Über die Autorin bzw. den Autor

Devon E. Hinton is a psychiatrist and medical anthropologist, and is Associate Professor of Psychiatry at Harvard Medical School and Massachusetts General Hospital. Byron J. Good is Professor of Medical Anthropology in the Department of Social Medicine at Harvard Medical School.

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Culture and Panic Disorder

Stanford University Press

Contents

Contributors........................................................................................................................................................................................................................viiForeword David H. Barlow...........................................................................................................................................................................................................xiiiPreface Alan Harwood...............................................................................................................................................................................................................xviiAcknowledgments.....................................................................................................................................................................................................................xxi1. Introduction: Panic Disorder in Cross-Cultural and Historical Perspective Byron J. Good and Devon E. Hinton.....................................................................................................................12. Theoretical Perspectives on the Cross-Cultural Study of Panic Disorder Laurence J. Kirmayer and Caminee Blake...................................................................................................................313. A Medical Anthropology of Panic Sensations: Ten Analytic Perspectives Devon E. Hinton and Byron J. Good.........................................................................................................................574. The Irritable Heart Syndrome in the American Civil War Robert Kugelmann.........................................................................................................................................................855. Twentieth-Century Theories of Panic in the United States: From Cardiac Vulnerability to Catastrophic Cognitions Devon E. Hinton and Susan D. Hinton..............................................................................1136. Comparative Phenomenology of 'Ataques de Nervios,' Panic Attacks, and Panic Disorder Roberto Lewis-Fernndez, Peter J. Guarnaccia, Igda E. Martnez, Ester Salmn, Andrew B. Schmidt, and Michael Liebowitz.....................1357. Dizziness and Panic in China: Organ and Ontological Disequilibrium Lawrence Park and Devon E. Hinton............................................................................................................................1578. Gendered Panic in Southern Thailand: 'Lom' ("Wind") Illness and 'Wuup' ("Upsurge") Illness Pichet Udomratn and Devon E. Hinton..................................................................................................1839. 'Ihahamuka,' a Rwandan Syndrome of Response to the Genocide: Blocked Flow, Spirit Assault, and Shortness of Breath Athanase Hagengimana and Devon E. Hinton.....................................................................20510. Panic Illness in Tibetan Refugees Eric Jacobson.................................................................................................................................................................................230Index...............................................................................................................................................................................................................................263

Chapter One

Panic Disorder in Cross-Cultural and Historical Perspective

Byron J. Good and Devon E. Hinton

PANIC DISORDER (PD), as currently conceived, is a medical condition that may be diagnosed when a person experiences recurrent, unexpected attacks of panic or anxiety, followed by persistent concern about having additional attacks or about losing control, going crazy, or having a heart attack. Panic attacks are intense periods of fear or discomfort, feelings that sometimes seem quite irrational. They are described as "attacks" because they often develop rapidly and include such symptoms as palpitations, sweating, trembling, shortness of breath, a feeling of choking, chest pain, nausea, dizziness, derealization or depersonalization, and numbness or chills or hot flushes, as well as fear of losing control or fear of dying.

PD, according to contemporary psychiatric classification, belongs to a group of neuropsychiatric conditions for which anxiety is the hallmark symptom. Although anxiety disorders are often thought of as relatively mild conditions, researchers estimate that in the United States these disorders account for 32 percent of the total economic costs of psychiatric illness, exceeding the costs associated with schizophrenia (21 percent) and mood disorders, including depression (22 percent) (Taylor 2000:4). Within the costs of panic attacks are emergency room visits and extensive medical tests to determine whether those experiencing the panic are suffering a heart attack or some other life-threatening condition as they fear. PD most commonly begins when the sufferer is between fifteen and thirty years of age. Studies suggest that between 1.5 and 3.5 percent of members of a population will suffer PD sometime during their lifetime.

PD was first recognized-or invented-as a distinctive form of mental illness in the 1970s; codified in 1980 as part of the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual, or DSM-III (APA 1980); and popularized as a treatable clinical entity in the 1980s. Also in the 1980s, many researchers argued that PD had a largely physiological and genetic basis rather than a primarily psychological one. Since Freud, acute anxiety had been interpreted as resulting from unconscious feelings surfacing into partial awareness. PD thus figures prominently in the history of the biological revolution in psychiatry. During the 1990s, PD was, to an important extent, reconceived by cognitive psychologists as spiraling episodes of anxiety arising from catastrophic cognitions that trigger physiological experiences of terror or panic. PD continues to be an important domain of research, clinical care, and pharmaceutical investment within psychiatry, both in the United States and globally. The story of PD is thus an intriguing chapter in the contemporary sociology of psychiatric knowledge and practice.

