In his 2007 review of the book The Loss of Sadness, 2 Dr Kenneth Kendler 3 wrote: The background story: panic on the precipice Recently, I came across an article that may have been the genesis of my distinguished colleague’s “hanging off the edge of a cliff” scenario. After all, psychotherapeutically speaking, there is a world of difference between a severely depressed patient who has just lost a loved one and an equally depressed patient who is being investigated for bank fraud-although, in my view, both are in a disordered state and deserve professional treatment. But before my psychodynamically oriented colleagues recoil in horror, I hasten to add that context is critically important in working psychotherapeutically with patients. 1Īnd so, I want to suggest that the general concept of disorderness in psychiatry ought to be-with very few exceptions-non-contextual. It leads us to erroneous conclusions in other areas of psychiatry, besides panic attacks, such as whether to regard bereavement-related major depressive syndromes as instances of normal sadness or of bona fide MDD. Furthermore, I want to suggest that “explanatory context” is usually a misleading guidepost, in so far as the determination of disorderness is concerned. And this “disorderness”-that state in which healthy and adaptive organismic function is disrupted-is not mitigated by any explanatory context. In my view, the hypothetical panic attack on the precipice is inherently pathological and disordered. Maybe so-but as Einstein once reminded us, “Common sense is the collection of prejudices acquired by age eighteen.” Science is the systematic testing of “common sense” assumptions against the range of alternative theories. Indeed, many clinicians may be inclined to say, “Hey, I’d have a panic attack, too, if I were hanging by my fingers, over a cliff!” So calling such a panic attack normal is just common sense.

This is a perfectly plausible position, and probably represents the prevailing opinion among the general public. After all, the context explains the person’s panic attack, and thus renders the attack non-pathological. Surely, he insisted, context is critically important in such a case. My critic gave the example of someone who has a full-blown panic attack while hanging by his fingers, over a steep cliff. He expressed great surprise at my claim that an explanatory context shouldn’t determine our clinical assessment of disorder or abnormality. How we answer these questions also has important implications for what we mean by the term “false positive” in psychiatry, and what categories we create for DSM-5.Īt the last annual meeting of the APA-where I had just spoken on the experiential differences between grief and major depression-a very well-respected senior researcher in the audience rose to comment, evidently quite perturbed. Was this episode normal and non-disordered anxiety, because it is understandable to you? What about a patient with the identical set of symptoms, in the context of, say, hanging by his fingers over the edge of a cliff? If you can understand the occurrence of a panic attack in this context, was it therefore normal? These may sound like very theoretical questions, but they go to the heart of what we think of as normal or disordered, in both psychiatry and general medicine.

Let’s hold off on suggesting any formal diagnoses (a panic attack is not a formal DSM diagnosis-only a “building block” for one). Since you are remarkably empathic, and have had some public speaking anxiety yourself, you think, “I can understand how someone could have an attack like that, under those circumstances. I don’t mean a case of the “jitters”-I mean a 10-minute episode of palpitations, shaking, sweating, choking, dizziness, derealization, and the belief that he is dying. Let’s say a patient comes to you with a recent history of a single florid panic attack, in the context of giving a speech before an audience of 2000 colleagues. this man is disordered in his desires and aversions.

Non pathological anxiety