It may seem zealous and extreme to compare civilian cases of Panic Disorder (PD) to the grotesque and traumatic horrors of war. After all, the trauma of facing a murderous enemy in battle seems infinitely remote from a fear of stepping out the front door of our own home. On the surface, the comparison appears ridiculous.

However, such a comparison is not so absurd. There are veterans that have developed PD, and such veterans have reported that their panic attacks were "worse" than facing death in combat. So, in fact, some people do feel as much fear stepping out of their home as they would starring down the barrel of an enemy cannon.

The reason this comparison strikes many people as absurd is that the common and popular understanding of fear is incomplete. We have all been afraid at one time or another, but few of us have experienced the great extremes of fear, or its many manifestations. Fear is not simply a matter of degree. Fear is actually very complex and varies greatly in its expression from person to person. This is where the history of war can teach us some valuable lessons about the human tolerance for fear.

War and fear have existed throughout human history. As far back as the 5th century BC, the Greek historian Herodotus recorded an account of the battle for the pass of Thermopylae. Before the battle, one soldier, named Aristodemus, from a hand-picked elite Spartan unit of 300 men, reported to the surgeon and claimed to be suffering from an "acute inflammation of the eyes." When the battle began, Aristodemus did not join the fighting, "finding his heart failed him." Afterwards, his fellow soldiers gave him the nickname of "The Trembler" and he "found himself in such disgrace that he hanged himself."

The Greeks strongly believed that courage was based on strength of character. They emphasized a connection between heroism, military training and moral character. Simply put, heroes controlled fear while cowards succumb to fear. So strongly did the Greeks hold to this view that for almost 400 years they resisted using superior military technology, believing that weapons of greater power would destroy the distinction between heroes and cowards.

Such "traditional" notions of courage and cowardice are very much alive today. Most people still perceive bravery as a matter of responsibility, rationality and strength of character. This implies that people who succumb to fear are somehow weak, irrational or shamefully irresponsible. Furthermore, many people still tend to measure bravery in terms of "tangible" circumstances. To fear being killed or maimed is typically understandable. To fear simple injury or emotional distress often seems immature. And to fear the mundane aspects of daily life almost always seems intolerably pathetic. Even today, such attitudes have a strong influence on the popular perceptions of human fear, and of PD.

However, over the centuries, war has gradually changed. Slowly, the changing face of war has challenged the "traditional" notions of courage and cowardice. Some powerful lessons regarding bravery and fear have been learned in the crucible of war, and these lessons are important to the understanding of fear and PD, in both military and civilian life.

Loss of Control

Over the centuries, war gradually changed. Weapons have become more destructive and soldiers have become exposed to combat for longer periods of time. In the past, large communities of soldiers fought together against an easily seen enemy. In modern war, soldiers are often grouped in smaller and more isolated units, and the enemy is often unseen. It has been suggested that these changes have increased the anxiety experienced by soldiers, despite the fact that their daily risk has actually decreased! So, how is it that decreased risk has resulted in increased anxiety?

Apparently, the seemingly paradoxical increase in anxiety with decreased risk is related to an individual's "loss of control." Simply put, if you and the enemy know where each other are, the situation is dangerous but you can at least fight back. On the other hand, if you and the enemy are not sure of each other's position, the situation is less dangerous but the conflict involves much greater uncertainty. With such uncertainty, or loss of control, the soldier's survival relies less on combat skill and more on uncontrollable chance. Life and death are no longer an honest contest, but a merciless and random lottery.

Among the veterans I have spoken with, most report that they preferred situations of "greater danger with greater control" over situations of "less danger with less control." Apparently, a person's "sense of control" plays a large role in the moderation of human fear.

Likewise, "loss of control" is a huge factor for civilian PD sufferers as well. Panic attacks are often very powerful episodes that can completely overwhelm the mind and body with extreme horror. As mentioned earlier, such attacks can exceed a person's fear of death. In fact, many undiagnosed PD sufferers have preferred a potentially fatal diagnosis over continued uncertainty. Furthermore, a full 20% of PD sufferers attempt suicide at least once (compare with 15% in cases of clinical depression). Such a willingness to face death demonstrates the extreme need of PD sufferers to gain "control" over their panic attacks.

Escape

The loss of control felt by PD sufferers tends to reduce the age-old "fight-or-flight" response to simply "flight," or "escape." As with loss of control, the need for escape becomes a powerful issue with PD sufferers. Here too, we find parallels between civilian and veteran experiences.

During the Napoleonic Wars, the losses due to troops deserting battle were regularly greater than the losses resulting from combat. Since desertion was relatively easy during such early wars, it probably kept the rate of combat trauma low in comparison to modern standards. Like a psychiatric safety valve, soldiers could often escape the horrors of war before developing severe psychiatric scars.

Yet, loss of troops for any reason was a serious problem for any army. As war continued to became more traumatic, armies embraced more drastic measures to prevent soldiers from deserting. Obedience was enforced by means of fines and a wide range of corporal punishments; including branding, flogging, and execution. A policy was even adopted that soldiers should fear their own officers MORE than the enemy. Such factors created an environment of "inescapable" trauma; which seems to have made the horrors of war even more horrifying and traumatic.

