plan at first. I only needed to spend a few days at the conference in London, and then embrace just a little more traveling to spend a few days with Jon in Western England and a few days with Philip in the Netherlands before returning home. The three of us had exchanged much e-mail working out the details. Jon and Philip were extremely helpful and generous regarding travel and accommodations. Furthermore, Jon, having a long and active background in history, was planning an authentic Roman banquet for me. And Philip, despite recently moving, welcomed me to stay with his family at his new home. This was everything I had wished for from the very beginning.

Unfortunately, the old adage "The Devil is in the details" started to become a reality. A few transportation uncertainties forced us to consider back-up travel plans, which magnified the complexity of our planning to some degree. Also, only two months remained for me to complete my conference paper; which would involve several reviews and revisions with the help of various family and friends. My paper would have to be finished before I could even start planning my conference presentation. The pressure to make flight and hotel reservations was growing with each passing day. And all the while I was living an extremely frugal lifestyle in an effort to save up the money needed for this trip with only a poverty-level income from disability. I was starting to feel overwhelmed and began to see that I was stretching myself and my resources too thin.

On July 4th I finally sent an e-mail to Jon and Philip canceling our visit plans. They were both disappointed, but they were also very understanding and supportive. I asked them if we could possibly get together in London. Philip said that he was capable of making such a trip, but was too short on funds following his recent move. Jon replied that London was just too far outside of his comfort zone. I forget if we discussed my visiting just one of them, but I think even that would have been too much for me and I really would have hated to choose between them at this point.

I was making a number of social comprises at home as well. Plans to visit with family or friends that summer were often postponed or canceled. I even took an extended break from my on-line peers within ASAP to keep my concentration focused. As anyone with panic disorder knows, periods of "functional time" are a precious and unpredictable resource. Two months on a calendar or schedule might only amount to a few weeks of fragmented and scattered functional time. I simply had to focus on the conference and tried to get everything ready as soon as possible.

I eventually managed to write four drafts of my conference paper. On completing each draft, I shared it with a number of trusted and knowledgeable people who kindly returned much appreciated critical feedback. Writing about my own case originally seemed like a simple exercise. Most of my writing was just a direct and uncomplicated account of my experiences with panic disorder, PTSD and how these experiences differed in my own case. However, there were also some real academic challenges in how I described my case. Given the large overlap of anxiety symptoms, I had to clearly explain how I distinguished one disorder from the other. In the absence of solid medical diagnostics, I had to justify my perspectives of physical verses psychological distinctions. And considering how functional I might appear when presenting this paper before an audience in another country, I needed to explain the disability issues very clearly or I'd easily seem like a complete hypocrite. As has long been the case, people with severe forms of panic disorder are rarely able to represent themselves in public, so my presence would require some explaining.

The final paper would be undeniably anecdotal. Being unable to scientifically prove much of my experience, I had no choice but to openly acknowledge the uncertainties. The credibility and value of my paper would rest greatly on explaining why such uncertainties were unavoidable and how such uncertainties still plagued the clinical treatment of my case (and cases like my own). Perhaps the most important message of my paper was how much could not be said with any real certainty.

There were many other stressors beyond my paper. My attempt to buy an airline ticket on-line resulted in a cryptic message, but after a brief talk with the telephone help line my second attempt was successful. For several weeks I stared at on-line maps of London's maze-like geography and agonized over hotels. Between suggestions from the conference folks and some e-mail with hotels, I finally made reservations. There were also issues of currency conversion, delays at the dry cleaner, a week-long complication with my medication refill, getting a note from my doctor excusing me from jury duty, misplacing my wallet, etc.

I truly knew that "Murphy's Law" had taken effect when my computer crashed only weeks before the conference! I hadn't even printed a hardcopy of my paper at this point! I could recover prior drafts of the paper that I had shared with others on-line, but this was still a potentially damaging setback so close to the conference. The excitement of the conference had distracted me from prudent back-up procedures, so much more than my paper was at risk of being lost (including extensive personal logs, a great deal of research information, important travel reservations, etc.). I became rather frantic about this and the stress was bad enough to create acute abdominal pain.

My friend Jay came charging to my rescue as soon as possible. In addition to being a best friend of several decades, Jay is absolutely brilliant with computers. During the late hours of a Friday evening, he analyzed my system settings and surgically disassembled my computer's hardware. He soon diagnosed a hard disk failure but, at first, wasn't sure if it was my primary drive, backup drive or both. Patiently, I watched in agonizing suspense as he tried various methods to revive my system. After several hours of effort, he finally brought my system back to life! To my great fortune, it was my backup drive that had died, not my primary. Everything was recovered! I was so stressed out that I couldn't even breath a sigh of relief for days, but I gave Jay a big hug and felt like he had just saved my life.