Acute anxiety and panic, however, quickly escape the confines of current diagnoses of anxiety disorders. They belong, on the one hand, to a long history of changing conceptualizations of neuropsychological distress in North American and European medical writing and practices, sharing complex relationships with categories such as cerebrocardiac neuropathy, irritable heart syndrome, neurasthenia, agoraphobia, anxiety reaction, anxiety neurosis, and neurasthenic neurosis. On the other hand, as Jackie Orr (2006) has recently shown in her book Panic Diaries: A Genealogy of Panic Disorder, acute anxiety and panic belong to a much broader cultural domain of changing experience and understanding in the twentieth-century United States-from the social panic produced by the 1938 radio broadcast of H. G. Wells' War of the Worlds, to concerns about measuring and managing fears and anxieties in American society, to David Sheehan's popular book The Anxiety Disease (1983), to multiple pharmaceutical interventions, clinical trials, and research studies sponsored by the National Institute of Mental Health (NIMH) and the pharmaceutical industry. The story of PD thus belongs to a very broad range of social, political, cultural, and medical concerns in Western societies.

What is little recognized, however, in most accounts of PD, whether medical writing, historical analyses, or cultural studies, is that acute anxiety and panic-like conditions appear in local social and cultural worlds in many parts of the globe. Psychiatric research has investigated cross-cultural differences almost exclusively in epidemiological terms-asking whether PD, defined uniformly across cultures, is more or less prevalent in one society or social class or subculture or risk group than in another, and concluding simplistically that "prevalence, course, gender distribution, and age of onset of PD appear to be generally consistent throughout the world" (Taylor 2000:5). It is only recently that rich ethnographic research on acute anxiety and panic conditions has begun to provide real understanding of what panic and panic disorder may mean in local cultural worlds-for example, in the lives of Tibetan Buddhist refugees or contemporary Chinese psychiatric patients or Puerto Ricans suffering from ataques de nervios. Such research begins to provide a much deeper understanding of the relation of PD to culture, allowing questions to be asked, research to be conducted, and generalizations to be argued in ways that were impossible as recently as a decade ago.

This book is a collection of essays examining the complex relationships among culture, social conditions, and PD from three broad perspectives. The first chapters of the book are theoretical, developing a general framework for investigating the relationship of acute anxiety experiences to culture through an anthropology of the sensations, cultural phenomenology, theories of catastrophic cognitions, and ethnotheories of the body, illness, and healing. These essays make a strong argument that current psychological theories of panic attacks-which understand these attacks as resulting from an escalating cycle of catastrophic interpretations of bodily experience-provide a particularly rich basis for cross-cultural studies of panic and PD. The second set of chapters is historical, providing a partial cultural history of acute anxiety and panic in the West. The essays in this section make clear just how historically specific and contingent are current conceptualizations of PD, complicating enormously any effort to compare PD as an entity across time and space, as one might compare tuberculosis through social, cultural, and historical lenses. The third set of essays is positioned within cross-cultural psychiatry and medical anthropology, providing ethnographic and clinical accounts of PD and panic-like conditions in a number of specific settings. These chapters begin to answer questions about how panic attacks and PD may vary across cultures, and how PD as conceived by contemporary psychiatry relates to local idioms of distress, local categories of illness, and local moral worlds.

In this introduction we outline some of the critical issues and themes that emerge in the volume. We begin by reviewing the history of the professional biologization of PD, its conceptualization as a seizure-like entity minimally related to cultural or social context. We do so by tracing the history of the DSM, starting with the Sterling conference held in 1983. The next section describes the emergence of theories of the cause of PD that challenged this simple biologization, and outlines the theoretical ramifications of the most prominent of these theories: the catastrophic cognitions theory of panic. The final section gives an overview of the contributions of the current volume to advancing the study of PD in historical and cross-cultural perspective.

The Biologization of Panic Disorder in the 'DSM'

We begin by tracing the development of the DSM-III and DSM-IV conceptualization of PD, placing it in the context of theories of anxiety and panic in the 1980s and 1990s.

Reimagining Anxiety: From a Psychoanalytic to a Physiopsychological Perspective

In September 1983, nearly sixty researchers and administrators associated with the NIMH gathered in the Sterling Forest Conference Center in Tuxedo, New York, to discuss the state of the field of clinical and biological research about anxiety and anxiety disorders. Organized by the Clinical Research Branch of NIMH, the conference was designed to identify research issues, outline critical directions for new research, and stimulate broad scientific interest in the study of anxiety and anxiety disorders. The conveners of the conference argued that the major preoccupation of the psychiatric research community in the 1950s and 1960s was with schizophrenia, and in the 1970s, with affective disorders. They predicted confidently, however, that in the 1980s anxiety disorders would replace schizophrenia and affective disorders as the most critical site of progress in research in the neurosciences and psychiatry. The conference was designed both to stimulate and to give direction to that research, as a similar conference sponsored by NIMH had done for depression ten years earlier.

The edited book that resulted from the conference, Anxiety and the Anxiety Disorders (Tuma and Maser 1985), provides a sense of the field at the beginning of the 1980s. The initial chapters focus on basic biological and psychological research on anxiety, with papers on the neurobiology of anxiety and fear, on cognition and psychophysiology, and on the use of animal models for research on fear and anxiety based in classic learning theory. The chapters that follow provide a broad picture of the state of clinical research on anxiety and anxiety disorders at that time. What the book fails to convey, however, is the excitement among participants at the meeting-the talk around the tables and in the corridors, the feeling of exhilaration about what emerging research was revealing, the powerful sense that the time was ripe for rapid progress in studying anxiety-and the place of PD in generating that excitement.

