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History of Psychiatry, 14/2, 195204 Copyright SAGE Publications 0957-154X [200306] 14:2; 195204; 035161

A historical inquiry into the appropriateness


of the term panic disorder

YIANNIS G. PAPAKOSTAS,a ARISTOTELIS EFTYCHIADIS,b


GEORGE I. PAPAKOSTASc and GEORGE N. CHRISTODOULOUd

Panic disorder was introduced in the standard psychiatric nosology with


the publication of the DSM-III in 1980. The myriad of earlier medical and
psychiatric names describing anxiety attacks and related conditions were all
abandoned, being housed under the term panic attack and panic disorder. In
this paper, the rationale and the appropriateness of this term are critically
examined from a historical perspective.
First, a brief historical account of anxiety that comes in the episodic form,
and the medical and psychiatric terminology that emerged during the last two
centuries regarding this condition, are presented. Next, the origins of the concept
of panic as a collective or individual fear reaction are traced from a mythological
and historical standpoint, up to its current, almost accidental, introduction into
the official psychiatric diagnostic systems.
Since the word panic has its roots in the Greek god Pan and the unpleasant
states inflicted by him, this god is described, as well as St Gilles also known as
St Aegidios, the Athenian the healing saint for those suffering from panic,
horror and phobias. Finally, the current diagnostic features of panic disorder are
systematically compared with the corresponding troubles inflicted on people by
the mythical god Pan.
It is concluded that the introduced term panic appropriately and successfully
replaced the old ones.
Keywords: anxiety disorder; history; Pan; panic; psychiatry

Introduction: a brief historical account of anxiety attacks


Despite the wide range of views about anxiety, the clinical descriptions of

a
Address for correspondence: Y. G. Papakostas MD, Athens University Medical School, Eginition
Hospital, 72-74 Vas Sophias Ave, 11528 Athens, Greece. E-mail: gnchrist@compulink.gr
b
Department of Medical History, Athens University Medical School, Greece.
c
Department of Psychiatry, Harvard University Medical School, Massachusetts General Hospital
and McLean Hospital, Boston, USA.
d
Department of Psychiatry, Athens University Medical School, Greece.
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196 YIANNIS G. PAPAKOSTAS et al.


anxiety that manifests itself in an episodic form as anxiety attacks display
a remarkable similarity over the centuries (Lesser and Rubin, 1986: 410).
According to Klein, the earliest description of an anxiety attack appears in
Platos Timaeus, although the relevant and original passage was associated
with the wandering womb and hysteria (Klein, 1996). Likewise, Aretaeus
description of hysterical suffocation includes anxiety and panic attacks in
addition to hysteria (Kotsopoulos, 1986).
Similar descriptions consistent with the current notion of anxiety attacks,
as formalized with the term panic in the DSM-III (APA, 1980), have
frequently appeared over the last two centuries, both in somatic and
psychological medicine, although under different diagnostic labels. Cardiac
neurosis, irritable heart (DaCostas syndrome; DaCosta, 1871), disordered
action of the heart, effort syndrome, nervous exhaustion, nervous tachycardia,
neurocirculatory asthenia, soldiers heart, vasomotor neurosis, vasoregulatory
asthenia, hyperventilation syndrome, beta-adrenergic anxiety neurosis
and agoraphobia (a term coined by Westphal, 1872) are but a few of the
names given to this condition (Angst, 1995; Nemiah, 1980; van den Hout,
1996).
It seems that the medical descriptions of anxiety attacks preceded those of
psychological medicine (Angst, 1995), the former dating back to the French
Revolution, while the latter were first used in a report by Domrich (1849). The
emphasis of somatic medicine on the cardiorespiratory manifestations of the
disorder differentiated it from psychological medicine which put the
emphasis on anxiety. This split in diagnostic approach led to what Nemiah
(1980) called diagnostic diplopia, as can be inferred from the various terms
mentioned above reflecting one orientation or the other. Thus, among the
somatic approaches the diagnosis irritable heart a functional syndrome
with no evidence of structural lesion of the heart, as proposed by the
physician DaCosta (1871) during the American Civil War became an
established medical diagnostic entity for many years.
From the psychiatric standpoint, it was Freud (1962) who, in his effort to
disentangle the entity of anxiety neurosis from neurasthenia, chose anxiety,
both its acute and chronic forms, as the most prominent feature of the
former condition. This term anxiety neurosis was officially established and
remained essentially unchanged until the publication of the DSM-III (APA,
1980). In this landmark edition, the term was split into two different
diagnoses: generalized anxiety disorder and panic disorder.
In this paper, the rationale and the appropriateness of the latter term are
critically examined from a historical perspective.