After a few unproductive days of stress recovery, I dived back into my conference preparations. I soon polished up the final draft of my paper, made backup copies and printed it out in hardcopy. With the final draft ready, preparing transparencies for my conference presentation was easy. Using the paper as a guide, I simply prepared bulleted lists of major topics from each section of the paper, including important graphics.

I almost felt ready for the conference in the last week before travel. My paper and presentation transparencies were in hand. I had saved up enough money. I had a valid passport, valid plane tickets and valid hotel reservations. My latest trip to the pharmacy ensured that I had adequate medication. A stack of printed maps, schedule and contact information were carefully prepared. I simply needed to relax and try my best not to obsess over everything.

Part 4 - The Journey Begins

The day of my flight finally came on September 3rd. My flight from Philadelphia to London wasn't until 9:35 that night, so I had all day to pack and get to the airport. Managing my anticipatory anxiety was difficult. Mostly, I obsessed over forgetting anything critical (my passport, presentation, medication, etc.). I took frequent breaks to calm down, as well as 2-mg Xanax throughout the morning. It helped that I always travel light. I only packed what was absolutely necessary and only what would fit into my trusty backpack that I could carry onto the plane. I was very methodical. I think I only unpacked and repacked once in response to obsessing, but double checked the contents of my pack several times throughout the day.

My original plans on getting to the airport changed at the last minute. Originally, I had planned to take two trains to get there, but my friend Steve kindly offered to drive me. I wanted to allow plenty of time for unexpected delays, so we left for the airport about 4:00 in the afternoon. On the drive over, Steve patiently listened to me obsess over my packing; "Yes, I have my presentation. Yes, I have my passport. Yes, I have my wallet. Yes, I have my ticket. Yes, I have my meds." He dropped me off at the International Terminal and wished me luck before driving off.

I promptly used my airline e-ticket printout (a full seven pages!) to pick up my boarding ticket. Next, I exchanged several hundred US Dollars for British Pounds. The waiting line for the security check was terribly long and slow moving. Having roughly five hours before my flight, I took a walk outside and hoped the security line would be shorter later. I explored the other terminals for a shop or restaurant to pass the time, but everything was at the other side of the security check. Fortunately, though, I accidentally found another security check with a very short line and leapt at the opportunity.

Airport security is taken very seriously these days. One of my obsessive fears was accidentally packing something that might be on some list of forbidden items. I worried a lot that some misunderstanding might somehow prevent me from flying and ruin all my efforts to attend the conference. I must have been visibly nervous and was sweating profusely. When asked if I had removed all metal items from my person, I said yes while having forgotten my belt buckle. Naturally, I set off the metal detector and was promptly directed aside for a detailed search. I was asked to remove my shoes and undo my pants in full view of everybody. I happened to be wearing athletic shorts under my pants, so I even volunteered to remove my pants to allay any concerns. I was told that wouldn't be necessary. Despite complying completely, I feared that my anxious state would cause suspicion and lead to problems. However, after only a few minutes I was cleared and allowed to pass.

My priority now was finding good ways to pass the time. At first, I simply wanted to sit down, relax and stop sweating like a rain cloud. Since my anxiety often causes fits of sweating or overheating, I had deliberately dressed in layers. So I removed my shirt and allowed my damp tank top to dry out and cool down. Though anxious, I really wasn't panicking and didn't need any Xanax at the moment. In fact, I was somewhat surprised over how relaxed I became after a short time. My biggest problem soon became dealing with a bad case of boredom while passing the next several hours until my flight. I often use such idle time to dwell on interesting ideas, but I guess the day's tension had left me mentally tired. I took a few walks up and down the terminal, periodically checked the flight schedules and watched a little CNN News in one of the lounge areas. Remarkably, I even felt relaxed enough to eat a slice of pizza; typically, I avoid food before any form of public transit due to anxiety related nausea.

The man apparently in charge (manager/concierge?) promptly and politely escorted me back to my room to check out my complaints. The problem with the lights and television were quickly resolved when he showed me that my key-card had to be inserted into a special slot to activate the room's electricity; this seemed new and odd to me, but no big deal. The room's uncomfortable heat was, in part, due to a past guest leaving the heat turned up. The main window which was supposed to open was, in fact, stubbornly stuck shut, but an upper window pane did open to allow some ventilation. I didn't complain about the shower/alarm sign since I tend to take cool showers in warm weather anyway. In the absence of a clock, there were several TV channels that constantly showed the time and there was the usual hotel telephone wake-up call service. I was surprised to learn that ice buckets were not at all common in British hotels, but the hotel bar made the apparently special accommodation of giving me a bucket of ice. I wasn't completely happy with the room at first, but was satisfied enough to give it a fair try. Slowly, I became comfortable with the room and embraced it as my temporary home.

