PANIC DISORDER
Panic disorder refers to recurrent unexpected panic attacks (Criterion A). A panic attack is an
abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and
during which time four or more of a list of 13 physical and cognitive symptoms occur. The
term recurrent literally means more than one unexpected panic attack.
Diagnostic Criteria
• A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense
fear or intense discomfort that reaches a peak within minutes, and during which time
four (or more) of the following symptoms occur;
1. Palpitations, pounding heart, or accelerated heart rate.
It is rapid, thumping or fluttering feelings that people experience in their chest. For
example, some people say their heart feels like its racing; others say their chest hurts,
thumps or flutters.
2. Sweating.
For example, starting to perspire even for the smallest event that goes wrong like
having a fight with someone close.
3. Trembling or shaking.
It is when the person shakes involuntarily with quick, short movements, as from fear.
It feels like a part, many parts, or your entire body is trembling and shaking.
4. Sensations of shortness of breath or smothering.
The person feels like they are being suffocated and find it difficult to breathe as
though someone was depriving them of oxygen.
5. Feelings of choking.
The person may feel like there is food stuck in their throat or their throat is tight or
there is lump in the throat sensation or feeling.
6. Chest pain or discomfort.
Chest pain is the pain felt anywhere in the chest area from the level of your shoulders
to the bottom of your ribs. This pain makes the person feel uneasy thereby
experiencing discomfort.
7. Nausea or abdominal distress.
The region between the chest and groin (also called the stomach region), having any
kind of pain or discomfort, it is called abdominal distress. It is the uneasy sensation
that you need to vomit, although it does not always lead to vomiting.
8. Feeling dizzy, unsteady, light-headed, or faint.
Dizziness is light-headedness, loss of balance or vertigo (a feeling that you or the
room is spinning or moving) or feeling like you might pass out.
9. Chills or heat sensations.
Hot flashes are feelings of intense heat in the upper part of the body, accompanied by
an increased heart rate and flushing of the chest, neck, and face, as well as profuse
sweating. Hot flashes are often followed by chills and cold sensations. Chills occur
when the body attempts to produce heat to increase its temperature from within,
causing muscles to contract and relax rapidly. Goosebumps also occur when chills
manifest.
10. Paresthesia
It is an abnormal sensation such as tingling, tickling, pricking, numbness or burning
of a person's skin with no apparent physical cause.
11. De-realization or depersonalization
It is the feeling when you persistently or repeatedly have the feeling that you're
observing yourself from outside your body or you have a sense that things around you
aren't real, or both.
12. Fear of losing control or “going crazy.”
This is the fear that if you don't manage to control the outcome of future events,
something terrible will happen. The crux of the problem is the demand for certainty in
a world that is always tentative and uncertain. It is precisely this unrealistic demand
that creates the anxiety.
13. Fear of dying.
It is the feeling of dread, apprehension or solicitude (anxiety) when one thinks of the
process of dying, or ceasing to 'be. You fear that what you have is terminal and
nobody knows. You may also fear that the chest pains are a deadly heart attack or that
the shooting pains in your head are the result of a tumor or aneurysm. You feel that
any one of the symptoms you experience are life threatening. You feel an intense fear
when you think of dying, or you may think of it more often than normal, or can’t get it
out of your mind.
Note: The abrupt surge can occur from a calm state or an anxious state.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of the
following:
1. Persistent concern or worry about additional panic attacks or their consequences. (e.g.,
losing control, having a heart attack, “going crazy”).
2. A significant maladaptive change in behavior related to the attacks. (e.g., behaviors
designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar
situations).
C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary
disorders).
D. The disturbance is not better explained by another mental disorder. (e.g., the panic attacks
do not occur only in response to feared social situations, as in social anxiety disorder: in
response to circumscribed phobic objects or situations, as in specific phobia: in response to
obsessions, as in obsessive-compulsive disorder: in response to reminders of traumatic
events, as in posttraumatic stress disorder: or in response to separation from attachment
figures, as in separation anxiety disorder).
Prevalence
In the general population, the 12-month prevalence estimate for panic disorder across the
United States and several European countries is about 2%-3% in adults and adolescents. In
the United States, significantly lower rates of panic disorder are reported among Latinos,
African Americans, Caribbean blacks, and Asian Americans, compared with non-Latino
whites; American Indians, by contrast, have significantly higher rates. Lower estimates have
been reported for Asian, African, and Latin American countries, ranging from 0.1% to 0.8%.
Females are more frequently affected than males, at a rate of approximately 2:1. The gender
differentiation occurs in adolescence and is already observable before age 14 years. Although
panic attacks occur in children, the overall prevalence of panic disorder is low before age 14
years (<0.4%). The rates of panic disorder show a gradual increase during adolescence,
particularly in females, and possibly following the onset of puberty, and peak during
adulthood. The prevalence rates decline in older individuals (i.e., 0.7% in adults over the age
of 64), possibly reflecting diminishing severity to subclinical levels.
Development and Course
The median age at onset for panic disorder in the United States is 20-24 years. A small
number of cases begin in childhood, and onset after age 45 years is unusual but can occur.
The usual course, if the disorder is untreated, is chronic but waxing and waning. Some
individuals may have episodic outbreaks with years of remission in between, and others may
have continuous severe symptomatology. Only a minority of individuals have full remission
without subsequent relapse within a few years. Although panic disorder is very rare in
childhood, first occurrence of "fearful spells" is often dated retrospectively back to childhood.
As in adults, panic disorder in adolescents tends to have a chronic course and is frequently
comorbid with other anxiety, depressive, and bipolar disorders. To date, no differences in the
clinical presentation between adolescents and adults have been found.
Differential Diagnosis
Other specified anxiety disorder or unspecified anxiety disorder. Panic disorder should not be
diagnosed if full-symptom (unexpected) panic attacks have never been experienced. In the
case of only limited-symptom unexpected panic attacks, and other specified anxiety disorder
or unspecified anxiety disorder diagnosis should be considered.
Comorbidity
Panic disorder infrequently occurs in clinical settings in the absence of other
psychopathology. The prevalence of panic disorder is elevated in individuals with other
disorders, particularly other anxiety disorders (and especially agoraphobia), major depression,
bipolar disorder, and possibly mild alcohol use disorder. While panic disorder often has an
earlier age at onset than the comorbid disorder(s), onset sometimes occurs after the comorbid
disorder and may be seen as a severity marker of the comorbid illness.
Reported lifetime rates of comorbidity between major depressive disorder and panic disorder
vary widely, ranging from 10% to 65% in individuals with panic disorder. In approximately
one-third of individuals with both disorders, the depression precedes the onset of panic
disorder. In the remaining two-thirds, depression occurs coincident with or following the
onset of panic disorder. A subset of individuals with panic disorder develop a
substance-related disorder, which for some represents an attempt to treat their anxiety with
alcohol or medications. Comorbidity with other anxiety disorders and illness anxiety disorder
is also common.
Panic disorder is significantly comorbid with numerous general medical symptoms and
conditions, including, but not limited to, dizziness, cardiac arrhythmias, hyperthyroidism,
asthma, COPD, and irritable bowel syndrome. However, the nature of the association (e.g.,
cause and effect) between panic disorder and these conditions remains unclear. Although
mitral valve prolapse and thyroid disease are more common among individuals with panic
disorder than in the general population, the differences in prevalence are not consistent.
