Drs. Bouwer and Stein Reply

To the Editor: We were pleased to learn that Tun� Alkin, M.D., has collected data documenting that panic disorder is associated with a history of near drowning and that this association is particularly strong when panic attacks are characterized by prominent respiratory symptoms. Although his study lacked a control group, his findings are certainly consistent with our own and appear to lend further support to the suffocation hypothesis of panic disorder (1).

We also appreciate Dr. Alkin’s drawing attention to different forms of suffocation possibly associated with panic disorder. In their article on the association of respiratory disorders and panic disorder, Verberg et al. (2) included a question on a history of “objects stuck in the throat,” and indeed, this seems to be a useful question in this context. It is interesting that in his article McNally (3) concludes that choking episodes may be followed by choking phobias that respond to anti-panic treatment.

Whether the association between panic disorder and a history of traumatic suffocation is a causal one is, of course, paramount. A skeptical reader might wonder whether panic disorder patients are simply more likely to remember past episodes of suffocation or choking than others. Ultimately, more objective methodologies will be needed if this association is to be explored in depth.