I spent the afternoon shopping for a few basic necessities. Items like safety razors I had not brought with me for fear of security complications at the airports. Likewise, I hadn't risked bringing my Oral-B power tooth brush since, with the brush removed, it had a metal point, so I needed to buy a manual toothbrush. Also, despite London's fine reputation, I bought bottled drinking water to reduce anxiety over tap water that my body might not be used to. I also ate only McDonalds' fast food for the first few days in an effort to keep biological and psychological stress to a minimum before the conference. I was simply trying to ensure that nothing would interfere with my attendance and participation at the conference.

Many months of academic preparation, significant personal expenditures, notable personal risk and effort had been invested in this conference. I had passed many hurtles and challenges, with several more yet to come. I know that probably sounds excessively melodramatic to most people but, honestly, this entire venture was one of the boldest things I had ever done as a panic disorder patient.

Part 6 - The Conference (Day 1)

Friday, September 5th, was technically the first day of the conference. However, the only thing scheduled for that day was the conference registration that evening. Perhaps this was the day that most people would be traveling to the conference, but I had arrived a day early just to be safe. I could have used the day to do some sightseeing, but that would have been too ambitious for me at this point.

I mostly used the day to relax and adjust to my new surroundings. I spent an hour or two hunting for an umbrella in anticipation of London's famous rainy weather. You would think that umbrellas would be easy to find in London, but I actually had to visit many shops and ask many people before I was finally directed to a local ASDA super-store; which was like a K-Mart and grocery store combined. ASDA had umbrellas and I promptly bought one. Of course, the few times it really did rain during my whole trip I happened to be indoors, so I never did use my umbrella.

On the way back to my hotel, I stopped at the McDonalds' to pick up some lunch. I innocently ordered a chicken sandwich and a large cup of ice to go. "Ice?" said the person behind counter with the kind of confusion usually reserved for people claiming to be a space alien. I kindly replied that yes, indeed, I wanted a large cup of ice and would be happy to pay for it. With a pause, the person asked me to wait while he checked with the manager. The manager soon agreed to my apparently bizarre request. I would often encounter this reaction to ice requests and I didn't understand why this was such sensitive issue during my trip. Some people were clearly perplexed but happy to comply, while others asked for explanations and seemed on the verge of denying my weird request (grin).

I returned to my hotel room and enjoyed my sandwich and ice water. The afternoon was devoted to practicing my conference presentation and watching Sky News (like CNN) on the 'telly' (television). Later, I showered, dressed and headed off to the 6:30 PM conference registration.

The conference site at the University of Westminster, Harrow Campus, was only two Tube stops away. The Northwick Park station exited directly onto the campus grounds and paper signs for the conference had been taped up to clearly point the way. After a short walk, I entered the correct building and some campus security officers kindly pointed me to a nearby dinning room set up for the registration. As usual, I had arrived a bit early. Nonetheless, I was promptly greeted by A. Stones-Abbasi, Ph.D., and Mr. Daryush Abbasi (of the Organizing Committee) and Dr. David Groome (of the Scientific Advisory Committee).

As more people filtered in I also met Capt. S. M. R. Rizvi and Azam Cheema (presenting for Rana Khan of Pakistan), Marina Lizon, M.D. (Canada), Beth Stone (Australia), Angela Brittain (United States), and others. We were all given nicely prepared conference packages which contained the speaking schedule, abstracts, and other handy items. We mixed about, introduced ourselves and talked about various issues. I can't exactly remember everything we talked about, but I would get to know a few people better in the following days.

We didn't want to socialize late into the evening since the conference would begin early the next morning. At about 8:30 PM we started to leave. Mrs. Brittain, or Angela as I came to call her, happened to be staying at the same hotel as I, so we escorted each other back. We stopped at the McDonalds' along the way. I forget if I asked for a cup of ice again (grin). Reaching the hotel, we agreed to meet in the lobby the next morning.

Returning to my room, I promptly scheduled my wake-up call for the next morning. After watching the news for a short time, I went to sleep. Naturally, I had a nightmare that I didn't receive my wake-up call and would be late for the conference! I woke with a jolt, but was relieved to see it was still night. I had to get up and turn on the 'telly' to see that it was really 3:00 AM. I promptly went back to sleep.

Part 7 - The Conference (Day 2)

I successfully received my 7:00 wake-up call. I had left plenty of time to get ready for the day. Despite being well prepared, I was very nervous because my talk was scheduled for that afternoon. Between my nerves and the continuing warm weather, my sweating grew difficult to control. I met Angela just outside the hotel lobby at 8:30 and we started off to the conference. Not wanting to risk food on a nervous stomach, I bought a bottle of caffeine-free soda which I sipped throughout the day. We arrived at the conference hall around 9:00, by which time I was sweating quite a lot. A few people kindly gave me napkins to dry myself. Fortunately, the conference hall was pleasantly cool and my sweating calmed down shortly after the talks began.