The concept of panic as a collective or individual fear reaction


The word panic derives from the Greek and describes the unpleasant state
inflicted by the intervention of the god Pan. Originally the term panic
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THE TERM PANIC DISORDER 197


implied mainly collective and excessive fear reactions, associated with loss of
self-control and irrational flight, occurring whenever people were faced with
disasters (Consensus Statement, 1987; Lader and Marks, 1971: 16; Pichot,
1996, 1999). The linking of the gods name with collective fear is credited to
Herodotus (Herodotus: 2579). In the victorious battle of Marathon, the
Athenians were convinced that it was Pan who helped Greeks, putting the
Persians to flight.
It is hard to establish the documentation of panic as a term describing
psychiatric conditions, in the form of a sudden, unexpected, unjustified and
intense fear displayed by an individual. The ancient Greek physicians as well
as the Byzantine texts did not apply the term panic to medico-psychiatric
conditions of anxiety attacks (Eftychiadis, 1983, 1995). Nevertheless, these
conditions did not escape the attention of the Tragics (Sophocles) (Stobaeus,
1543), Plato (Klein, 1996), Hippocrates (Hippocrates: 141) and Aretaeus
(Kotsopoulos, 1986).
According to Pichot (1999), writing about the modern European
languages, the Greek word panikos first appeared in France in the
expression peur panique created by Rabelais in 1594; it was then adopted in
English in 1603, and finally in German in the eighteenth century. Pichot
(1996, 1999) also credits Maudsley (1879) as being the first to apply the
term panic to a specific psychiatric symptom (melancholic panic).
Furthermore Berrios (1999) spotted the term panophobia coined by Ribot
(1911) in the case of the patient who fears everything. Berrios (1999),
however, notes the objections to this term raised by Devaux and Logre
(1917) who suggested the more accurate term pantophobia for these cases, as
panophobia etymologically refers to god Pan and not to what Ribot meant
to describe. The first official application of the term panic was by Kempf
(1920) in 1920, under the category of homosexual panic, a term that like
melancholic panic and panophobia bears little or no resemblance to the
current meaning of the term as established by the DSM-III.
However, it is possible that the first use of the term panic to describe
individuals suffering from anxiety attacks and nightly fears might have occurred
much earlier. Written in the Middle Ages, martirologia (martyrology) and
synaxaria (legendaries) formed the roots of the old liturgical books Les
anciens Missels (Missel Quotidien, 1947). These liturgical books, in turn, cite
the words la panique (panic) and les frayeurs (fears) in reference to Abba St
Gilles who lived in the eighth century and was the healing saint for those
suffering from these maladies.
At any rate, the establishment of panic attack and panic disorder with
their current meaning into the official diagnostic systems is credited to
D. F. Klein (1964, 1993, 1996). Klein is recognized as the leading force in
this development; he challenged the prevailing view of pathological anxiety as
psychologically or environmentally driven, and stressed instead the under-
lying neurobiological underpinnings of this disorder. Thus, he and M. Fink
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198 YIANNIS G. PAPAKOSTAS et al.


succeeded in their initial attempts to differentiate pharmacologically the
anxiety that comes in an episodic form as anxiety attacks from other forms
of anxiety (Klein and Fink, 1962). Furthermore, the adoption by Klein of
the term panic occurred while he was searching for a synonym for the
anxiety attack, in order to clarify its distinction from chronic anticipatory
anxiety (1996, 1999). When the word panic popped out, his most plausible
explanation was that he remembered that word from the expression panic
attack which he might have read in a Freudian text. However, as pointed out
by Pichot (1996, 1999), the original sentence written by Freud in France was
attaque dangoise (anxiety attack), wrongly translated as state of panic, an
error corrected in a later edition. As it turned out, the establishment of the
term panic was based on an error in translation!
In spite of initial scepticism (Consensus Statement, 1987; Gelder, 1989),
this diagnosis not only persisted but it also gained a clearer and more
prominent status in the wording and order of the DSM system from its first
appearance in the DSM-III to the last two successive editions, DSM-III-R
and DSM-IV (Compton, 1998). Thus, in the latter (APA, 1994), panic
attack is defined as a discrete period of intense fear and discomfort associated
with somatic and cognitive symptoms being developed abruptly and peaking
within minutes. On the other hand, panic disorder is characterized by
recurrent and unexpected episodes of panic attacks. Moreover, the patient is
concerned about additional attacks and the implications or the consequences
of the attacks, and so changes his/her behaviour in relation to the attacks.
This condition is not due to medical or psychiatric disorder, or to drugs.

