Background: Military population is unique in certain respects. Our clients are young, physically fit and in full employment. On entry, the demography is not very different to the rest of the community for people looking to start a new career. The age range of those entering military service is 16.5 to 37 years. Majority of them enlisting are school leavers, but some are unemployed or have held a job elsewhere. Mature entrants are usually professionals and tradesmen.

During the initial phases of training, the entrants are free to give notice and leave. On completion of training and taking up a posting, soldiers commit themselves to serving a minimum period. The training phase is not only a learning period for the soldiers, but also a formative period for the youngsters, moulding their character and bonding them with one another as a family. The discipline they learn is not just about respecting authority and obeying orders, it is also about time-discipline, structure and orderliness, not to mention life-style and values.

Community Mental Health: Our department is one of a handful of similar departments spread across the country and abroad. During last year, over a 12-month period our department received over 400 new referrals. Some were referred for clinical conditions, but the majority were for soldiers who were going through a transient adjustment reaction because of personal or work related issues. We deal with the whole range of psychiatric symptomatolgy. Common presentation is with mixed mood disturbance. Some presented with alcohol excess and some others with anxiety and panic. Unlike popular belief, the incidence of PTSD is not common.

Panic: We wish to present illustrative case histories of two soldiers who suffered acute panic attacks. The panic occurred in non-combat situations.

• Case History 1 A soldier was returning to his base from home leave. He arrived at his destination city after a short flight but found himself having to wait for his the military transport, which was delayed in traffic. He developed an acute panic reaction with palpitations and sweating. He was terrified and could not wait any longer. He purchased a return ticket and flew back home. He reported to his local doctor and was referred to our department some days after.

  Work background: The soldier has served 7 years and held the rank of a Corporal. He was happy in the Army and was preparing for an impending deployment, which he was happy to undertake. Administrative report by the commander was very complimentary. It said that this has been a very good soldier with an excellent record for professional ability and personal temperament.

  Personal background: The soldier was 24 years of age, married and had one young child. There was no previous history or family history of mental illness. His alcohol intake was occasional and scant. His marriage was strong, but there was some tension between the couple. There was a recent incident - the soldier had been accused of a civil offence near his base. The allegation was later withdrawn because it turned out to be a case of mistaken identity. The wife was however unhappy with the soldier. She was reported to have held the position–never mind mistaken identity- that he should not have been in a situation in the first place where such allegations could be levelled.

• Case History 2 This again was a soldier returning to base from home leave. His connecting journey involved travelling by London Underground. While in transit, he developed an acute and spontaneous panic reaction involving shortness of breath, palpitations and sweating. He felt he needed fresh air and got out of the train. He looked so ill that a passing Police Officer asked if he was all right or required any help. He initially reassured the Officer and sent her away, but panicked soon after and shouted for help. He was taken to a hospital in an ambulance. Tests were all clear and the soldier was allowed to go, but he aborted his journey and made his own way back home.

  Work background: The soldier was a Private in the Army, having served about 4 years. Like in the previous case, this soldier also was due to be deployed soon. He told us that he was happy to go on the tour and that had never been the issue. He wanted to have a successful career in the Army. Administrative report from his commanders said that he was a good soldier.

  Personal background: A 23-year old soldier, married and with a young child. His wife was also a serving soldier. He and his wife were working together in one location until the previous year, but his wife got promoted and posted to a new location some months ago. This has caused some friction between the couple because of disagreement in how to manage practical matters. There was no previous history or family history of mental illness. He was an occasional social drinker.

Possible mechanisms involved: The one common feature in both the cases namely, their imminent deployment raises an obvious question whether panic was caused by avoidance behaviour. If there was any avoidance, it must have been operating at a sub-conscious level, as the soldiers strenuously denied any problems in going on the tour. They willingly co-operated with our treatment programme and worked towards resolution of the problems within a short period.

While the cases were straightforward in clinical presentation and with the positive outcome on brief intervention therapy, we wished to examine possible mechanisms involved in their pathogenesis. Existing and well-established theories do not seem to explain all the complexities of the case.

We have considered theories like ‘Separation Anxiety’ and ‘Loss of Control’. We feel that these theories do not fully explain the facts of the case. It is true that the soldiers were physically separated from their spouses working at a distant base. However location of work had not altered and the soldiers have since returned to work and have remained symptom free. Similarly, the soldiers could have perceived ‘loss of control’ with their respective marital situation that they were not in total control of the direction in which the relationship was heading. In both cases, we did not undertake any conjoint work, as the soldiers could not bring their spouses for review. As far as we were aware, the problems that were the bone of contention between the couple remained unresolved at the end of our treatment, but in both cases the soldiers returned to work and remained free of panic symptoms.

Conflict theory as our hypothesis: We hypothesise that the soldiers in our presentation faced a conflict in one or more areas in their lives and that such ‘conflict’ could have played a part in the pathogenesis of their acute panic attacks. In this context, conflict is not meant to refer unresolved issues, but rather the individual’s inability to perceive the perspective, process the information and to weigh up options. In the military population, such mental conflicts do arise when soldiers struggle in the adaptation and projection of different roles at different times.

In the illustrative cases we have described, our intervention took the form of brief intervention therapy with a ‘problem solving’ model. This resulted in symptom resolution and rapid restoration of full functionality. The soldiers have since returned to work. We believe that the case histories and the successful outcome support the hypothesis of ‘conflict’ theory in the causation of panic attacks.

We accept that panic attacks and panic disorders may manifest in different ways in different personalities and that they may be caused by many factors. Our hypothesis is meant to add to our understanding of the causation of panic attacks and we conclude with the suggestion that further work is directed in this area.