• A. Stones-Abbasi, Ph.D., started the conference with a Welcome address. She commented that roughly 60% of the conference participants were unable to attend due to visa problems or related issues; which, unfortunately, wasn't surprising in these days of heightened security. Attendees and some presenters from Canada, Pakistan, Nigeria, Russia, Yugoslavia and other countries would be unable to attend. Personally, I was most disappointed that Dr. Bradwejn and colleagues were unable to attend and give their presentation on the anxiety producing chemical cholecystokinin or CCK (I've long been familiar with Bradwejn's work and had hoped to meet him). Nonetheless, the conference would continue albeit with an altered schedule. Having personally experienced panic disorder, Dr. Stones' career interests had shifted from mathematics to studying the psychology and physiology of panic. She explained that in the 1980s panic disorder was not at all understood in the UK and expressed the need to be open to all aspects of panic disorder; physiological, psychological and spiritual.

• David Groome, Ph.D. (University of Westminster) gave the Keynote address. He currently conducts research on panic attacks' affect on memory. He had never experienced a panic attack himself and used to think of it as mainly a psychological condition. However, after meeting a mental health nurse, he came to realize how very physical a panic attack can be. He noted that panic disorder (PD) was not taken seriously until recent decades. There are many theories of PD and all are correct in some way because PD is a mixture of psychological and physiological factors. The mixture of factors determines how an individual is affected and the most effective treatment depends on the type of PD.

• Donald Klein, M.D. (Columbia University College of Physician & Surgeons) "Opioid Blockade and Lactate Panicogenesis in Normal Human Subjects." He reported on a preliminary study to investigate whether acute opioid receptor blockade by naloxone would make normal control subjects sensitive to lactate in the way that PD patients are. As a preliminary study, only 12 people were tested. Of these 12 people, 8 had episodes which met the DSM-IV criteria for a panic attack. Based on this study, he suggested that "naloxone/lactate protocol may yield a laboratory model of nonfearful panic" and that "Endorphinergic dysregulation may underlie separation anxiety, CO2 and lactate sensitivity, the hypothesized suffocation false alarm, and panic disorder."

• Rachel Klein, Ph.D. (New York University School of Medicine, NYU Child Study Center) "CO2 Sensitivity and Risk for Panic Disorder in Children and Adolescents." She spoke about carbon dioxide (CO2) sensitivity and how it is common in adult PD. This sensitivity was found to be the same with children suffering separation anxiety disorders. Sensitivity to CO2 might be a marker for risk of anxiety disorder. The definition of a "panic attack" is currently not exact. No difference was observed in children of parents with or without PD.

• Donald Klein, M.D. Unfortunately, my notes on Dr. Klein's second talk lack clarity and are not complete. Nonetheless, some of his interesting observations included the following. Asphyxiation causes lactate to rise first. Children with PD often develop epilepsy. Thirst, hunger and air hunger all produce uncontrollable behavior responses.

• Jose Martinez, M.D. (Mt. Sinai School of Medicine, NY) "Respiratory Variability Measures in Panic Disorder." Dr. Martinez noted that PD patients have greater sensitivity to CO2 than nonpatients. He described a canopy system used in the study which, like an oxygen tent, was used to regulate CO2. Participants in the study were required to be off medication for two weeks to establish a baseline. This 12-week study suggested that normalizing respiration resulted in an apparent 100% recovery rate.

• Arthur Anderson, "A Comparison of Physiological Panic Disorder with Psychological Trauma." My own talk focused on my differing experiences with comorbid panic disorder and PTSD. Though sharing many symptoms, I could distinguish the two types of attacks by presence or absence of flashbacks. Over several years, my PTSD responded well to psychological techniques (such as CBT and talk) while many more years of the same techniques have had no impact on my preexisting PD. I argued that my case strongly suggested a physical cause for my ongoing panic attacks. I also commented on the need for improved medical diagnostics for PD, as well as some related medical and disability issues.

• Dr. David Groome, who had given the keynote address earlier, concluded the day's talks with some comment of an on-line questionnaire investigating relationships between panic attacks and sexual abuse. Though still in the midst of analyzing more than 700 replies (10% male, 90% female), roughly one third reported instances of sexual abuse of some fashion.

Naturally, I was very tired by the end of the day. I didn't do much else except buy more bottled water and some more McChicken. Returning to my hotel room, I relaxed and watched Sky News. The phone rang at about 8:50 PM. My Mother and Stepfather were calling from America. They asked how my talk went and how I was doing. I replied that all seemed to be going well. We didn't talk long, but it was a nice end to a good day.

Part 8 - The Conference (Day 3)

Like the day before, I received my wake-up call and headed off to the conference.

• A. Stones-Abbasi, Ph.D. (Global Egg Donation Resource, London, UK) "Panic Attacks and Infertility." Dr. Stones study examined 120 infertility patients over a 6 month period, all with current panic attack episodes. Many patients felt that their panic attacks medically interfered with their infertility treatments. However, infertility is more than a physical condition, but is an emotional condition as well. In a number of cases, patients felt their panic attacks were causing their fertility problems even when there was no evidence of this. Consequently, attributing infertility to panic attacks may have been more of a psychological coping mechanism than a true medical relationship. She commented that panic attacks are often used as an explanation for other unrelated health problems.

