Have we made any progress in the understanding and treatment of panic attacks? From an historical context it is hard to deny progress. Panic attacks have existed at least as long as humanity. We have gone from knowing nothing to appreciating many facets and details about the condition. Early shamen treated panic attacks with both rituals and substances. Attempts to explain panic attacks medically date back to classical Greek civilization. Formalized descriptions have been refined over the centuries and modern science continues to identify causes. Diagnosis and treatment of panic attacks currently seem the best they have ever been. Awareness has improved and the suffering of patients is better respected than even a few decades ago. Furthermore, popular use of the Internet has greatly helped to foster a patient community among people who are understandably reclusive and who have traditionally been terribly isolated.

Perspectives of progress, however, can be surprisingly diverse. Historians of psychology and medicine can easily point out many steps backward among the many steps forward. What constitutes a step forward is not always clear as much about panic attacks remain uncertain. Because many of us are not historians, there is also a tendency to view progress within a contemporary context and within our own experience. Our notions of progress can be highly subjective.

I recently asked a number of patients and doctors about their impressions of progress. Their comments touch upon some important topics which I will briefly elaborate on later. First, however, I think it is constructive to focus on their quotes.

The first person I asked was my physician at the University of Pennsylvania Hospital. He does not specialize in anxiety or panic disorders, but he has overseen my treatment for the last seven years and helped me to consult psychiatric and psychological specialists. Furthermore, he has encountered many other patients like myself. Asking him about 'progress' he replied:

We are still feeling around in the dark. It's a multifactoral condition, with many causes and involving many hormones and neurotransmitters that are not well understood yet.

Have we made any progress? I think not. Panic disorder is diluted by the use of the term panic to mean intense anxiety. Now people go to the doctor and say "I was panicked" and the doctor nods his head and hands out Paxil. Voila, another person with panic disorder. The wholesale marketing of panic disorder by the drug companies has made a mockery of the core group of people with 'real' panic disorder who remain poorly diagnosed and poorly treated.

With my recent stay in the hospital experience, no. No progress at all.

I think there has been progress made in public awareness and understanding. I don`t think there`s been great strides made in the diagnostic and treatment aspect of our disorders.

Here in Australia, I think there has been an increase in public awareness. There is less stigma attached to mental health in general. Having high profile people openly discuss depression and anxiety disorders have helped. From my experience diagnosis is quicker and more accurate than it was 20 years ago, but errors remain. Treatment using CBT has increased and better use of meds but still many benzophobic doctors around. Much room for improvement still.

I began suffering with a life-limiting anxiety disorder around 29 years ago. ... Over that time I've noticed a distinct improvement in understanding and treatment of anxiety.

When I first sought help for my disorder, the attitude of the medical profession at first was "Ignore it and you will be fine." I couldn't and I wasn't. This was then followed by "Take this pill and you will be fine." The pill was Valium and it did absolutely nothing for me. I wasn't fine. Furthermore, none of the professionals explained to me what was going on with me. My condition wasn't labelled and nothing was explained as to why I was feeling so panicky and fearful. Maybe they didn't know. I don't know.

Later I had to visit my GP regularly, and he was slightly more understanding and helpful, better drugs were available and were effective, but I gained more knowledge and helpful advice from groups of fellow sufferers than from the medical profession.

In more recent years, more drugs have come to the fore with the SSRIs etc., a lot more seems to be known by the medical profession about anxiety disorders. Doctors, nurses, surgeons etc. don't seem to look at a sufferer any longer as if they came from Mars, with that "Pull yourself together" attitude, and there are more resources available to help a sufferer cope, such as Mental Health Teams trained in therapies like CBT.

One other step forward I've noticed is that here in the UK, the forms for claiming benefits include anxiety disorders as recognized disabilities.

Diagnostic details are a major source of mixed feelings. Patients who suffer panic attacks are generally grateful that their symptoms are acknowledged and that their conditions have clinical labels. Such labels are helpful towards seeking information, treatment options or even disability assistance. Yet, current diagnostics have serious shortcomings when choosing treatments for the individual. Existing tests often can not differentiate between psychology and biology. Even when a medical condition is suspected, no tests are available to guide the selection of medication beyond blind trial-and-error. It's frustrating for patients to hear that Selective Serotonin Reuptake Inhibitor (SSRI), Benzodiazepine (BDZ), Tricyclic Antidepressant (TCA) and Monoamine Oxidase Inhibitor (MAOI) medications are all known to address well defined neurochemical problems while, in the next breath, being told that these same problems can not be tested for diagnostically to help guide individual treatment! Clearly, diagnosis is an area where progress has been made, yet much more progress is needed.

