A review of “Why panic attacks are nearly always pathological.”

Article summary provided by Hillary Greene

THE MAIN POINT: This article, written by Dr. Ronald Pies, provides insight regarding how to consider context when determining the normality or abnormality of behavior, in particular, with panic attacks. Dr. Pies offers theoretical reasoning and support for his position that panic attacks are ubiquitously pathological regardless of an individual’s context, although context remains a crucial consideration for treatment. This article reflects Dr. Pies’ experience and expertise in the field. The details of this article are presented below (Pies, 2013).


  • The consideration of context in assessing the pathology of behavior is often debated within mental health and medical settings. Many clinicians argue that if a behavior seems reasonable within a particular context, then the behavior is not pathological. Using Dr. Pies’ example, if someone has a panic attack while hanging off a cliff, some individuals might consider this response to be expected or understandable given the circumstances and therefore not disordered. Similarly, he describes the context debate regarding how best to conceptualize depressed mood after losing a loved one, as either MDD or bereavement.
  • If we can understand a behavior or response, if it seems reasonable to us given the context, then is it pathological? In this article, Dr. Pies argues yes, “the general concept of disorderness in psychiatry ought to be—with very few exceptions—non-contextual.”
  • Dr. Pies elaborates his views regarding panic attacks, context, and competing perspectives within the field. He recognizes the pragmatic truth that panic attacks driven by highly threatening, understandable contexts may not reflect serious underlying psychopathology warranting treatment, as compared to panic driven by specific triggers. This perspective aligns with the current DSM-IV-TR criteria for panic disorder as requiring recurrent, unexpected panic attacks, which is akin to the idea of “contextless” panic attacks.
  • However, Dr. Pies argues for a different approach in considering the context of panic attacks and disorder. He argues that panic attacks reflect maladaptive responses regardless of the context and that there are no proven situations in which panic attacks are adaptive for functioning. Regarding the commonly held belief that panic attacks in threatening situations reflect adaptive responses of the fight or flight system, Dr. Pies highlights evidence indicating how the physiology of these processes differ.
  • Concerning practical implications, Dr. Pies advocates that clinicians recognize all panic attacks as pathological responses regardless of context. However, he emphasizes that context is “critically important” to consider in treating patients as not all individuals with panic attacks require treatment and not all panic attacks warrant a diagnosis of panic disorder. For instance, the climber who has a panic attack only once while hanging off a cliff by a finger likely does not have a significant anxiety problem necessitating treatment.

The article discussed here is available for free by going to the link directly OR by searching for the link in your internet search engine: http://www.psychiatrictimes.com/blog/pies/content/article/10168/2122285


Pies, R. W. (2013). Why Panic Attacks Are Nearly Always Pathological. Retrieved from Psychiatric Times website: http://www.psychiatrictimes.com/blog/pies/content/article/10168/2122285


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