As with soldiers, the option of "escape" is important to civilian PD sufferers as well. When someone experiences uncontrollable panic, there is a strong tendency to associate that panic with the situation at hand. So, naturally, people have a strong compulsion to escape panic by escaping a situation. However, if escape is awkward or impossible, people often feel trapped in a state of panic, which only augments the trauma.

Furthermore, the option of escape ultimately fails when taken to extremes. When a person associates their panic with a specific situation, they tend to avoid that situation in the hope of avoiding panic. This can result in a growing avoidance of ever more situations until a person feels trapped in their own home; what we call agoraphobia. Like a soldier who cannot escape the battlefield, a PD sufferer ultimately cannot escape their horrific attacks through avoidance.

Without the options of "fight" or "flight", a person finds them self in a horrible state of "inescapable" fear. Such fear often has severe consequences, both mental and physical.

The Ubiquity of Panic

By the time of the American Civil War in the 1860's, the mental and physical consequences of extreme fear were becoming hard to ignore. Among the soldiers discharged with so-called "nervous disease," roughly half suffered conditions that mimicked epilepsy or paralysis, but for which no physical cause could be found. Doctors were beginning to acknowledge that extreme fear could cause dramatic physical responses; such as fainting, paralysis, seizure-like episodes, tremors, cardiovascular effects (such as turning white with fear), vomiting, incontinence, cognitive dysfunction, and a variety of other symptoms.

Still, the mental and physical injuries of fear were not considered ubiquitous. Those who fell victim to fear were still considered somehow weak, and the "traditional" notions of courage and cowardice remained. The notion that "true heroes" were somehow immune from fear continued to be a powerful myth.

Several more wars had to pass before panic was recognized as a ubiquitous problem. From the Russo-Japanese War of 1904 to World War II, military psychiatrists slowly accepted that no one was immune from panic. Seemingly physical injuries due to "shell shock" and gas attacks were found to actually be psychiatric in nature. Furthermore, attempts at large-scale psychiatric screening failed to reduce rates of psychiatric collapse on the battlefield. Despite all efforts, the rates of psychiatric collapse among soldiers continued to exceed the number killed in action!

Gradually, the "traditional" views of courage and cowardice melted away in the light of actual data. Military psychiatrists finally realized that psychiatric breakdown is precisely what normal people do when the strain becomes too great. Reluctantly, the military had to accept that even the bravest people are vulnerable to prolonged or extreme fear.

As in military psychiatry, civilian psychiatrists are recognizing the ubiquity of panic. Patients suffering nervous disorders are less often seen as cowardly or timid, and panicked patients with a courageous past seem less surprising. The physical symptoms of panic are also gaining recognition and understanding among the medical community in general. Altogether, the diagnosis and treatment of PD and related disorders are improving.

Despite progress in psychiatry, however, the general public still clings to the "traditional" notions of bravery and cowardice. This is not entirely surprising since many people rarely, if ever, experience the extremes of fear, and so they feel little reason to seek further education on the matter. A problem with this situation is that the general public influences decisions regarding war and health issues, and thus there is risk of naive promotion of human horror.

Treatment

As with panic itself, there are parallels between the military and civilian approaches to treating panic. Such approaches have included psychological techniques and anxiolytic substances (herbs and drugs). As might be expected, these approaches have had mixed results.

Extensive training of soldiers has been a common practice during the 20th century. Such training not only refines military techniques, but also provides psychological benefits by exposing soldiers to combat related environments and beliefs. This practice is essentially a preventive form of Cognitive-Behavioral Therapy (CBT) which, undoubtedly, has benefits. However, the exposure techniques of CBT can prove damaging if employed too aggressively. Soldiers can be traumatized during training, and CBT has limited effectiveness in treating the psychiatric casualties of war.

Likewise, CBT has mixed results in the civilian world as well. Often, such therapy is beneficial during recovery. Yet, when pursued too aggressively, exposure techniques can further traumatize a patient. Such over aggressive treatment is usually the result of financial pressures to recover quickly.

The use of anxiolytic substances also has a tainted history. As far back as 2000 BC, tribal warriors throughout the world have used chemicals derived from natural plants to help manage their fears; including mushrooms, valerian, alcohol, marijuana, and opiates. Of course, not all anxiolytics are good anxiolytics. Many traditional anxiolytics have a history of abuse and are highly addictive. Nonetheless, panic has been found to have strong biological components, and humans confronted with extreme or prolonged panic need some means of compensating for the biochemical complications of fear. Consequently, pharmacological anxiolytics that are far less addictive continue to play a useful role in modern war.

Civilian use of anxiolytics also has a tainted history, and for similar reasons. Centuries of abuse and addiction have made the traditional anxiolytics infamous among the general public. This popular bias against anxiolytics has since overshadowed the development of much improved medications; resulting in ironies like alcohol being more socially acceptable than benzodiazepines.

As panic becomes better understood, the treatment of panic will improve in both military and civilian life. Gradually, psychological techniques and anxiolytic substances will be employed more effectively against intolerable horror.

Conclusions

The history of war has taught us some very important lessons about panic and human tolerance. Such lessons are relevant and important to everyone; military and civilian. Chief amongst these lessons are...

• Even the bravest and strongest of people have a limited tolerance of fear.

• People in fear feel a natural need for control or escape.

• Panic related disorders are terribly disabling, and require appropriate medical and psychological assistance.