Panic disorder

Essential (Required) Features:

• Recurrent panic attacks, which are discrete episodes of intense fear or apprehension characterized by the rapid and concurrent onset of several characteristic symptoms. These symptoms may include, but are not limited to, the following:
• Palpitations or increased heart rate
• Sweating
• Trembling
• Sensations of shortness of breath
• Feelings of choking
• Chest pain
• Nausea or abdominal distress
• Feelings of dizziness or light-headedness
• Chills or hot flushes
• Tingling or lack of sensation in extremities (i.e., paraesthesias)
• Depersonalization or derealization
• Fear of losing control or going mad
• Fear of imminent death
• At least some of the panic attacks are unexpected, that is they are not restricted to particular stimuli or situations but rather seem to arise ‘out of the blue’.
• Panic attacks are followed by persistent concern or worry (e.g., for several weeks) about their recurrence or their perceived negative significance (e.g., that the physiological symptoms may be those of a myocardial infarction), or behaviours intended to avoid their recurrence (e.g., only leaving the home with a trusted companion).
• Panic attacks are not limited to anxiety-provoking situations in the context of another mental disorder.
• The symptoms are not a manifestation of another medical condition (e.g., pheochromocytoma) and are not due to the direct effects of a substance or medication on the central nervous system (e.g., coffee, cocaine), including withdrawal effects (e.g., alcohol, benzodiazepines).
• The symptoms result in significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Note: Panic attacks can occur in other Anxiety or Fear-Related Disorders as well as other mental disorders and therefore the presence of panic attacks is not in itself sufficient to assign a diagnosis of Panic Disorder.

Additional Clinical Features:

• Individual panic attacks usually only last for minutes, though some may last longer. The frequency and severity of panic attacks varies widely (e.g., many times a day to a few per month) within and across individuals.
• In Panic Disorder, it is common for panic attacks to become more ‘expected’ over time as they become associated with particular stimuli or contexts, which may originally have been coincidental. (For example, an individual who has an unexpected panic attack when crossing a bridge may subsequently become anxious when crossing bridges, which could then lead to ‘expected’ panic attacks in response to bridges.)
• Limited-symptom attacks (i.e., attacks that are similar to panic attacks, except that they are accompanied by only a few symptoms characteristic of a panic attack without the characteristic intense peak of symptoms) are common in individuals with Panic Disorder, particularly as behavioural strategies (e.g., avoidance) are used to curtail anxiety symptoms. However, in order to qualify for a diagnosis of Panic Disorder, there must be a history of recurrent panic attacks that meet the full diagnostic requirements.
• Some individuals with Panic Disorder experience nocturnal panic attacks, that is, waking from sleep in a state of panic.
• Although the pattern of symptoms (e.g., mainly respiratory, nocturnal, etc.), the severity of the anxiety, and the extent of avoidance behaviours are variable, Panic Disorder is one of the most impairing of the Anxiety Disorders. Individuals often present repeatedly for emergency care and may undergo a range of unnecessary and costly special medical investigations despite repeated negative findings.

Boundary with Normality (Threshold):

• Panic attacks are common in the general population, particularly in response to anxiety-provoking life events. Panic attacks in response to real threats to an individual’s physical or psychological integrity are considered part of the normative continuum of reactions, and a diagnosis is not warranted in such cases. Panic Disorder is differentiated from normal fear reactions by: frequent recurrence of panic attacks; persistent worry or concern about the panic attacks or their meaning or alterations in behaviour (e.g., avoidance); and associated significant impairment in functioning.
• The sudden onset, rapid peaking, unexpected nature, and intense severity of panic attacks differentiate them from normal situationally-bound anxiety that may be experienced in everyday life (e.g., during stressful life transitions such as moving to a new city).

Course Features:

• Onset of Panic Disorder typically occurs during the early 20s.
• Some individuals experience episodic symptom outbreaks with long periods of remission, while others experience persistent, severe symptoms.
• The presence of co-occurring disorders (e.g., other Anxiety or Fear-Related Disorders, Depressive Disorders, and Disorders Due to Substance Use) has been associated with poorer long-term course trajectory.
• A co-occurring diagnosis of Agoraphobia is generally associated with greater symptom severity and poorer long-term prognosis.

Developmental Presentations:

• Although some children report physical symptoms of panic attacks, Panic Disorder is very rare in younger children because cognitive capacity for catastrophizing about the significance of symptoms is not yet fully developed. The prevalence of Panic Disorder increases across adolescence and early adulthood.
• Adolescents with Panic Disorder are at greater risk for a co-occurring Depressive Disorder including suicidality as well as for Disorders Due to Substance Use.

