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Panic Attacks and PanicDisorder in Cross-Cultural Perspectiveby M. AMERING,MD, and H. KATSCHNIG, MD

ery few empirical studies ad-dress the question ofwhether panic attacks, asdefined in the DSM-ITER,!

also exist in othercultures, andifso,whether their phenomenology issimilar. Such knowledge would beof considerable importance for an-

swering the fundamental questionofpsychiatric research: Do psychiat-ric disorders have a primarily bio-logical or psychosocial origin?

Cross-cultural comparisons are not

Dr Amering is Professor of Psychiatry, Psychiat-ric Clinic, University of Vienna, Austria.Dr Katschnig is Professor of Psychiatry, Psychi-

atric Clinic, University of Vienna, Austria.This article was based on the chapter, “Panic

Altacks and Panic Disorder in Cross-CulturalPerspective," by H. Katschnig and M. Amering,which originally appeared in Ballenger J, ed.Clinical Aspects of Panic Disorder. New York,NY: Alan R. Liss Ine; 1990:67-80. Reprinted with

sion from Wiley-Liss, a division of fohnWiley & Sons, Inc., copyright © 1990,

Address reprint requests to M. Amering, MD,Psychiatric Clinic, University of Vienna, Wélrin-ger Giirtel 18-20, A 1090 Vienna, Austria.

Psychiatric Annals 20:9/September 1990

phenomenon.

From the empirical evidence existing sofar, itcan be concluded that panic attacks and PD tosomeextent are a universally occurring

only beset by the usual method-ological difficulties that all epidemi-ologic comparisons encounter, but

they also are especially problematicbecause of the different languagesspoken and different semantic no-tions of emotions held in differentcultures.? Standardized psychiatricinterviews andself-rating instrumentsthat have been translated and back-translated (eg, the presentstate ex-

amination or the general healthquestionnaire) help to some extent,but cannot overcomethis basic prob-lem. Translated diagnostic tools may

even contribute to clouding cross-cultural variations because they usu-ally have been produced in Westernindustrialized countries andare spe-cific to the concepts of mentalillnessdeveloped there and may not beapplicable to deviant behavior inothercultures.

This article briefly examines thefollowing types of empirical evi-dencefor a tentative answerto thisquestion:@ a survey of epidemiologic field

studies conducted in differentcultures,

511

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Panic Attacks and Panic Disorder in Cross-Cultural PerspectiveAmering, M, MD;Katschnig, H, MDPsychiatric Annals; Sep 1990; 20, 9; Nursing & Allied Health Databasepg. 511

Cross-Cultural Perspective

TABLE1

Epidemiologic Field Surveys of Panic Attacks/PanicDisorder in Different Cultures

Prevalence

Study Panic Attacks* Panic Disorder

EnglishUnited States?5 10% 1.4%-1.5%Canada § 34.4% (1 yr)

SpanishLos Angeles’ _ 1.2%Puerto Rico® _— 1.7%

GermanMunich? 9.3% 2.4%Zurich'® 6.0% (1 yr) 1.5% (1 yr)Vienna" 17.7% _

“Lifetime prevalence unless otherwise noted.

TABLE 2

Population Surveys of Panic Disorder Using theDiagnostic Interview Schedule'2*

Population Male Female Total

English-SpeakingECAStudy, Los Angelessite 1.0 2.6 1.8ECA Study, New Havensite 0.6 21 1.4ECAStudy, Baltimore site 1.2 1.6 1.4ECAStudy, St. Louis site 0.9 2.0 1.5

Spanish-SpeakingECA Study, Los Angelessite 0.4 1.9 1.2(Mexican-Americans)

Puerto Rico Study 1.6 1.9 1.7

German-SpeakingMunich Study 17 2.9 2.4

*Lifetine prevalencerates. @ a review of clinical descriptions

of panic attacks and panic disor-der (PD) in different countries,and

@ an analysis of reports of so-calledculture-bound syndromes, suchas Koro or Kayak-Angst, as thesesyndromescould represent equiv-alents of panic attacks in non-Western cultures.

512

EPWEMIOLOGIC FIELD SURVEYSEpidemiologic field surveys with

results that can be used for cross-cultural comparisons are few innumber. Such surveys have so farbeen conducted among black andwhite Americans in the UnitedStates and Canada; among Hispanicpopulations in California and inPuerto Rico; and among German-

speaking people in Austria, Switzer-land, and Germany. The advantageof the epidemiologic methodis thatrandom samplesofthe total popula-tion are examined, enabling theresults to be generalized. The disad-vantages are the high cost of suchinvestigations and the rather super-ficial case identification proceduresusing, as a rule, lay interviewers orself-rating procedures.