• H. K. Zarin (Aazad University of Iran, Iran) "Study of Panic Attacks on Iranian Students." Dr. Zarin's study focused on psycho-social factors related to development of panic attacks. He commented on the great academic stress faced by Iranian students; involving strong competition for admission into good universities, significant family pressures to succeed and serious concern over career and social consequences of failure. His results confirmed that "social factors and experiences as well as age and gender, play an important role in Panic Attacks development and its symptoms."

• Beth Stone (University of Sydney, Australia) "Non verbal Paths in Treatment and Outcome Measures: Pictures and Words." As a psychologist, Ms. Stone has used forms of Art Therapy to treat PTSD and Panic Attacks; such as Imagery-Art -Dialogue (IAD) and the Pictured-Feelings Instrument (P-F). "Because traumatic experiences are primarily encoded in amygdala-involved nonverbal sensory imagery, e.g. flashbacks, it's logical that nonverbal imagery of feeling-experiences be used as a major path of treatment and assessment of arousal, decoding, encoding and re-integration." Her presentation included a number of pictures created by patients, descriptions of picture analysis and use in therapy, as well as case studies showing evolution of pictures during patient recovery.

• L Owens, M Hawkins & C Hammond (National Organization for Panic Attacks, Anxiety Disorders, Neuroses, Information and Care) "Cognitive Behavior Therapy Telephone Recovery." Ms. Lilian Owens described the background and methods employed by the UK charity known as "No Panic." Essentially, No Panic is an organization that operates telephone help-lines for people with panic attacks, OCD and other anxiety disorders. Operating for 12-years, this organization is comprised entirely of trained volunteers. People seeking help are invited to engage their 14-week structured program based on CBT. Telephone based group therapy sessions, therapeutic assignments and printed material are included.

• Beth Stone (University of Sydney, Australia) "A Non verbal Vocabulary of Feelings: Closer to emotions and different from words: The Pictured-Feelings Instrument [P-F]." Ms. Stone's second talk focused on the P-F. Basically, the P-F is a collection of simple line drawings representing basic facial and bodily expressions that correspond with 26 feelings (equated with 6 to 8 emotions). In therapy, these images would help to create an evolving emotional profile of patients being treated for PTSD and panic attacks.

• S. Khan & T. H. Tanoli (Sanai Institute, Pakistan) "Treatment of Panic Attacks." Though Prof. Khan was unable to attend in-person, his presentation was given by Capt. S. M. R. Rizvi. To quote Prof. Khan, "Panic attacks are psychological disorders, which cause disturbances of multidimensional nature." After evaluating a patient, Prof. Khan employs a variety of spiritual methods based on the Islamic Quran. Primary among these methods, he believes that praying is the most effective way to treat all types of disease. Further methods include concentration, meditation, Rhythmical Method (involving sounds produced from the throat), the healing benefits of charity and alms, as well as musical singing of Quranic verses.

• Angela Brittain, "Don't Forget To Look Up: The Spiritual Battle in Overcoming Panic Attacks." Having experienced panic disorder herself, Mrs. Brittain developed a self-help "Spiritual therapy" combining CBT with verses from the Christian Bible. Her therapy encourages the use of appropriate verses to reinforce positive retraining of thought processes. She believes that God does not give people impossible tasks, that fear is a spirit sent from Hell and that faith is the only antidote for fear.

The conference ended with a nice wrap up by Dr. Groome. He commented on how the conference had, indeed, succeeded in presenting a diversity of perspectives; physiological, psychological and spiritual. Gradually, this led to a spontaneous and lively group discussion among the remaining members of the audience. Though opinions remained rather diverse, the general sense of mutual respect and civility that had characterized the conference lasted to the very end. With our scheduled auditorium time coming to an end, there were a number of friendly good-byes. Yet some of us agreed to meet at a bar/restaurant for further discussion.

I think about seven of us rendezvoused at the bar/restaurant; including Dr. Stones-Abbasi and some of her family, Dr. Lizon, Mrs. Brittain and myself. At this point, our conversation had become a mix of academic and purely social discussion. We had all enjoyed the conference, each other's company and hated to let it end. After a while, Dr. Stones and her family had to leave, but she and I made plans to meet the next morning. Soon, Mrs. Brittain had to leave as well. Dr. Lizon and I were the last to remain. I was very open about my case, so our friendly conversation sometimes bordered on psychotherapeutic dialog. With obvious caring, she strongly encouraged me to find and embrace direct social interaction on a more regular basis. Shortly after 9:00 PM, Dr. Lizon calls for a cab and I give her a friendly hug good-bye.

Soon, I was back in my hotel room. I felt mentally and physically exhausted at this point. As usual, I watched some more Sky News before going to sleep.