The Greek god Pan


In Greek mythology, a whole range of gods could cause mental diseases.
Thus Hecate, a lunar goddess, caused epileptic insanity, Dionysus elation,
Diana hysteria and Pan fear (Roccatagliata, 1986: 6, 71). Pan was the god of
nature, fields, forests, streams, wild animals, flocks and shepherds. Living in
the countryside, Pans haunts were the hills and the mountains, particularly
those of his homeland, Arcadia and Mt Lycaeus. But Pan did not fit the
popular image of a god (Barlow, 1988). He was very short and ugly, and was
not completely human in form, since he possessed the ears, horns, legs and
beard of a goat. His parents are variously named. Thus, depending on his
father, he would be referred to by complex names, such as Titano-pan, Dio-
pan, Hermo-pan. In case he was denied fatherhood, the name of Aegi-pan
was also used to indicate his association with an aega, the Greek word for
goat. His mother was usually thought to be a nymph: the daughter of
Dryops, or Penelope. Everyone feared Pan because of his appearance and his
screaming. Even his own mother startled and fled and she abandoned the
child, for she was frightened when she saw his coarse features and full beard
(Hesiod: 4437).
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THE TERM PANIC DISORDER 199


But among the gods, Pan is unique in that we have not only information
about his birth but also about his death. The news of his death came from
Plutarch (Plutarch: 419) in the first century AD, who describes it as follows:
A sailor named Thamus heard a divine voice shouted across the sea
Thamus, are you there? When you reach Palodes, take care to proclaim
that the great god Pan is dead.
It seems that this is a crucial moment, because:
the cry which the sailors had heard towards the time of the Emperor
Tiberius the god Pan is dead, as it was reported by Plutarch, marks the
limit between the end of myth and the birth of new perception. From this
moment on there would always be a distinction between the period before
Christ and after Christ. (Roccataglia, 1986)
After Pans death, and with the prevalence of the new Christian beliefs, Pan
was linked to the devil and the devils appearance. Furthermore, according to
the new dogma, mental illness was the product of sin and/or the devil and
people still could be treated through purification or by a capable priest.
Thus, a new figure emerged to replace the image of Pan in his representation
of episodic anxiety. The old liturgical books and book of Saints Les anciens
Missels enlist Aegidios the Athenian, more widely known as St Gilles, within
the fourteen healing saints (Les quatorze saint auxilaires) for people suffering
from la panique and les frayeurs (Missel Quotidien, 1947).
According to Acta Sanctorum, a book of saints of questionable historic
value, Aegidios was born in Athens during the seventh century, being the
only son of a noble family. The names of his parents were Theodore and
Pelagie (Coleti and Albrizzi, 1756). Ironically, his Greek name Aegidios
means protection from the word aegis, a shield made of goat skin. Hence,
an association between St Aegidios and his healing grace on the one hand,
and goat-like Pan and his afflictions on the other, is obvious. While in
Athens, Aegidios performed several miracles but eventually left the country,
apparently to escape from unwanted publicity and fame. He went to
Provence, France, where he became known by the name Gilles1 (Missel
Quotidien, 1947) and founded the eponymous and later famous Saint
Gilles Monastery. He died in 721 or 722. The tomb containing his relics was
found in 1865, and the Catholic Church celebrates his memory on 1
September, when many devotees suffering from panic and related conditions
visit the tomb to receive his grace and be cured.

Comparing panic disorder and Pan-induced panic


The main thesis of this paper is that the diagnostic label of panic, recruited
almost accidentally by Klein (Pichot, 1996, 1999) and officially introduced
by the DSM-III in 1980, was appropriate and, as it turned out, widely
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200 YIANNIS G. PAPAKOSTAS et al.


approved and successful. By introducing this term, the DSM-III succeeded
in several respects.
First, this new diagnostic label is free from any aetiologic connotations as
opposed to such terms as irritable heart and hyperventilation syndrome. It is
obvious that both these terms are not purely descriptive but reflect or imply a
theory, albeit unproven, about pathology and underlying mechanisms (van den
Hout, 1996). Therefore, the new term satisfies the criterion of neutrality
regarding unproven aetiology, a virtue highly desired and followed by the
architects of the DSM-III.
The establishment of this term put an end to the terminological
bifurcation between medical and psychiatric terms Nemiahs diagnostic
diplopia (Nemiah, 1980). The other names were all abandoned, being
included under the DSM-IIIs term panic attack and panic disorder. With
few exceptions (Bandelow et al., 1996), this new diagnosis seems to have
gained firm and wide acceptance, as indicated in the revealing title Panic
disorder used in both a public service announcement by the National
Institute of Mental Health and a JAMA editorial (Glass, 2000).
Most important, however, we argue that the troubles supposedly imposed
on men by the intervention of god Pan carry with them all the essential
defining features of the psychiatric condition that we currently call panic
disorder (APA, 1994; Barlow et al., 1994). This claim should be justified by a
comparative evaluation of the two conditions. DSM-IVs criterion of intensity
is an unquestionable attribute of fear and discomfort caused by Pan.
Nymphs, people, his own mother, were all terribly afraid of Pan. Even the
other gods were subject to his terror and at his mercy, (Barlow, 1988) and a
sudden shout from Goat-Pan was sufficient to put them to flight (Graves,
1960). Pan could make his appearance (attack) unexpectedly, thus satisfying
an important definitional feature of panic disorder. Indeed, Pan could
play frightening tricks on unwary travellers (Ley, 1992), and Barlow explains
why:
Pan had a habit of napping in a small cave or thicket near the road. When
disturbed from his nap by a passer-by, he would let out a blood-curdling
scream that was said to make ones hair stand on end. (Barlow, 1988)
Similarly, Graves describes him as
loving nothing better than his afternoon sleep, and revenged himself on
those who disturbed him with a sudden loud shout from a grove, or
grotto, which made the hair bristle on their heads. (Graves, 1960)
These descriptions fit well with the clinical observations that panics occur
during relaxation (Barlow, 1988) and deepening non-rapid eye movement
sleep (Mellman and Uhde, 1989a, 1989b), i.e., in situations in which there is
lack of danger clues or cognitions (Klein, 1993), and underline the unexpected,
the intense and the abrupt as well, as the somatic components of the panic
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THE TERM PANIC DISORDER 201


