Panic Disorder With Agoraphobia: A Medical and Personal History: Where Things Stand Today 2018
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McCloud was suffering from untreated panic disorder with agoraphobia (PDA)—a disorder so poorly understood in the United States that no formal diagnostic criteria or treatment existed yet. What little he was able to learn came from European and Australian sources. Only in 1980 would the DSM-3 list his symptoms as a diagnosable condition.
The next fifty years would see great strides made in identifying and treating PDA. Panic Disorder with Agoraphobia offers a fascinating examination of the medical history behind PDA diagnoses, supported by elements of McCloud's own search for answers about his condition.
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Panic Disorder With Agoraphobia - Douglas Pollock McCloud
Abbreviations
1
Diagnosis: You Can’t Diagnose a
Disease You’ve Never Heard Of
In 2018, it will be 50 years since I developed panic disorder with agoraphobia (PDA) at age 25 in the summer of 1968. At that time, there was no diagnosis for panic disorder, no recognized symptoms or syndrome, and no proper treatment of the illness in the United States. But why was that? There were psychiatrists at the time in the United States and abroad who had conducted clinical trials of antidepressant drugs that were shown to block panic attacks, and they were published in leading medical journals in the 1960s and 1970s. The medical condition of agoraphobia was known and written about in the British Commonwealth nations. But neither the medical term panic disorder nor the term agoraphobia existed as a diagnosis in the United States until 1980, when the new DSM-III ( Diagnostic and Statistical Manual of Mental Disorders ) replaced the DSM-II.
The DSM-II came out in 1968, the very year I became ill, and listed anxiety disorders under the psychoanalytic or Freudian label of neuroses. The DSM-III threw out the psychoanalytic (Freudian) terminology in favor of classifying psychiatric disorders based on careful analysis of clusters of symptoms to identify different psychiatric syndromes so that their cause and treatment could be specified. This would lead to different treatment regimens appropriate to the specific categories of illness. The DSM- I (1952) and the DSM- II (1968) went 28 years without a single mention of agoraphobia, although the condition was first written about in 1897 by Westphal.¹ During those 28 years, psychoanalytic diagnoses blocked the use of the medical model of grouping patients with similar clusters of symptoms into categories that would permit diagnosis and development of specific treatments rather than treating a person’s mental disorder as unique.
The DSM-III represented a completely new classification system that completely shed the influence of DSM-II (Mayes & Horwitz, 2005). The earlier versions of the DSM conceptualized mental illness symptoms as manifestations of deeper underlying subconscious conflicts. Thus, the diagnostic label was almost meaningless without knowing the complete context of the patient’s life (Mayes & Horwitz, 2005). When psychiatrists were asked to diagnose the same patients using the DSM-II, their level of agreement was only slightly higher than chance (First, 2010)!
The DSM developers dropped the descriptive paragraphs that were present in the earlier systems and created a specific set of observable criteria for each specific disorder. In order for an individual to be diagnosed with any specific disorder, they had to surpass a certain number of criteria. The DSM-III was seen as a system that relied on objectivity, logic, and truth (Mayes & Horwitz, 2005).²
Donald W. Goodwin, MD, in his 1986 book Anxiety, describes the barriers and impediments thrown up by psychoanalytic psychiatry to prevent a useful, observable, classification of psychiatric disorders.
A classification of diseases has been slow to emerge in psychiatry, principally because of the 40-year dominance of the field by psychoanalysts. Among the diseases in DSM-III are anxiety disorders. Millions of people suffer from these disorders but only in the last five years have they been separated into categories that permit diagnosis and the development of specific treatments. It has been long in coming.³
For over 40 years, beginning in the mid-1930s, Freudian psychoanalysis dominated American psychiatry. Almost all the chairmen and professors of psychiatry were psychoanalysts or at least enthusiastic about Freudian theory. Generations of American medical students were taught psychoanalytic theory as received truth. Articles by analysts appeared regularly in American medical journals. The New York literary establishment adopted psychoanalysis with religious fervor. In novels, movies, newspapers, and other media, psychoanalysis and psychiatry were treated as identical specialties. The takeover of psychiatry by the psychoanalysts occurred only in America.⁴
The Freudians had little interest in diagnosis. They exploited their position of power to transform the diagnostic manual into psychoanalytic propaganda. Nobody seemed to mind; the Adlerians and Jungians were just as indifferent to diagnosis.⁵
Goodwin goes on to say that psychoanalysis was famous for producing silly as well as untestable theories that were neither scientific nor supported by data as effective treatments. Freud himself saw his work’s focus as uncovering a psychology of the unconsciousness, not as a method of treatment. The psychoanalysts exploited their positions of power in the DSM-I and DSM-II. When invited to participate in the DSM-III, most declined; so not much psychoanalysis got into DSM-III. Biological psychiatrists took over.
The passing of the guard from psychoanalysis to biological
psychiatry was clearly evident in the 1984 membership of the psychiatry section of the National Board of Medical examiners. In 1984, seven of eight members were clearly of the biological school; 25 years previously psychiatrists of psychoanalytic persuasion dominated the section. And these are the people who select the questions that determine whether medical students are permitted to practice medicine!⁶
The US Army recruited psychoanalysts in World War II and incorporated psychoanalysis into the official training manual of army psychiatrists. Karl Menninger, a leading proponent, was made a brigadier general and recruited psychoanalysts. There is a story that when American soldiers came down with battle fatigue in North Africa in the war, they were first turned over to psychoanalysts for talk treatment.