Part 9 - The Day After the Conference

As planned, Dr. Stones-Abbasi and I met the next morning. We happened to encounter Mrs. Brittain as well, so the three of us sat down in the hotel's bar/restaurant and chatted for a short while. Like the night before, our discussion was a mixture of social and academic reflections. Mrs. Brittain had plans for the afternoon, so, after a quick photo, she had to leave us before lunch.

Mrs. Brittain - Arthur - Dr. Stones

Dr. Stones and I really had much in common. We shared mathematically oriented backgrounds, we had both experienced panic disorder firsthand and our lives had been very altered by the experience. We both tended to view all of this through lenses of science and humanism, and we both accepted that panic disorder had physiological and psychological dimensions. Yet, we also had differences. Her experience had led to a functional life of family and formal academic pursuits. My life, however, was still rather dysfunctional, socially isolated and my panic-related accomplishments were thoroughly grass-roots and unorthodox. The comparisons and contrasts were intriguing to say the least.

As Dr. Stones and I started to have lunch, I expected that we would focus on development of a web site for the conference proceedings, or perhaps discuss strategies for better helping the global panic disorder community. We did talk about these issues for a while. However, like my discussion with Dr. Lizon the night before, our conversation gradually became an almost therapeutic dialog about my own case. She recognized my passion for attacking panic disorder issues, but she also knew I had other passions and needs that were being neglected in the process.

I really felt very touched by our lunch. Dr. Stones not only shared a lot of insight and compassion, but I very much enjoyed the intellectual stimulation. Her overall recommendation was for me to find some way back into academia and related social interaction; advice very similar to Dr. Lizon's. As with Dr. Lizon, I gave Dr. Stones a friendly hug good-bye.

I wasn't sure what to do with the rest of the afternoon. Though it was only 2:30 PM, I felt it might be a bit too ambitious to attempt any sightseeing around London. Besides, I was planning to attempt some sightseeing the next day, so it seemed wise to relax and prepare myself. Such planning and careful pacing of activity often seems helpful in managing my anxiety.

Part 10 - A Day of Museums

I wanted to attempt some sightseeing during my one free day in London. Weeks or months earlier, friends and family had suggested I see two well-known art museums; the National Gallery and the Tate Modern. Having done my homework, I knew how to get to these museums, but was I really up to the attempt?

I had been remarkably functional so far. Yet, I knew from past experience that such short-term functionality came with a price. The stressors I had been enduring were gradually making me more and more vulnerable to anxiety and panic attacks. My "stress budget" had been significantly depleted and I couldn't be sure how much more stress I could absorb before a serious breakdown.

Working up the nerve to get started that morning took considerable effort. I very much wanted to visit the museums and I knew the experience would be therapeutic, so I summoned up my reckless adventurer persona and tried to stay as positive as possible. Still, I must admit that I needed 2-mg of Xanax to calm myself enough to simply leave my hotel.

I was soon riding The Tube into the heart of London. From Wembley Park, I took the Metropolitan Line to the Baker Street station. At Baker Street, I transferred to the Bakerloo Line and continued on towards the Charing Cross station. Only in central London did The Tube really become the "underground tube" that I had known from films and the 'telly' since childhood.

Emerging from Charing Cross station, I suddenly found myself at London's famous Trafalgar Square. Trafalgar Square featured impressive monuments with large beautiful fountains and was overlooked by the main entrance of the National Gallery (nationalgallery.org.uk). I had arrived a full hour before the museum would open at 10:00, so I spent some time relaxing in the square. Finding some tables and benches, I sat down. To my surprise, a friendly waiter promptly appeared and offered me a menu. The tables and benches were actually part of a very discrete cafe on the square.

At the risk of inviting more misunderstandings over "ice," I asked the waiter for an "ice tea." Not surprisingly, ice tea was not on the cafe menu. So I politely asked if I could have a black tea, no milk, with a large cup of ice on the side. The waiter happily brought this to me. I had soon created and began to enjoy a fine cup of ice tea, and I gave the waiter a handsome tip for not being a bother about the ice. (smile)

Sipping my tea in the cool and open air helped to relax me significantly. After my tea, I wandered the square and passed the time until the museum opened.

The National Gallery had an impressive collection of paintings. I quietly wandered the halls and indulged in the visual pleasures of Vermeer, Botticelli, Turner, Monet, Renoir, Seurat, Van Gogh, Cezanne and others. For reasons that are perhaps all too obvious, Gustave Moreau's "Saint George and the Dragon" particularly caught my attention as I was trying to slay a beast of sorts myself (see the gallery web site for image). I don't mean to imply that I'm a Saint, nor that I have the power to single-handedly subdue the dragon of panic disorders in general. I simply related to the painting's theme; an empowered person confronting an intangible entity. I didn't exactly rush through the National Gallery, but I tried not to linger too much either since I wanted to visit the Tate Modern museum as well.

