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.

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.

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 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 20^th-century thought. Generations of medical students were falsely taught it as truth.

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:

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 far beyond any psychoanalytic recognition or vision.

Modern medicine is said to have begun in the 1880s by identifying and separating out the various fevers, searching for the different micro-organic causes, and discovering the different substances and later the antibiotics that cured them. Louis Pasteur and Robert Koch’s germ theory of medicine finally became generally accepted by 1881, when Koch discovered the tuberculosis bacillus. Joseph Lister’s antiseptic approach to surgery and wound healing was also finally accepted. Until then, bacteria microorganisms were generally viewed as a by-product of the disease, not as deadly pathogens. Similarly, 100 years later, psychiatry finally was able to overturn the fabled hierarchy of Freudian analysis and to seek biological causes and remedies, as well as psychological approaches, more pertinent to the specific problems, such as those seen in panic disorder. The 1980 DSM-III was revised in 1994 with the DSM-IV and again in 2013 with the DSM-5.

In the fall of 1978, I was going through the stacks of books in the medical section of a small local library when I came across the fifth edition of British psychiatrist William Sargant’s book An Introduction to Physical Methods of Treatment in Psychiatry, published in 1972. There, in one chapter, was a description of the symptoms under the label “atypical depression” that resembled my own anxiety symptoms, including the spontaneous panic attacks and the problems with going out, driving, shopping, seeing friends, going to entertainment, and traveling—as well as the cluster of physical symptoms that made up the out-of-the-blue panic attacks: a pounding heart, nausea, imbalance, dizziness, and inchoate breathing. Also the acute psychological feeling—not thought, but feeling—of losing control, going out of my mind, or instantly dying, which is the hallmark of PD. I had never heard or read about this malady in American medical literature or in any other writings despite years of medical research, not to mention consulting with doctors and psychiatrists. I was dumbfounded.

Later, I came across the term agoraphobia (AG), which, when used medically, described the phobias and rationale behind the avoidance behavior I felt compelled to do. The Australian doctor Claire Weekes, MD wrote books and published articles in medical journals in the 1960s and 1970s that were fairly well known in the British Commonwealth nations. She developed exposure therapy, or CBT (cognitive behavioral therapy), which is now believed to be the best psychological approach to and treatment for PDA. In 1975, the British parliament discussed a bill considering whether to designate agoraphobia as a disability that qualified for monetary benefits.

Sargant wrote that the use of current antianxiety drugs, such as Librium and Valium, were not sufficient in themselves to benefit atypical depression, but that an MAOI (monoamine inhibitor) should be added to block the panic attacks that accompanied the disorder. Soon after I read in the Journal of American Psychiatry and in the Archives of General Anxiety summaries of studies undertaken by David Sheehan, MD at Harvard using the same drug approach to treat the same syndrome. In addition, Donald Klein, MD at Columbia described the syndrome as panic disorder, but used the tricyclic (TCA) antidepressants, such as imipramine (IMI), to block the panic attacks, along with the same antianxiety agents to treat the illness. Klein’s studies were conducted in the 1960s and Sheehan’s in the 1970s, but I never came across these studies when researching the medical literature and discussing the illness with doctors in the 1970s. Klein’s studies were published in 1962 but ignored until 1978. What is more, even at that time these psychiatrists did not consider panic disorder to be just the extension of, or the most severe form of, normal anxiety. They believed it to be a biological or organic disorder that was qualitatively distinct from normal anxiety, not merely quantitatively distinct. This meant they considered panic disorder to have a different medical basis or etiology than the normal situational anxiety that many people experience under severe stress, and therefore they thought it had to be treated differently. The main reason is that panic attacks would come upon the person with panic disorder spontaneously, or out of the blue, when the person was not under any stress. The attacks would come when one felt healthy enough and when doing the most ordinary, routine activity. The patients seemed to lack nerve control over anxiety and had a lower threshold for panic. It was as if they lacked a certain percentage of anxiety nerves (30 percent, 50 percent, 70 percent) to keep anxiety under control.

In 1980, Sheehan and Klein were instrumental in replacing the DSM-II with the DSM-III, which recognized the physical and mental symptoms of a new category of anxiety disease called panic disorder, with or without agoraphobia. The recognition of the illness as a distinct and known entity was a godsend for people like myself who thought up to that time that we were the only ones in the world with such a malady and that without a proper diagnosis there could be no progress in correct treatment, much less a cure.

Sargant used the MAOI antidepressants Phenelzine (Nardil in the U.K.) or Parnate to treat these patients who were considered to be a subgroup of patients with depression.

Soon after, I came across a chapter by Samuel Kraines, MD describing a cluster of similar symptoms that sometimes appears in biological depression. In 1972, he wrote a book on biological depression with a chapter on anxiety symptoms that arise in this disorder, which resemble what is now known to be PDA. If there were such anxiety symptoms in depression and the antidepressant drugs helped depression, perhaps the antidepressant drugs could help the anxiety symptoms directly. He described severe anxiety attacks that caused fearful, varied physical symptoms, along with the psychological terror that one may die, go crazy, or perhaps harm someone or commit suicide. He mentions that these patients fear both staying alone at home or leaving alone, fear going to grocery stores and restaurants, and fear they may act peculiarly in public, such as scream unnecessarily. They fear fainting and imbalance. So here was a description of PDA within the context of depression that was written and known about back in 1972.¹¹

In 1979, I came across the Manual of Psychiatric Therapeutics by Richard Shader and Psychiatric Drugs: A Desk Reference by Gilbert Honigfeld and Alfreda Howard that gave me the first hint of the use of TCAs and MAOI antidepressants for panic attacks. They wrote of a condition called panic anxiety, a state of chronic anxiety-tension, where there was a feeling there may be no hope at hand when unexpected panic attacks occur. The person feared leaving home unless accompanied by a family member or someone considered safe. Librium and Valium used alone were ineffectual if the person was overwhelmed by fear, sleep disturbance, severe anticipatory anxiety, or phobic anxiety. In such cases, antidepressants should also be used.