Diagnostic Criteria of Panic Disorder

Understanding Panic Attacks (Foundation for Panic Disorder)

What is a Panic Attack?

Definition: An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes

Key Characteristics:

Abrupt: Sudden onset, comes on rapidly (not gradual build-up)
Intense: Overwhelming, severe (often person’s most frightening experience)
Peaks quickly: Reaches maximum intensity within minutes (usually within 10 minutes)
Time-limited: Typically lasts 10-30 minutes (though may feel much longer)
Accompanied by physical and cognitive symptoms

The 13 Panic Attack Symptoms

At least 4 of the following 13 symptoms must be present (reaching peak within minutes):

Physical/Somatic Symptoms (1-10)

1. Palpitations, Pounding Heart, or Accelerated Heart Rate:

Awareness of heart beating
Heart racing, pounding
Feeling heart thumping in chest
Very common symptom
Often one of most frightening sensations

2. Sweating:

Sudden sweating
Profuse perspiration
Breaking out in sweat
Palms, forehead, whole body
Cold sweat

3. Trembling or Shaking:

Visible shaking
Internal trembling sensation
Hands, legs, whole body
May be difficult to hold objects
Voice may tremble

4. Sensations of Shortness of Breath or Smothering:

Feeling can’t get enough air
Difficulty breathing
Feeling of suffocation
Chest tightness
Hyperventilation (rapid, shallow breathing)
One of most distressing symptoms

5. Feelings of Choking:

Sensation of throat closing
Feeling like can’t swallow
Lump in throat sensation
Feeling like choking or gagging

6. Chest Pain or Discomfort:

Pain, pressure, or discomfort in chest
Tightness in chest
Often mistaken for heart attack
May be sharp or dull
Major reason people go to ER during panic attacks

7. Nausea or Abdominal Distress:

Upset stomach, queasiness
Feeling of nausea
Abdominal cramping or discomfort
Butterfly sensation in stomach
May feel like going to vomit

8. Feeling Dizzy, Unsteady, Light-headed, or Faint:

Dizziness or vertigo
Feeling like might pass out (though rarely do)
Unsteady on feet
Room spinning
Lightheadedness
Need to sit or lie down

9. Chills or Heat Sensations:

Sudden feeling of being very cold or very hot
Hot flashes or cold chills
Alternating between hot and cold
Flushing
Shivering

10. Paresthesias (Numbness or Tingling Sensations):

Numbness or tingling
“Pins and needles” sensation
Often in hands, feet, face, or lips
Caused by hyperventilation (affects blood chemistry)

Cognitive/Psychological Symptoms (11-13)

11. Derealization (Feelings of Unreality) or Depersonalization (Being Detached from Oneself):

Derealization:

Feeling of unreality
World seems unreal, dreamlike, foggy, distant
Things don’t seem real
Like watching through a veil or glass
Colors may seem different
Sounds may seem distant

Depersonalization:

Feeling detached from self
Observing self from outside (like watching yourself)
Feeling disconnected from own body or thoughts
Robotic feeling
Out-of-body experience
“This isn’t really me”

12. Fear of Losing Control or “Going Crazy”:

Fear of losing control of self
Fear of doing something embarrassing or uncontrollable
Fear of losing one’s mind
Fear of becoming insane
“I’m going crazy”
“I’m losing it”
Fear of screaming, running away, acting bizarrely

13. Fear of Dying:

Conviction that one is dying
“I’m having a heart attack”
“I’m going to die”
Fear that this is a fatal medical emergency
Sense of imminent death
May call 911 or go to ER

Note on Symptoms 11-13: These cognitive symptoms are particularly distressing and often drive fear of future attacks

Types of Panic Attacks

Expected (Cued) Panic Attacks

Occur in response to specific trigger or situation
Person can predict when they might occur
Associated with specific phobia or social anxiety
“If I see a spider, I’ll panic”
“If I have to give a speech, I’ll panic”

Unexpected (Uncued) Panic Attacks

Occur “out of the blue” with no apparent trigger
Cannot predict when they will occur
Spontaneous
“I was just sitting watching TV and it hit me”
“I woke up from sleep in a panic”
Required for diagnosis of Panic Disorder

Both types can occur in same person, but Panic Disorder specifically involves unexpected attacks

Limited-Symptom Panic Attacks

Have fewer than 4 symptoms
Still sudden onset of fear with some symptoms
Not sufficient for panic disorder diagnosis
But may occur in panic disorder along with full attacks

DSM-5 Diagnostic Criteria for Panic Disorder

Criterion A: Recurrent Unexpected Panic Attacks

Recurrent unexpected panic attacks

“Recurrent”:

Multiple panic attacks (more than one)
Typically many attacks over time
No specific number required, but “recurrent” implies pattern
Most people with panic disorder have had many attacks