When they did not recover, British psychiatrists were called in and used multiday sleep therapy with sedatives. Ninety percent of the soldiers eventually recovered using this therapy and were able to fight again. The psychoanalysts were sent back home. In 1963, when Menninger published The Vital Balance in which he recommended that all mental illness be treated by psychotherapy, this treatment method took over completely. Hopes for medically based psychiatry were dashed.
It took decades to overthrow the influence of the psychoanalysts on psychiatry because they had long held the positions of power and prestige in American psychiatry. Of course, psychoanalytic psychotherapy may have value in limited areas of psychiatry, but it blocked scientific progress when it sought to encompass all psychiatry. Hans Eysenck in Decline and Fall of the Freudian Empire explores the myths and pseudoscience of psychoanalysis. He notes that psychoanalysis will remain forever one of the saddest and strangest landmarks in the history of 20th-century thought. Generations of medical students were falsely taught it as truth.
Even from the hermeneutic point of view, then, Freud and psychoanalysis must be regarded as a failure. We are left with nothing but imaginary interpretation of pseudo-events, therapeutic failures, illogical and inconsistent theories, unacknowledged borrowings from predecessors, erroneous ‘insights’ of no proven value, and a dictatorial and intolerant group of followers insistent not on truth but on propaganda. This legacy has had many extremely bad consequences for psychiatry and psychology.
When discussing psychoanalysis, we should always bear in mind the fate of the patients; the scientific pretensions of psychoanalysis are one thing, but its therapeutic effects are another, much more important from the human point of view. Psychoanalysis is a discipline meant to cure patients; its failure to do so, and its reluctance to admit the failure, should never be forgotten.
The second consequence of Freud’s teaching has been the failure of psychology and psychiatry to develop into properly scientific studies of normal and abnormal behavior. It is probably true to say that Freud has set back the study of these disciplines by something like fifty years or more. He has managed to sidetrack the scientific research of the early days onto lines which have proved unsuccessful and even regressive. He has elevated the absence of proof, devaluing its necessity, into a religion which too many psychiatrists and clinical psychologists have embraced, to the detriment of their discipline.⁷
In the DSM-II, in 1968, the Freudian view was that mental anguish and maladaptive behavior were due to neurotic symptoms resulting from defense mechanisms operating to prevent conscious awareness of painful intrapsychic conflicts. Imagine how useful this point of view would be to understand the severe panic attacks and phobic symptoms of panic disorder with agoraphobia (PDA) patients when these symptoms themselves were not recognized or acknowledged. Nonresponders were considered to lack will or rational thought or to have character flaws if they failed to get well with talk therapy. If the anxiety was extreme, as it is in panic, the patient would have to be considered irrational.
By the early 1980s, even the New York literati lost faith in psychoanalysis and published articles in the New Yorker and the New York Review of Books criticizing its use in medicine and favoring biological psychiatry.⁸ In fact, the thinking and understanding of the entire medical profession had changed by then, not just those specializing in psychiatry.
The general medical doctors, outside psychiatry, for years only made superficial inquiries into the diagnostic symptoms or possible biological causes for their anxiety patients. They simply referred them to psychiatrists, who thought they could cure patients by endless probing. The general practitioners were just as unlikely to help the anxiety patients as the psychiatrists. In the early 1990s, a leading psychoanalyst at Harvard wrote in the university’s alumni magazine that he could not recall one patient who was cured and only a handful who were helped in his entire career in psychoanalysis. In 1997, another Harvard psychoanalyst wrote:
The answer is that psychoanalysis, both as a theory and as a practice, is an art form that belongs to the humanities and not to the natural sciences. It is closer to literature than to science. . . . Looking back at what we now know about Freud, I think the case can easily be made that Freud was more an artist/subjectivist/philosopher than a physician/objectivist/scientist.
Fifteen years ago I spent most of a year reinterpreting Freud’s first dream. What one discovers is that Freud had a new hypothesis every day. It is astonishing to see how little evidence he needed; a single patient hour was enough to launch a whole new theory of mental illness.
Early in my career as a psychiatrist and a psychoanalyst I believed that every form of mental illness—be it psychosis, neurosis, or personality disorder—could be understood in terms of psychoanalytic developmental stages. If one wanted to understand psychopathology better, one had to learn more about infant and child development. This idea was basic and it was unquestioned.
Our problem is that, in light of the scientific evidence now available to us, these basic premises may all be incorrect. Our critics may be right. Developmental experience may have very little to do with most forms of psychopathology, and we have no reason to assume that a careful historical reconstruction of those developmental events will have a therapeutic effect. I know that it is difficult to assimilate this idea; it certainly is for me.
There is certainly no longer any consensus that schizophrenia, bipolar disorder, depressive disorders, or substance abuse can be understood with reference to normal child development. In fact most research psychopathologists would say that child development explains very little about most so-called Axis 1 disorders. (There is, of course, one very important exception—post traumatic stress disorder; but the trauma is not crucially related to childhood development.) Psychoanalysts can no longer assert that what they learn about their patient’s childhood will help them to explain the etiology of the patient’s psychopathology.⁹
It is interesting to note that even at this late time in the history of psychiatry when this was written, 1997, the professor did not mention panic disorder (PD), as its syndrome always remained