In Table 1, the overall results ofepidemiologic field surveys con-ducted since 1984 are grouped ac-cording to the three languages spo-ken in the countries studied.*"! Byand large, for PD as a diagnosticentity, the similarities are morestriking than the differences. PDwas found in 1.4% to 1.5% of thepopulation studied in three USsitesby the NIMH EpidemiologicalCatchmentArea Study (New Haven,Connecticut; Baltimore, Maryland;

and St. Louis, Missouri); in 1.2% ofMexican-Americans in Los Angeles;in 1.7% of the native population inPuerto Rico; and in 2.4% of a ran-dom sample of the population ofMunich (all lifetime prevalencerates).

For single and occasional panicattacks, the picture is more varied,although no clear-cut culture-specific pattern emerges. Panic at-tacks seem to be quite frequent inNorth America (34.4% l-year preva-lence rate in Winnipeg, Canada;10% lifetime prevalence rate in fiveUSsites) and in German-speakingcountries (17.7% lifetime preva-lence rate in Vienna, 9.3% lifetimeprevalence rate in Munich, and 6%

1-year prevalencerate in Zurich).Theresults presented in Table 1

are based on studies using differentcase definitions and data collectionprocedures. However,in a few stud-ies the same instrument,the ‘‘Diag-nostic Interview Schedule,’’!? wasemployed for data collection allow-ing more valid comparisons. Sex-specific rates for these studies arepresented in Table 2 for English-speaking, Spanish-speaking, andGerman-speaking populations.Again,with sex differences, too, sim-ilarities are more impressive than


discrepancies. In all sites, femalelifetime prevalence rates are consis-

tently higher than male rates, al-though a greater variation exists inmale rates than in female rates,

producing quite different female tomale ratios (from five times in Mexi-can-Americansin Los Angeles to 1.2times in Puerto Rico).

For agoraphobia, the availabledata are morelimited. Oneinterest-ing findingis that the lifetime preva-lence rates found in Puerto Rico

(3.9%) and Munich (3.6%) arewithin the range of rates found foragoraphobia in the North AmericanECA sites (from 2.7% in St. Louis,Missouri, to 5,8% in Baltimore, Mary-land). Again, female rates are con-sistently higher than male rates.

CLINICAL DATAOccasional clinical reports outside

Europe and North America suggestthat PD is universal. For instance,

Otakpor!? reported that in a Nige-rian outpatientclinic, 3% ofthe pa-tients met DSM-I//criteria for PD andhad “for 3 years on the average.. .oscillated between assorted treat-mentcentersin search of help but tono avail,’ a statement that soundsvery familiar to Western clinicians.

Recently, a large internationalmulticenter study, comparable insize and quality to the ‘‘Interna-tionalPilot Study of Schizophrenia”of the World Health Organiza-tion,!+!5 has evaluated pharmaco-

logical treatments of PD patients inclinical settings.!° A total of 1168patients were recruitedfor the studyin 14 different countries in north-em and southern Europe (Sweden,Denmark, United Kingdom, WestGermany, Belgium, France, Spain,and Italy) as well as in North andLatin America (United States, Mex-ico, Colombia, and Brazil). Clinicaldata were collected by psychiatristsusing, among other instruments,the Standardized Clinical Interview

for DSM-III-R Upjohn Version(SCID-UP), which was translatedfrom English into the following lan-guages: Spanish, Portuguese, Ital-ian, French, German, Swedish, andDanish. Thereliability was checked


TABLE3Numberof PatientsIncluded in the Cross-National CollaborativePanic Study SecondPhase’&Cultural Group n

North America 220

(United States, Canada)

Latin America 257(Mexico, Colombia,Brazil)

Northern Europe 324(Sweden, Denmark,England, West Germany,Austria)

Southern Europe 367(Spain,Italy, France,South Belgium)

throughoutthe project by repeatedreliability interviews and found tobe quite high, Whereas the qualityof these psychopathologic data canbe assumed to be excellent acrossdifferent countries and cultures, aswell as superiorto the quality of datacollected in epidemiologic field sur-veys by lay interviewers or self-ratingprocedures, some problems withrepresentativity may exist becauserecruitment procedures were differ-ent in different cultures. Neverthe-less, such clinical data are of consid-erable interest for a cross-culturalperspective because the data canprove a disorder can in fact befound in different cultures and be-cause the higher or lower frequencyof specific symptomsin specific cul-tural contexts may give hints tocultural influences despite the prob-lem of selecting patients for the

clinical population.Thefirst finding of this study was

that PD occurred in all countriesparticipating in the study, sincenoneof the centers had difficultiesin recruiting a substantial number

Amering & Katschnig

of such patients in a rather shorttime. For comparison purposes, the14 countries were groupedinto fourcultural clusters according to geo-graphic and language characteris-tics (Table 3), The next findingconcerned differences in the symp-tomatologic expression of panic at-tacks in different cultures (H.K. un-published data, 1990); most differences occurred between north-ern and southern countries.