“Unexpected”:

Out of the blue, without obvious trigger
Occur spontaneously
Person cannot identify what caused them
Not tied to specific situation or cue
Key feature distinguishing Panic Disorder from other anxiety disorders

Panic Attack (Review):

Abrupt surge of intense fear/discomfort
Peaks within minutes
At least 4 of 13 symptoms present

Common Patterns:

Frequency varies: Some have multiple attacks per week; others have attacks separated by weeks or months
Intensity varies: Some attacks more severe than others
Duration: Usually 10-30 minutes (though after-effects may last hours)
Timing: Can occur any time (during day, at night, even from sleep)
Situational: Some attacks may be expected (situational), but must have unexpected attacks for diagnosis

Nocturnal Panic Attacks:

Waking from sleep in panic (not from dream)
Particularly frightening
Occur during transition between sleep stages
Contribute to fear of sleeping

Criterion B: At Least One Month of Worry or Behavioral Change

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

Worry About Additional Panic Attacks:

Anticipatory anxiety: Constant worry “When will next attack happen?”
“I’m afraid I’ll have another panic attack”
Scanning for signs of impending attack
Hypervigilance to body sensations
Anxiety about anxiety
Worry consumes significant time and energy

Common Worries:

“What if I have an attack while driving?”
“What if I have an attack during important meeting/event?”
“What if I have an attack and no one can help me?”
“When will the next one hit?”
“I can’t handle another attack”

Worry About Consequences:

Physical Consequences (Catastrophic Misinterpretations):

“I’m having a heart attack and will die”
“I’m having a stroke”
“I’m going to suffocate”
“Something is seriously wrong with my heart/brain/body”
“These attacks will cause permanent damage”
“I’ll have a heart attack from the stress”

Mental/Psychological Consequences:

“I’m going crazy”
“I’m losing my mind”
“I’ll lose control and do something crazy”
“I’m going insane”
“I’ll be institutionalized”
“This means I have serious mental illness”

Social Consequences:

“Others will see me panic and think I’m crazy”
“I’ll embarrass myself”
“I’ll have attack in public and humiliate myself”
“People will judge me”
“I’ll lose friends/relationships”
“I’ll lose my job”

Loss of Control:

“I’ll lose control of myself”
“I’ll scream or run away”
“I’ll do something embarrassing”
“I’ll faint” (rarely happens, but common fear)

Impact of This Persistent Worry:

Creates chronic anxiety between panic attacks
Person is never fully relaxed (always on guard)
Quality of life significantly diminished
May be more distressing than attacks themselves
Leads to avoidance behaviors

Maladaptive Behavioral Changes: Changes in behavior that are unhelpful, counterproductive, or significantly interfere with functioning

Avoidance Behaviors:

Situational Avoidance:

Avoiding places where attacks occurred
Avoiding places where escape would be difficult or help unavailable
Avoiding situations associated with panic-like sensations

Common Avoided Situations:

Driving (especially highways, bridges)
Public transportation (buses, trains, planes)
Crowded places (malls, theaters, stadiums)
Elevators
Enclosed spaces
Being alone
Being far from home
Exercise (causes physical sensations similar to panic)
Caffeine and stimulants
Hot, crowded places

May Develop Agoraphobia (see separate section below)

Safety Behaviors:

Always carrying medication “just in case”
Always having cell phone to call for help
Only going places with trusted companion
Sitting near exits
Carrying water bottle
Avoiding physical exertion
Excessive checking of heart rate, pulse
Repeated visits to doctor or ER

Lifestyle Changes:

Changing or quitting job
Dropping out of school
Moving to be closer to hospital or family
Becoming dependent on others
Restricting activities significantly
No longer exercising
Giving up hobbies or interests

Impact:

Behaviors significantly interfere with life
Maintain and worsen panic disorder (prevent learning that attacks are not dangerous)
Increase disability and impairment
Reduce quality of life
May lead to depression, isolation

Duration: “1 Month (or More)”:

Worry or behavioral changes must persist for at least 1 month after at least one attack
Usually persists much longer
Distinguishes panic disorder from isolated panic attack(s)
Indicates significant ongoing impact

Criterion C: Not Attributable to Substance or Medical Condition

The disturbance is not attributable to the physiological effects of a substance (e.g., drug of abuse, medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders)

Must Rule Out Medical Causes:

Medical Conditions That Can Mimic Panic Attacks:

Cardiac/Cardiovascular:

Arrhythmias: Irregular heartbeat can cause palpitations, chest pain, dizziness
Mitral valve prolapse: Associated with panic-like symptoms
Angina/myocardial infarction: Chest pain, shortness of breath
Hypotension: Low blood pressure causing dizziness, fainting feeling

