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A decision to designate recurrent panic attacks as a separate disorder has been controversial ever since panic disorder was introduced into psychiatric nosology. The survival of panic disorder as a diagnostic entity first depends on demonstrating that unexpected panic attacks are not a product of fiction. If unexpected panic attacks cannot be reliably distinguished from situational attacks on the basis of the criteria other than lack of context in which they appear, the raison deter for panic disorder may cease to exist.

For panic disorder to be a viable concept, it would then need to be redefined, perhaps by proposing a set of different defining features. Once panic disorder is reconceptualized, its detection and recognition will hopefully improve, especially at the levels of primary and emergency care. Future research needs to elucidate whether there are pathophysiologically distinct panic attacks. This could make possible a more accurate classification of panic attacks and better understanding of the role that they play in panic disorder, agoraphobia, and other conditions. Clarifying the links between panic disorder and agoraphobia would put an end to an increasingly fruitless debate about the primacy of panic disorder or agoraphobia when both are present.

Considering its complex relationship with various medical problems, panic disorder is perhaps the most ''physical'' of all the anxiety disorders. An important aspect of this status of panic disorder is its link with cardiovascular morbidity. More prospective research is needed to understand to what extent and under what circumstances panic disorder constitutes a risk factor for heart disease. If it turns out that panic disorder (or some ''type'' of it) is indeed akin to a life-threatening condition, it will certainly require a different treatment approach, perhaps pharmacotherapy that would target its components more specifically. In that case, too, there would hardly be any role for psychological treatments that essentially provide reassurance that panic attacks and panic disorder cannot (ultimately) lead to a somatic catastrophe.

Because of the potentially serious complications of panic disorder, there is no room for complacency about the relatively good results of current pharmacological and psychological treatments. More effort is needed to prevent occurrence of panic disorder in predisposed individuals, deliver treatment early, improve access to it, and minimize dropout. As a result, CBT for panic disorder may be modified accordingly (e.g., through Internet-based delivery and various self-help approaches) and on the basis of greater appreciation of how its ingredients work to bring about a meaningful therapeutic change. Identifying who is more likely to benefit from which type of treatment is another task. The main challenge to the pharmacotherapy of panic disorder comes from a high risk of recurrence following the cessation of treatment, and future research needs to illuminate ways of minimizing this risk. Yet another task is to investigate how pharmacotherapy and CBT could be combined to improve the outcome.

References:

1. Foa EB, Steketee GS, Grayson JB. 1981. Success and failure in treating obsessive-compulsive. Biological Psychiatry, 5: 1099--1102.

2. Narrow WE, Rae DS, Robins LN, et al. 2002. Revised prevalence estimates of mental disorders in the United States: Using a clinical significance criterion to reconcile 2 surveys' estimates. Archives of General Psychiatry, 59: 115--123.

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