Table 4 reveals that palpitations,which next to dizziness/faintnesswas the most common symptom,did not show any difference amongthe cultural groups. On the otherhand, respiratory symptoms(ie,shortness of breath, choking orsmothering sensations, and chestpain or discomfort) were reportedmore commonly in southern coun-tries. It makes sense that the fre-quency of paresthesias also was re-

ported more in southern countries,as paresthesias may be a conse-quence of hyperventilation. It also

makes sense that the only othersymptom, much more commoninsouthern Europe and Latin Amer-ica than in northern Europe andNorth America, was“fear of dying,”as choking and smothering sensa-tions are more proneto induce fear

of dying than other symptoms, suchas sweating or chills. In contrast,“trembling or shaking’’ was re-ported much more frequently innorthern countries.

Another psychopathologic fea-ture, agoraphobia, was much morecommon in northern countries(Table 5). This difference was espe-cially striking between North Amer-ica (90.5% agoraphobia) and LatinAmerica (65%). Whether agorapho-bia does develop more in NorthAmerica then in Latin America can-not be concluded from these data,although it would make sense thatwherelife is much more dependenton closed spaces because of harshclimates, indoor and outdoor livingare much more clearly separatedthan in morefavorable climatic con-ditions where less effort might benecessary to cross the ‘‘border’’ be-tween indoor and outdoor. There is

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TABLE 4Symptoms of a Typical Baseline Panic AttackinNorthern and Southern Countries (DSM-III-R)

Symptom North South Total

Palpitations 89.0 86.5 87.6

Shortnessof breath 68.9" 80.7 75.2

Choking or smothering sensations 51.8” 76.2 64.2

Chestpain or discomfort 53.4* 67.1 60.6

Nausea/abdominaldistress 51.5f 58.8 55.4

Trembling or shaking 80.5* 71.6 75.8

Sweating 75.3 75.6 75.4

Paresthesias 48.6t 58.2 53.7

Flushesorchills 77.9 82.2 80.2

Dizziness,faintness 88.6 88.4 89.0

Depersonalization, derealization 50.3 49.4 49.8

Fearof going crazy 58.6 54.7 56.6

Fearof dying 51.9* 74.6 63.9

North = United States, Canada, Sweden, Denmark, United Kingdom, Germany, and Austria.South =Mexico, Colombia, Brazil, Beigium, France,Italy, and Spain.*P<.001.tP<.05.$P=<.07.

TABLE 5Percentages of DSM-III-R Panic Disorder Patients Withand Without Agoraphobia

Varlahle NE SE NA LA North South Total*

DSM-III-R 79.3t 71.7 905+ 650 83.8t¢ 689 75.9PD with

DSM-III-R 20.4 243 9.6 31.5 16.0¢ 27.2 22.0PD without

agoraphobia

NE=Sweden, Denmark, United Kingdom, Germany, and Austria.SE= Belgium, France, Italy, and Spain.NA= United Slates and Canada.LA=Mexico, Colombia, and Brazil."2.7% notclassifiable.tP<,07,FP<.001. some contradiction with the alreadyquoted epidemiologic findings thatagoraphobiarates in Puerto Rico are

514

within the range of frequenciesfound in the North American ECAsites.

In any case, these clinical datasuggest that PD occurs in such dif-ferent places as Goteborg, Rio deJaneiro, Mexico City, Vienna,Paris,and Ann Arbor, Michigan. Whetherthe differences found in symptomsare true differences remains to beproven by furtherstudies.

PANIC ANXIETY IN CULTURE-BOUNDSYNDROMES

Onewayto learn about panic anxi-ety in differentculturesis to look intowhat is known as culture-bound syn-dromes, a term coined by Yap in theearly 1960s to describe ‘‘psychogenicreactions that are in fact nonvoli-tional elementary biopsychologicalreactions sensitive to culturally spe-cific stimuli and... moulded pa-thoplastically by the distinct beliefsystems related to illness or disor-der.”"!7 Today, there are about 150conditions (culture-bound syn-

dromes) that can be found in theliterature.'!® Most descriptions ofthese so-called culture-bound syn-dromesare based on reports of tray-elers, nonpsychiatric medical doc-tors, anthropologists, and othernonpsychiatrists and for this reasonlack substantially in what is calledreliability andvalidity in modern psy-chiatric research. Consequently,most case descriptions identified asrepresenting a specific culture-bound syndromeare neither repre-sentative norof high clinical quality.