Endocrine/Metabolic:

Hyperthyroidism: Palpitations, sweating, tremor, anxiety, heat intolerance
Hypoglycemia: Sweating, trembling, palpitations, confusion (diabetics)
Pheochromocytoma: Rare tumor causing adrenaline surges (palpitations, sweating, hypertension)
Hyperparathyroidism: Can cause anxiety symptoms

Respiratory:

Asthma attacks: Shortness of breath, chest tightness
Pulmonary embolism: Life-threatening; shortness of breath, chest pain
COPD exacerbations: Breathing difficulties

Neurological:

Seizure disorders: Some seizures present with panic-like symptoms
Vestibular disorders: Inner ear problems causing dizziness, disorientation
TIA or stroke: Though panic attacks don’t cause these

Other:

Anemia: Can cause palpitations, shortness of breath
Meniere’s disease: Vertigo, dizziness

Important: Many people with panic disorder undergo extensive medical testing before correct diagnosis

Substances That Can Cause Panic-Like Symptoms:

Stimulants:

Caffeine: High doses can cause anxiety, palpitations, tremor
Amphetamines, cocaine: Cause intense sympathetic arousal
Diet pills, energy drinks: Often contain stimulants

Withdrawal:

Alcohol withdrawal: Can cause severe panic symptoms
Benzodiazepine withdrawal: Rebound anxiety, panic
Other substances: Many drugs cause anxiety during withdrawal

Medications:

Steroids: Can cause anxiety, agitation
Bronchodilators (asthma medications): Can cause jitteriness, palpitations
Thyroid medications: If dose too high
Some antidepressants: Can initially increase anxiety

Key Distinction:

If panic attacks occur only due to substance/medication or medical condition → Diagnose “Substance/Medication-Induced Anxiety Disorder” or “Anxiety Disorder Due to Another Medical Condition”
If panic disorder exists independently (attacks occur without substance/medical cause) → Diagnose Panic Disorder

Note: Person can have both panic disorder and medical condition (diagnose both if panic disorder existed before medical condition or persists beyond what medical condition explains)

Criterion D: Not Better Explained by Another Mental Disorder

The disturbance is not better explained by another mental disorder

Must Distinguish From:

Social Anxiety Disorder:

If panic attacks occur only in social situations
Fear is of social evaluation, not of panic attack itself
However, can have both if have unexpected panic attacks plus socially-cued panic attacks

Specific Phobia:

If panic attacks occur only when confronted with specific phobic stimulus
However, can have both if also have unexpected panic attacks

Separation Anxiety Disorder:

If panic attacks occur only in response to separation from attachment figure

OCD:

If panic attacks occur only in response to obsessions
However, can have both

PTSD:

If panic attacks occur only in response to trauma reminders
However, can have both if also have unexpected panic attacks

Key Distinction:

Panic Disorder requires unexpected (uncued) panic attacks
If panic attacks are always cued by specific situation/stimulus, likely a different anxiety disorder
However, many people have both unexpected panic attacks (panic disorder) and situationally-cued panic attacks (from phobia or other anxiety disorder)
Can diagnose both disorders if criteria met for both

Panic Disorder With or Without Agoraphobia

DSM-5 Change: Panic Disorder and Agoraphobia are now separate diagnoses (in DSM-IV, agoraphobia was only diagnosed with panic disorder)

Can Now Diagnose:

Panic Disorder without Agoraphobia
Panic Disorder with Agoraphobia (both disorders present)
Agoraphobia without Panic Disorder (never had panic disorder)

Understanding Agoraphobia in Context of Panic Disorder

What is Agoraphobia?: Fear or anxiety about situations where escape might be difficult or help unavailable if panic-like symptoms occur

Why Agoraphobia Develops in Many with Panic Disorder:

Sequence:

Person has unexpected panic attacks
Develops fear of having another attack
Begins to fear situations where panic attack would be dangerous, embarrassing, or difficult to escape from
Starts avoiding these situations
Avoidance expands to multiple situations
Agoraphobia has developed

Feared/Avoided Situations in Agoraphobia (at least 2 of 5 categories):

Using public transportation
Being in open spaces (parking lots, marketplaces, bridges)
Being in enclosed spaces (shops, theaters, elevators)
Standing in line or being in a crowd
Being outside the home alone

Underlying Fear: “If I panic here, I won’t be able to escape or get help”

Prevalence: About 1/3 to 1/2 of people with panic disorder develop agoraphobia

Severity Range:

Mild: Avoids few situations; life mildly restricted
Moderate: Avoids multiple situations; significant lifestyle restrictions
Severe: Housebound; cannot leave home without companion or at all