attack. The description of victims as unwary is also in line with the current
finding that sympathetic activity is not elevated in patients with panic
disorder when at rest (Wilkinson et al., 1998).
From a semantic point of view, the term panic, in contrast to terms that
indicate passivity such as fear and terror, (i.e., he is terrified), introduces
a more active element, implying flight or a disorganized behaviour (Pichot,
1996). This holds true especially for the victims of Pan who, full of dread,
tried to avoid him, as Theocritus (p. 11) informs us:
No, no man; theres no piping for me at high noon. I go in too great dread of
Pan for that. I wot high noons his time for taking rest after the swink o
the chase; and hes one o the tetchy sort; his nostrils ever sour wraths
abiding-place.

Among the nymphs chased by Pan, Pitys escaped him only by being
metamorphosed into a fir tree, Syrinx became a reed, and Echo became an
echo. These are just a few examples indicating that the victims of the god
Pan did worry about additional attacks, and the implications or the
consequences of these attacks, thus changing their behaviour as do patients
with the DSM-IV diagnosis of panic disorder.
Pan, however, was not that bad. He was also full of spirit, amorous and
easy-going (Graves, 1960). Ley (1992) describes Pan in a more sophisticated
and sympathetic way:
A clever and mischievous fellow who frequently used disguises to mask
his true identity . . . Although Pan often wore disguises that aided him in
his cruel and mischievous behavior, he was a safeguard for those who
believed in him, for those who saw him for what he was a complex and
many-sided figure.

After all, Pan possessed no weapons for his defence, other than his appearance
and his cry. The magnitude and the seriousness of his threat, if any, depend
entirely on the recipients perception of the threat, as Pans weapons cause
no harm by themselves. It is obvious then that this feature of weapon-
lessness harmoniously stands for the DSM-IV requirement that panic is not
due to a medical or psychiatric illness, in striking contrast to what the victims of
panic believe when experiencing such noisy symptoms.
This brief comparative evaluation thus reveals remarkable similarities
between the DSM-IV defined panic disorder and the afflictions induced by
Pan, suggesting that the mythological concept of panic encapsulates all the
particulars of this specific anxiety state, as currently defined. Awareness of
the mythological origins and characteristics of the terms panic attack and
panic disorder may enhance clinicians understanding of this condition
and its differences from other forms of acute anxiety or from more chronic or
diffuse background anxiety states.
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202 YIANNIS G. PAPAKOSTAS et al.

Closing remarks
Although Pan was declared dead by Plutarch, this may not be so. Barlow
maintains that Pans power is experienced daily by millions. In fact, panic
may be so common, so widespread and so much a part of our experience that
we have managed to overlook its importance (Barlow, 1988). Klein (1964,
1993, 1996; Klein and Fink, 1962) and modern psychiatry (APA, 1980) have
re-instituted Pans name, paying tribute to the gods complex involvement with
mens affairs. One might wonder why the diagnostic label of panic had to
wait for so many years before its official and accidental psychiatric use, just
twenty years ago. Could it be because Pan frequently used disguises to mask
his true identity? (Ley, 1992).
Pan may not be dead, in spite of Graves statement that Pan is the only
god who has died in our time, for, as Graves realizes, the sailor Thamus may
have misheard the ceremonial lament: the all-great Tammuz2 is dead!
(Thamus Pan-megas Tethnece) as Thamus, Great Pan is dead (Graves,
1960). In any case, Pan, like Narcissus, Oedipus and Adonis has been
immortalized through the widespread use of his name in modern psychiatry.

ENDNOTES
1. Gilles: he who migrates; Petit Larousse Illustre (Paris, 1914).
2. Tammuz: the king of Egypt residing in Thebes.

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