Psychotherapies are generally recognized as very important in the treatment of panic attacks. Regardless of the specific cause of attacks, chronic exposure to panic is bound to have a psychological impact on anyone. For a variety of reasons, rates of suicidal ideation tend to be high in this group. Consequently, psychotherapy does save lives and often reduces impact on functionality. The trend from classical 'psychoanalysis' towards Cognitive Behavioral Therapy (CBT) is generally viewed as progress.

Patient three's mention of "benzophobic doctors" is very common and warrants some explanation. The use of BDZs are among the most hotly debated topics in this field. At the time of their introduction in the early 1960s, BDZs were a significant improvement over existing medications in both efficacy and safety. The improvement in safety, however, created a climate of overconfidence which soon led to over-prescription and abuse. The early excessive use of BDZs seems mostly responsible for today's concerns of BDZ addiction. A few decades later, the SSRI medications seemed to offer an even safer alternative and are now widely preferred among doctors; though there is growing concern and controversy over SSRIs (1, 2, 3, 4, 5, 6, 7, 8). Even when a patient has a bad history with SSRIs and a good history with BDZs, doctors sometimes still encourage SSRIs and discourage BDZs! Consequently, patients often complain about 'benzophobic' doctors who may not be paying adequate attention to individual patient history. Inadequate attention to individual history can easily be perceived as a lack of progress.

The current bias towards SSRIs hints at another topic of ambivalent 'progress'. Pharmaceuticals have become one of the most profitable industries in the world. A substantial share of recent pharmaceutical profits have come from the sale of SSRIs. The aggressive marketing of SSRIs ranges from public advertising campaigns to allowing sales representatives to meet with patients in the doctor's office. In at least one instance, pharmaceutical marketers mailed unsolicited SSRI medications to roughly 300 patients, recklessly encouraging a change in treatment without their doctor's knowledge or consent (9). In the United States, the pharmaceutical lobby is among the most influential and the fidelity of clinical trials and government pharmaceutical regulation have come to be questioned (10, 11, 12, 13, 14, 15, 16). When one of the most powerful industries in the world targets one of the most vulnerable patient populations in the world, concern and skepticism are clearly warranted, and our perspectives of progress are further challenged.

In conclusion, I want to express how important this conference is. Sharing a diversity of perspectives is certainly helpful towards promoting further progress. Furthermore, such a conference inspires hope among patients who suffer chronic panic attacks. It is no exaggeration that hope can mean life for many patients. By simply having this conference we are saving lives. I look forward to this year's presentations and my sincere thanks to everyone for your participation.

1. "Antidepressant Medications for Children: Information for Parents and Caregivers," statement by the US National Institute of Mental Health, Bethesda, MD, April 23, 2004. http://www.nimh.nih.gov

2. "FDA agrees with kids' antidepressant risk," CNN, September 17, 2004.

3. Lisa Richwine, "US reviewer says depression drugs, suicide linked," Reuters Health, 2004-09-13.

4. Anthony J. Brown, M.D., "Different antidepressants confer similar risk of suicidal behavior," Reuters Health, 2004-07-20.

5. "Study bolsters antidepressant-suicide link," CNN, July 20, 2004.

6. Lisa Richwine, "Antidepressants to come with pregnancy precaution," Reuters Health, 2004-06-10.

7. Sharyl Attkisson, "Anti-Depressant Taken Off Market," CBS News, May 19, 2004. http://www.cbsnews.com/stories/2004/04/15/eveningnews/main612150.shtml

8. "Prozac affects babies, sexual function," CNN, April 28, 2004.

9. Vicki Mabrey, "Pitching Prozac," CBS News, February 19, 2003. http://www.cbsnews.com/stories/2003/02/19/60II/main541202.shtml

10. "Members of Congress blast FDA, drug makers," CNN, September 10, 2004.

11. Susan Heavey, "FDA lawyer collaborated with drug firms - lawmaker," Reuters Health, 2004-07-14.

12. "Probe planned of FDA's antidepressant, suicide review," CNN, April 16, 2004.

13. "Prescriptions And Profit," 60 Minutes, CBS News, March 14, 2004. http://www.cbsnews.com/stories/2004/03/12/60minutes/main605700.shtml

14. Sharyl Attkisson, "FDA Mum On Suicidal Side Effects?" CBS News, March 30, 2004.

15. Susan Heavey, "U.S. FDA fails to curb misleading drug ads: report," Reuters Health, 2004-01-30.

16. "Dangerous Prescription," Frontline, WGBH Boston, 2003. http://www.pbs.org/wgbh/pages/frontline/shows/prescription/