Impact: Agoraphobia dramatically increases disability and impairment

Additional Diagnostic Considerations

Prevalence

Lifetime Prevalence: 2-3% of population

12-Month Prevalence: 2-3%

Age of Onset:

Peak onset: Late adolescence to mid-30s
Average age: Early to mid-20s
Can begin at any age (childhood to older adulthood)
Rarely begins after age 45

Gender:

More common in females (about 2:1 ratio)

Course and Prognosis

Typical Course:

Sudden onset: Often begins with unexpected “out of the blue” panic attack
Chronic and fluctuating course
Periods of remission and relapse
Chronic without treatment in many cases
Treatment can be very effective

First Panic Attack:

Often remembered vividly (life-changing event)
May occur during stress or after major life event
Sometimes occurs without obvious trigger
Seeking medical help (ER, doctor) very common

Natural Course (Without Treatment):

Some: Chronic, persistent attacks for years
Some: Episodic course (periods with attacks, periods without)
Few: Spontaneous remission (rare)
Most: Benefit significantly from treatment

Prognosis:

With treatment: Most people improve significantly
Without treatment: Often chronic; significant disability
Factors affecting prognosis: Severity, presence of agoraphobia, comorbid conditions, treatment engagement

Comorbidity

Very High Comorbidity:

Other Anxiety Disorders (50-60%):

Agoraphobia (30-50% of those with panic disorder)
Generalized anxiety disorder
Social anxiety disorder
Specific phobias

Mood Disorders (50-60%):

Major depressive disorder: Most common comorbidity
Depression often develops after panic disorder begins (secondary to panic disorder)

Substance Use Disorders (20-30%):

Alcohol use disorder: Self-medication
Benzodiazepine use/dependence
Cannabis use

Other:

Somatic symptom disorders
Personality disorders (especially avoidant, dependent)

Impact of Comorbidity:

More severe symptoms
Greater impairment
Worse prognosis
More difficult to treat
Higher suicide risk

Suicide Risk

Increased Risk:

Higher than general population
Especially if comorbid depression
Feeling hopeless, trapped
Impulsivity during attacks
Important to assess and address

Cultural Considerations

Cultural Variations:

Symptom Expression:

Some cultures express psychological distress through physical symptoms
Specific symptoms emphasized may vary

Culture-Specific Syndromes Related to Panic:

Ataque de nervios (Latin cultures): Intense episode with panic, anger, dissociation
Khyâl attacks (Cambodian): Wind-related panic attacks
Fear of specific symptoms may vary (e.g., “soul loss” fears)

Help-Seeking:

Stigma varies by culture
May present to medical doctor rather than mental health professional
Family involvement varies

Medical Utilization

Very High Medical Use:

Frequent ER visits (thinking having heart attack)
Extensive medical testing and workups
Multiple doctor visits
Costly medical evaluations
Often diagnosed after extensive medical evaluation

Common Medical Presentations:

Chest pain → Cardiac workup
Shortness of breath → Pulmonary evaluation
Dizziness → Neurological testing
Multiple symptoms → Extensive testing

Average Time to Diagnosis: Often years after first panic attack

Key Points for Exams

Four Criteria (A-D):

Criterion A: Recurrent unexpected panic attacks
- Panic attack: Abrupt surge of fear/discomfort, peaks within minutes, at least 4 of 13 symptoms
Criterion B: At least 1 month of either:
- Persistent worry about additional attacks or their consequences, OR
- Significant maladaptive behavioral changes related to attacks
Criterion C: Not attributable to substance or medical condition
Criterion D: Not better explained by another mental disorder

13 Panic Attack Symptoms (need 4+):

Physical (1-10): Palpitations, sweating, trembling, shortness of breath, choking, chest pain, nausea, dizziness, chills/heat, paresthesias
Cognitive (11-13): Derealization/depersonalization, fear of losing control/going crazy, fear of dying

Key Features:

Unexpected (uncued) attacks required (distinguishes from other anxiety disorders)
Recurrent panic attacks
Persistent worry about attacks or consequences
Behavioral changes (avoidance, safety behaviors)
Many develop agoraphobia (now separate but commonly comorbid diagnosis)

Epidemiology:

2-3% prevalence
2:1 female to male ratio
Peak onset late teens to mid-30s
Chronic course without treatment

Comorbidity:

Very high (50-60% have other anxiety disorder or depression)
Depression often secondary to panic disorder

Clinical Features:

High medical utilization (ER visits, extensive testing)
Often takes years to correctly diagnose
Very treatable with CBT and/or medication
Without treatment, often chronic and disabling

Associated Features:

Nocturnal panic attacks
Catastrophic misinterpretations of bodily sensations
Hypervigilance to body sensations
“Fear of fear” (anxiety sensitivity)
Avoidance of activities that produce panic-like sensations