Riding The Tube once again, I took the Bakerloo Line further to the Waterloo station, transferred to the Jubilee Line and then continued to the Southwark station. I emerged among some cryptic streets, but followed some friendly signs and one of my maps.

Without too much of a walk, I found the Tate Modern (tate.org.uk). In the spirit of modern art, the museum building had an imposing, block-like and industrial appearance that delightfully contrasted with the comforting park-like environment surrounding it. Walking along pathways among trees and grass, I found myself on the banks of the Thames river as I approached the museum's main entrance. The grounds featured two giant inflated sculptures associated with Paul McCartney.

Like before, I didn't exactly rush through the exhibits, but there was much to see and I only lingered when something really caught my attention. Many things did catch my attention; including a few great Dali paintings and an interesting collection of Soviet propaganda posters from the Cold War era. Perhaps the most bizarre experience was a video art exhibit; in which an artist, wearing boxing gloves, repeatedly punched himself in the head and, then, stood to reveal his nakedness and began masturbating with the boxing gloves. This exhibit caused many to blush and turn away, including myself, yet it left me thinking a lot about social norms.

The inherent subjectiveness of art appreciation aside, I later enjoyed simply sipping a soft-drink while standing on the banks of the Thames and watching the boats go by. My one complaint is that the vender had no ice to put in my drink (moan). Still, it was a beautiful day and much had gone very well.

I negotiated The Tube once again and returned to my hotel. Since I would begin my journey back home tomorrow, I organized for the next morning's packing up.

Watching Sky News that evening, it was perhaps an amusing irony that the media was full of alarmist stories. The Tube, that I depended on to get me back to the airport, was being questioned for its' safety. There were reports that British Airways, my airline, might potentially equip its' jetliners with anti-missile technology to thwart terrorists in near future. And, naturally, there were plenty of reminders that I would be flying home on the eve of 9-11, which the media hesitantly speculated about.

Personally, I had little fear regarding The Tube, British Airways or the eve of 9-11. My main concern was managing my anxiety and panic disorder for all the usual and mundane reasons that constantly haunt my life.

Part 11 - Returning Home

Just as I had obsessed over forgetting things on my trip to London, I also obsessed over forgetting things on my trip back to Philadelphia. I had been given a great conference package and gifts, I had made many notes, I had collected contact information, I had acquired a few conference related books, and I wanted to lose or forget none of it all. With a little creativity, I systematically, and obsessively, managed to squeeze everything neatly into my trusty backpack.

I checked out of my hotel around 9:30 that morning without complication. Making a brief stop at the local post office, I sent postcards to Jon, Philip and others. I then headed for The Tube. Nothing bad happened on my Tube journey back to Heathrow Airport. I acquired my boarding ticket and passed the security check without too much bother.

By mid-day, I was wandering the Heathrow international terminal concourse. As usual, I had arrived far ahead of time and now found myself with four hours to pass before my flight. Fortunately, Heathrow's concourse is much like a modern shopping mall and has plenty of distractions and comforts. Having not yet bought a single souvenir of London, I searched the shops and eventually bought a nice "City of London" T-Shirt. I spent some time in a bar drinking ginger ales, smoking a few cigarettes and watching Sky News. I don't remember eating anything that day before my flight since I didn't want to risk nausea. Nonetheless, I was once again surprisingly relaxed in the hours before my flight.

My flight started boarding earlier than I expected. The early boarding was mainly because we had to take buses out to our plane rather than the usual boarding tunnel. I made some joke about this being the London to Philadelphia bus (grin). Leaving the bus, I walked up the mobile stairway and entered the plane; a nice 777 like before. Once onboard, I was feeling very relaxed and asked a flight attendant if I could move from my aisle seat to a window seat. Initially, this didn't seem possible, but he later noticed a window seat vacancy and offered it to me. I happily changed seats and began enjoying my view. The plane started off on schedule at 16:15 (4:15 PM) and we were soon airborne.

As with my previous flight, I was notably relaxed and not at all anxious about flying. I watched Western England pass below and thought about Jon being somewhere down there. We later passed over Ireland and headed out over the North Atlantic.

The in-flight meal was pretty good and I ate my fill. Again, however, my full stomach promptly triggered a rapidly rising panic attack which I just barely managed to control with 2-mg Xanax sublingual.

When I eventually started to relax again, the plane passed into a rough patch of air turbulence. Honestly, I would have enjoyed the shaking, rising and falling of the plane had I not been trying to control a hot cup of decaffeinated coffee, half of which spilled onto my pant leg (ouch!). Still, I think I managed the coffee pretty well considering we hit, at least, half-g accelerations a few times. For a short while, even the flight attendants had to take to their seats and buckle up. Once the turbulence had passed, I enjoyed what remained of my coffee.