Onthe other hand,these descrip-tions often deal with dramatic be-havior of short duration, with eye-catching events for an observer. Wesearched these descriptionsfor theoccurrenceofthe short-lived, ratherdramatic event of a sudden surge ofintense feeling of anxiety that isaccompanied by somatic symptomsand subsides spontaneously aftershort duration. We have foundquite striking similarities to the newWestern concept of panic attacksand PD in such “‘exotic’’ and there-fore seemingly different conditions

as Kayak-Angst, ascribed to the Es-kimo culture of West Greenland,and Koro, one of the few well-studied culture-bound syndromesthat for a long time was believed to


Amering & Katschnig

TABLE 6

Common Features of DSM-III Panic Attacks, Koro, and Kayak-Angst

Feature

Speedof onset

Intensity

Symptoms

Duration

DSM-III

Sudden onset

Intense apprehension

DyspneaPalpitationsChestpain or discomfortChoking or smotheringsensations

Dizziness, vertigo, or unsteadyfeelings

Feelings of unreality

Paresthesias(tingling in hands orfeet)

Hotand cold flushesSweatingFaintnessTrembling or shakingFearof dying, going crazy ordoing something uncontrolledduring an attack

Usually minutes, rarely hours

Koro

Attack of koro, seized suddenly

Highintensity, severe

BreathlessnessPalpitationsPrecordial discomfortNausea/abdominaldistress

Dizziness, nausea

Paresthesias

Hot and cold sensationsSweatingFaintnessTrembling or shakingFear of dying

20, 30, or 60 minutes; terminatesspontaneously or by group

Kayak-Angst

Attacksoutofthe blue,like afit

Intense state of anxiety

Palpitations

Sweating

Dizziness, unsteadyfeelings,nausea

Feelingsof unrealityParesthesias

Hot and cold sensationsSweatingFaintness

Trembling or shakingFearof dying, fear of losingcontrol

Terminates on reaching landorwith arrival of other

support or reassurance

be restricted to Chinese living inSoutheast Asia (Table 6).

Kayak-AngstInformation on Kayak-Angst, a

formerly well-known condition com-mon in East and West GreenlandandPolar Eskimos,!® consists largelyof material gathered by Scandi-navian doctors. For example, in1900, Gustav Meldorf?° estimatedthat 10% of all menover the age of

18 in the Julianaab district sufferedfrom Kayak-Angst; in 1901, Pontop-pidan”! even regardedit as the “na-tional disease” of the West Green-land Eskimos.

Kayak-Angst is described as anacute state of anxiety that affectshunters whenthey are out in the seain their one-man boat hunting forseals. It occurs out of the blue,


especially on days with sunnyskiesanda calmsea,andis chacterized bya violent vegetative reaction, a feel-ing of helplessness,a loss of orienta-tion, and a fear of drowning thatcan only be overcome by somehowmanaging to get close to the shoreor that subsides whenfellow huntersarrive,

KoroReports in the literature about

cases of Koro range fromsingle casedescriptions over small samples ofvery few cases*?5 to reports on epi-demics affecting several thousandsof people,” some of which were

even studied by psychiatric teamswith the specific purposeofclinicaland sociodemographic data collec-tion on Koro patients. Koro isexperienced as the suddenfeeling

of shrinkage andretraction of thepenis into the abdomen(in thelesscommonevent of women being af-flicted, the breast nipples and labiaare thought to shrink), accompa-nied by vegetative symptoms, andgreat fear that eventually completeretraction will result in the death ofthe individual.

A numberof additional featuresin both Kayak-Angst and Koro sup-port the suspicion that a considera-

ble proportionof people affected bythese syndromessuffer from a con-dition that is equivalent to panicattacks and even PD as defined bythe DMS-HI or DSM-III-R. Anticipa-tory anxiety seemsto play an impor-tant role in the origin as well as inthe course of Kayak-Angst and Koro;avoidance behavior develops, notrarely to an extent that social handi-

515



cap results, like the severe conse-quence ofhavingto give up hunting

in afflicted Eskimo hunters. It is aprevalent idea that emotionally up-setting experiences increase risk forthe occurrence of both conditions.In both cases, cognitive factors assuggested by Clark?> seem to beimportant: in Kayak-Angst, a sensorydeprivation situation leading toperceiving physiologic sensations asthreatening obviously triggers theanxiety state!®; in Koro, a height-ened awareness and ‘‘catastrophicalmisinterpretation”’ of physiologicchanges in penile circumference”®may contribute to the onset.

CONCLUSIONFrom the empirical evidence ex-

isting so far, it can be concludedthat panic attacks and PD to someextent are a universally occurringphenomenon. However, this find-ing alone does not allow a clearinterpretation as to whether bio-logic or psychologic factors aremore important. In contrast, itseems clear that how panic attackspresent themselves depends tosome degree on specific culturalpatterns of norms and values, cul-ture-specific concepts of time, se-mantic issues of labelling emotionalstates, and the likelihood of gettingprofessional help. Disentanglingthese many influences is the taskthat lies ahead for cross-cultural re-search into panic anxiety.

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panicattacksand panic disorderin cross-cultural perspective

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