Culture-Related Features;

• The symptom presentation of panic attacks may vary across cultures, influenced by cultural attributions about their aetiology. For example, individuals of Cambodian origin may emphasize panic symptoms attributed to dysregulation of khyâl, a wind-like substance in traditional Cambodian ethnophysiology (e.g., dizziness, tinnitus, neck soreness).
• There are several notable cultural concepts of distress related to panic disorder, which link panic, fear, or anxiety to etiological attributions regarding specific social and environmental influences. Examples include attributions related to interpersonal conflict (e.g., ataque de nervios among Latin American people), exertion or orthostasis (khyâl cap among Cambodians), and atmospheric wind (trúng gió among Vietnamese individuals). These cultural labels may be applied to symptom presentations other than panic (e.g., anger paroxysms, in the case of ataque de nervios) but they often constitute panic episodes or presentations with partial phenomenological overlap with panic attacks.
• Clarifying cultural attributions and the context of the experience of symptoms can inform whether panic attacks should be considered unexpected, as must be the case in Panic Disorder. For example, panic attacks may involve specific foci of apprehension that are better accounted for by another disorder (e.g., social situations in Social Anxiety Disorder). Moreover, the cultural linkage of the apprehension focus with specific exposures (e.g., wind or cold and trúng gió panic attacks) may suggest that acute anxiety is expected when considered within the individual’s cultural framework.

Sex- and/or Gender-Related Features:

• Panic Disorder is twice as common in females than in males, with gender differences in prevalence rates beginning during puberty.
• Gender differences in clinical features or symptom presentation have not been observed.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Generalized Anxiety Disorder: Some individuals with Panic Disorder may experience anxiety and worry between panic attacks. If the focus of the anxiety and worry is confined to fear of having a panic attack or the possible implications of panic attacks (e.g., that the individual may be suffering from a cardiovascular illness), an additional diagnosis of Generalized Anxiety Disorder is not warranted. If, however, the individual is more generally anxious about a number of life events in addition to experiencing unexpected panic attacks, an additional diagnosis of Generalized Anxiety Disorder may be appropriate.
• Boundary with Agoraphobia: The perceived unpredictability of panic attacks often reflects the early phase of the disorder. However, over time, with the recurrence of panic attacks in specific situations, individuals often develop anticipatory anxiety about having panic attacks in those situations or may experience panic attacks triggered by exposure to them. In particular, it is common for individuals to develop some degree of agoraphobic symptoms over time in the context of Panic Disorder. If the individual develops fears that panic attacks or other incapacitating or embarrassing symptoms will occur in multiple situations, and as a result actively avoids these situations, requires the presence of a companion, or endures them only with intense fear or anxiety and all other diagnostic requirements for Agoraphobia are met, an additional diagnosis of Agoraphobia may be assigned.
• Boundary with Depressive Disorders: Panic attacks can occur in Depressive Disorders, particularly in those with Prominent Anxiety Symptoms, including Mixed Depressive and Anxiety Disorder, and may be triggered by depressive ruminations. If unexpected panic attacks occur in the context of these disorders and the main concern is about recurrence of panic attacks or the significance of panic symptoms, an additional diagnosis of Panic Disorder may be appropriate.
• Boundary with Hypochondriasis (Health Anxiety Disorder): Individuals with Hypochondriasis often misinterpret bodily symptoms as evidence that they may have one or more life-threatening illnesses. Although individuals with Panic Disorder may also manifest concerns that physical manifestations of anxiety are indicative of life-threatening illnesses (e.g., myocardial infarction), these symptoms typically occur in the midst of a panic attack. Individuals with Panic Disorder are more concerned about the recurrence of panic attacks or the significance of panic symptoms, are less likely to report somatic concerns attributable to bodily symptoms other than those associated with anxiety, and are less likely to engage in repetitive and excessive health-related behaviours. However, panic attacks can occur in Hypochondriasis and if they are exclusively associated with fears of having a life-threatening illness, an additional diagnosis of Panic Disorder is not warranted. In this situation, the ‘with panic attacks’ specifier can be applied to the diagnosis of Hypochondriasis. If there are persistent and repetitive panic attacks in the context of Hypochondriasis that are unexpected in the sense that they are not in response to illness-related concerns, both diagnoses should be assigned.
• Boundary with Oppositional Defiant Disorder: Irritability, anger, and noncompliance are sometimes associated with Panic Disorder in children and adolescents. For example, children may exhibit angry outbursts when presented with a task or situations that make them feel anxious (e.g., being asked to leave the home without a trusted companion such as a parent or caregiver). If the defiant behaviours only occur when triggered by a situation or stimulus that elicits anxiety, fear, or panic, a diagnosis of Oppositional Defiant Disorder is generally not appropriate.
• Boundary with other Mental, Behavioural or Neurodevelopmental Disorders: Panic attacks can occur in the context of a variety of other mental disorders, particularly other Anxiety or Fear-Related Disorders, Disorders Specifically Associated with Stress, and Obsessive-Compulsive or Related Disorders. When panic attacks occur in the context of these disorders, they are generally part of an intense anxiety response to a distressing internal or external stimulus that represents a focus of apprehension in that disorder (e.g., a particular object or situation in Specific Phobia, fear of negative social evaluation in Social Anxiety Disorder, fear of being contaminated by germs in Obsessive-Compulsive Disorder, fear of having a serious illness in Hypochondriasis, reminders of a traumatic event in Post-Traumatic Stress Disorder). If panic attacks are limited to such situations in the context of another disorder, a separate diagnosis of Panic Disorder is not warranted. If some panic attacks over the course of the disorder have been unexpected and not exclusively in response to stimuli associated with the focus of apprehension related to another disorder, an additional diagnosis of Panic Disorder may be assigned.