Passing just south of Iceland and Greenland, I enjoyed the view out the window. For much of the trip, the ocean was obscured by extensive cloud-cover. At times, the dramatically vast cloudscapes gave the illusion that the entire planet had become an arctic landscape. Through the occasional break in the clouds, I searched for large ships upon the sea below but didn't find any. The clouds disappeared as we reached the Labrador coast of Eastern Canada. I could see vast stretches of apparently unspoiled wilderness. The geology seemed carved by long gone glaciers that had left a strange array of long straight cracks across the landscape. Hazy clouds began to obscure my view again as we crossed the St. Lawrence River and began to pass over Maine.

We landed in Philadelphia slightly ahead of schedule; about 7:00 PM local time. I passed through customs without much trouble and changed my remaining British currency back to US Dollars. I then took the regional rail into the city, and then spent a short time on the local rail. A short hike later and I was finally home. In familiar surroundings once again, the whole trip felt like a dream. Naturally, I was pretty tired and simply relaxed in front of the TV until I was ready to sleep.

Part 12 - After the Trip

The next day, September 11, I checked my e-mail for the first time in more than a week. I was stunned to read several messages from ASAP friends informing me that our friend Jon Guite had died just days ago. His death was completely unexpected and the coincidence with my trip was a bit eerie. Chillingly, had we stayed with our original visit plans, it's conceivable that I might have been the person to discover his body. Such an event would have been somewhat similar to the discovery of my father's body which had caused my PTSD; an experience I described during my conference presentation. Despite my PTSD recovery and greatly differing circumstances, I'm honestly not sure how I might have reacted to finding Jon.

Through my ASAP friend Jackie's kind efforts, I soon sent a letter to Jon's family.

Jon's death was a double blow to me. Not only had I lost a friend, but I had also lost an opportunity to interview a true pioneer of the patient community. Jon had operated the Internet's first "chat" group devoted to anxiety and panic disorders, known as "#anx/pan," for a number of years. To the best of my ability, I try to document the unfolding history of anxiety disorders. Losing this opportunity to speak with Jon reinforced the urgency I felt towards recording the lives and events that characterize the contemporary anxiety disorder community. Nonetheless, I wont forget Jon nor his accomplishments.

Much of the following weeks were spent recuperating from all the trip's stressors. Overall, my post-travel anxiety wasn't quite as bad as I had expected. Apparently I had done a good job of pacing my activity and managing my stress. For the most part I simply suffered a lot of cognitive dysfunction which made me feel mentally tired and burnt out. However, a few of my post-travel panic attacks were among the worst I've ever experienced; one attack setting a new personal record of 4-mg Xanax to get under control. The worst attacks aside, I recovered from the trip reasonably well and managed to transcribe my travel notes to computer files within a week. The following weeks were mostly devoted to relaxation and writing this detailed account.

Towards the end of September, I met with my primary care physician. I described my experience with the Outpatient Psychiatry Clinic some months ago. I also finally told him about the conference and gave him a copy of my paper. He didn't seem terribly surprised. Over the years I guess he's gotten used to me being an ambitious patient. We spent a few moments talking about various issues relating to my case. We agreed that there seemed no good reason to change my medical treatment. He also supported my interest in trying to find some kind of volunteer activity in academia that might be accepting of my unpredictable functional time. Such activity would help to relieve the social isolation that still haunts too much of my life between my more adventuresome moments.

In later e-mails, Dr. Stones tried to explain the European "ice" issue (grin). In London, cold drinks are simply served cold. In climates that are often cool or cold, ice is usually unnecessary and only reduces the taste of cold drinks. Just as putting ice into beer would seem bizarre to most Americans, Europeans have a similar sentiment towards adding much ice to almost any cold drink. It seems simply a cultural difference influenced by climate and history. With this cultural difference in mind, I can only imagine what Londoners might have thought of my innocent ice requests. If they assumed I wouldn't be using the ice for drinks, what other intent might I have in mind for the stuff? Medical use? Mischief?

Participating in the conference proved a wonderful experience. Despite the anxiety of submitting an abstract, daunting disability issues, planning and expense insecurities, writing worries, presentation phobias and travel trepidations, the trip worked out very well. I had embraced a number of serious gambles and, without diminishing my efforts, acknowledge that I owe much to simple good luck. As someone with panic disorder, the whole experience had the feel of high adventure. Amongst all the difficult anxiety and panic attacks, there were also some enjoyable thrills and I met some wonderful people. The impact of my presentation is impossible to guess, but I hope it will help raise further awareness and benefit fellow patients. Most especially, my hopes are for fellow patients who are often unable to speak out publicly because of our common conditions. Despite all the uncertainty and stress, I will remember this conference, trip and experience very fondly for the rest of my life.

Special thanks to
A. Stones-Abbasi, Ph.D., Mr. Daryush Abbasi,
David Groome, Ph.D., The University of Westminster,
Mrs. Angela Brittain, and many good family and friends.