It should be remembered that 1983 was only three years after the publication of the third edition of the DSM (APA 1980). In the context of psychiatric nosology, the DSM-III was a revolutionary document, purposely based in a neo-Kraepelinian or descriptive model of psychiatric classification and diagnosis, a model that eschewed efforts to classify disorders by their psychological causes in favor of establishing clear, symptom-based criteria that could be validated through empirical investigation. (For a critical description of the neo-Kraepelinian movement, see Good 1992:182-187; for apologists' accounts, see Blashfield 1984; Klerman 1978; Weissman and Klerman 1978). The DSM-III represented a rejection of the previous theoretical framing of psychiatric classification of disorders in psychoanalytic terms, as represented by the DSM-II. Although advocates for the so-called neo-Kraepelinian approach claimed that the DSM-III was "atheoretical," it was solidly grounded in a medical- or biological psychiatry paradigm. The DSM-III represented psychopathology as a set of discrete, heterogeneous disorders or diseases, based on the hypothesis that such disorders would ultimately be shown to result from pathologies of structure and function at the level of human neurobiology. This view stands in stark contrast with the psychoanalytic assumptions about subjectivity, personality, and psychopathology that framed much of the previous diagnostic manual, the DSM-II, particularly in its classification of the neuroses. The DSM-III represented symbolically a major paradigm shift within psychiatry, with diagnosis and classification, neurobiology, and pharmaceutical treatments all assuming new importance.

The emergent paradigm reflected in the DSM-III provided the organizing frame and the context for the Sterling Forest Conference. The participants exuded a sense of confidence that research on anxiety and anxiety disorders had finally begun to catch up with other areas of the neurosciences, that enormous progress was under way, and that PD was a critical site for demonstrating the value of the neo-Kraepelinian approach. Studies of neurotransmitters and the neuroendocrine system supplemented the classic fight-or-flight-response understanding of anxiety as a distinctive physiological system based in human evolution. Studies had begun to demonstrate the role of specific neurotransmitters to explain how benzodiazepines and other anxiolytic medications function and to provide a deeper understanding of the hypothalamic-pituitary-adrenocortical system. Basic research on learning, studied experimentally in animal models, was helping to explain, at the level of molecular biology, classic observations about relations among stressful stimuli, fear responses, arousal, habituation, and inhibition or disinhibition. These studies were being linked through cognitive psychology to clinical phenomena and newly emerging cognitive therapies for the anxiety disorders. There was strong support for the categorization of anxiety disorders into five basic types-phobias, panic, generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder (PTSD). The organizers and most participants in the meeting took it for granted that these categories are based in natural reality and that it would prove most fruitful to pursue research and clinical approaches that focus primarily on one or another of these discrete disorders.

But why was PD seen as so important to this field? Why was there such excitement about PD, a sense that it would be the major "growth industry" in anxiety research in the 1980s, as Robert Spitzer, a driving force behind the DSM-III, predicted? The discussion around the conference tables and in the dining room seemed to make clear what was only occasionally referred to in the scientific panels: not only was PD a newly recognized psychiatric disorder, especially promising for yielding scientific knowledge, but it also provided neo-Kraepelinian psychiatrists and neuroscientists with a unique opportunity to attack the stronghold of psychoanalysis. Whereas psychoanalysis had made little progress in decades of writing about anxiety and anxiety attacks, many at the conference felt that in a very short time biological psychiatry had made enormous scientific progress and promised far more to come. Only three of the forty-three scientific papers in the meeting addressed psychodynamic perspectives on anxiety, and the talk in the corridors was of psychoanalysts as dinosaurs, about to disappear.

PD provided a particularly powerful basis for arguing that the neo-Kraepelinian paradigm could advance understanding of acute anxiety, long considered the domain of the neuroses and psychoanalysis. There were three broad reasons for this claim. First, new evidence suggested that PD is a discrete, heterogeneous disorder, distinct from other anxiety disorders. Particularly interesting was the discovery that panic attacks do not respond to the benzodiazepines, typically used for anxiety, but respond specifically to the drug imipramine, usually considered an antidepressant (Klein 1980). Klein had shown that imipramine was effective against spontaneous panic attacks but not against chronic anxiety, suggesting that panic attacks are a distinctive disorder (see Barlow 2002:125-126; McNally 1994:1-4). Defining clear criteria for PD allowed researchers to investigate the specific biological, genetic, pharmacological, and epidemiological characteristics of this distinctive disorder.

In addition, Klein (1980) and Sheehan (1983) argued strongly that PD consisted of panic attacks that were largely unprovoked and experienced by sufferers as coming out of the blue. This formulation suggested that panic attacks are generated physiologically rather than psychologically, that they result from neurobiological processes rather than from the surfacing of unconscious psychological conflicts associated with seemingly unrelated stimuli. This argument was supported by findings of apparent physiological differences associated with PD, including intriguing research suggesting that infusion of sodium lactate would trigger panic attacks in persons suffering unmedicated PD, but not in normal populations.

(Continues...)

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