By Richard J. McNally Guilford Press, 1994 Review by G.C. Gupta, Ph.D. on Jul 3rd 2000
Dr. McNally provides an insightful analysis into the psychopathology of panic disorder from the perspectives of biological psychiatrists, behavioral psychologists, and psychopharmacological treatments. Using Donald F. Klein's classification, the author differentiates three types of panics, the spontaneous, the stimulus-bound, and situationally predisposed, highlighting the similarities and differences amongst them. Basically, the panic has at its core a fear-anxiety syndrome that gets triggered in one of the three ways, characteristic of the three types, striking the individual with a psychophysiological attack associated with a wide range of autonomic and cardiovascular features. Panic has a sudden onset, massive autonomic arousal, accompanied by intense fear. The author makes an in-depth analysis of the three types, especially of the differences amongst them. He follows Klein in this characterization of panic. According to him, "the concept of panic was foreshadowed in Freud's writings on anxiety neurosis." Referring to Freud, he writes, "panic can erupt into consciousness without being triggered by any antecedent thoughts, although fears of impending death or insanity often accompany an emerging attack."
Definition of Panic Disorder, as it has been given to this disorder under DSM III (1980) and DSM-III-R (1987) initially and the changes introduced in it under DSM-IV (1994), are presented in the chapter on `Phenomenology.' It is not initially clear, however, why a quantitative perspective on Panic Disorder is finally adopted (pp. 5-6.). The author provides a rationale under "Overview of the evolution of the DSM Panic Disorder Concept" by stating that "disorder diagnosis DSM-IV requires not only repeated, unexpected attacks, but also persistent anxiety about subsequent attacks." The author continues to clarify the concept by dealing with the following topics: "Is panic qualitatively distinct from anxiety?", "Is panic distinct from fear?", "Alternative sub-typing Schemes", "Variants of Panic", "Non-clinical Panic", " Non-fearful Panic", and "Nocturnal Sleep Panic."
From here on, the author discusses the biological and psychological aspects of the disorder and their respective line of treatments in the next four chapters, Chapter III, Biological aspects, Chapter IV, Psychopharmacologic treatment, Chapter V, Psychological aspects, and Chapter VI, Psychological treatment. Treatment of any disorder is an integrated approach, both biological and psychological, using chemotherapy and psychotherapy. Analysis of treatment separately from the biological and psychological perspective is welcome from the analytical point of view, from the academic point of view, but to the present reviewer, clinically, it has to be an integrated multiple approach. Analyzing the treatment from this stance would have given it an applicational perspective.
Chapter 7 on Syndromal Validity and Chapter 8, on Metatheoretical Issues carry the author's arguments to a logical end, providing a critical conceptualization of syndromal validity of the panic disorder and the Chapter 8, a critical analysis of metatheoretical issues arising out of this sort of analysis, an analysis that has been very thoughtfully carried out. The two chapters together provide a broad-perspective philosophy of this disorder, if it is accepted as a disorder. Beginning with nosological evolution of the disorder and moving on to `Can panic disorder be reliably diagnosed', `age of onset', `sex ratio', and `precipitants and course set the stage, enabling him to compare American and European point of views on this disorder. Following the functional logic of the syndrome, depression, alcoholism, hypochondriasis, illness phobia and personality disorder are significantly related to panic disorder, and may overlap with it.. `Is panic disorder inheritable?, family studies, twin studies, and others, according to the author do show that panic disorder does run in families but relative contribution of these factors is rather uncertain (p.186).
The role of developmental antecedents, for instance, of childhood separation anxiety, parental rearing styles, and behavioral inhibition is also not convincingly emphatic. Comparing Panic disorder and GAD (General anxiety disorder), however, it has been reported `that panic patients had a symptom profile suggestive of autonomic activity , whereas GAD patients had a symptom profile characteristic of central nervous system arousal' (p.191). Concluding this chapter the author points out that `Panic disorder commonly begins in late adolescents or early adulthood. It can, however, begin prepubertally or late in life.'
Panic disorder is about twice as common in women as in men, and panic disorder with agoraphobia occurs even at higher rates in women. `Panic attacks commonly begin in the wake of major negative life events, or in anticipation of such events (p. 196).' `Cognitive variables are the best predictors of agoraphobia avoidance among people who experience panic attacks.'
Chapter 8 on `Meta-theoretical Issues' raises questions that cut across several disciplines and point to basic concerns, relevant in several controversies `about the formulation of the concept of disorder', `does panic reflect a dysfunction in an adaptive, evolved mechanism/', `Does panic disorder exist in non-western cultures?' `Is the DSM concept of panic disorder merely a cultural construction foisted upon the diverse phenomena of human emotion?', 'Or does it "cut nature at its joints," capturing a disease entity that exist in nature irrespective of the vicissitudes of culture?'. How are psychological and biological explanations of panic to be reconciled? There are other aspects of the issues that the chapter opens up. The answers are not easy, one can only discuss since each of them involve several perspectives. The author has raised these issues and questions and has also discussed them shows one thing at least, that all these issues are open as yet and are alive.
The book is a critical analysis of the contemporary picture of panic. It is true, as the author accepts, that the picture is far from complete, presently. Yet, the author has been successful in raising several controversial issues that needs pursuing by the researchers. According to the author, researchers `need to identify developmental and other risk factors.' `The unfolding of vulnerabilities over time has scarcely been studied.' Cross-cultural study of panic disorder is an important issue. All in all, the author has done a good critical analysis, suitable both for psychiatrists and psychologists. Graduate students in both fields ought to find the book to be useful reading on panic disorder, suggestive of several issues worth examining and researching upon.