Panic Disorder DSM-5

Panic Attack Criteria

• sudden surge of intense fear / discomfort that reaches a peak in minutes

• can start from a calm or anxious state

• requires 4+ symptoms

  1. palpitations / pounding heart / accelerated heart rate

  2. sweating

  3. trembling / shaking

  4. feeling short of breath / ‘smothered’

  5. feeling of choking

  6. chest pain / discomfort

  7. nausea / abdominal distress

  8. feeling dizzy / unsteady / light-headed / faint

  9. chills / heat sensations

  10. paresthesias (numbness / tingling)

  11. derealisation / depersonalisation

  12. fear of losing control / going crazy

  13. fear of dying

• can have culture-specific symptoms not listed, but they don’t count towards the required 4 

Diagnostic Criteria

a) recurrent unexpected panic attacks

b) at least one panic attack followed by at least 1 month (or longer) of persistent concern / worry about additional panic attacks or their consequences, a significant maladaptive change in behaviour related to panic attacks (eg: behaviours designed to avoid panic attacks), or both

c) not attributable to physiological effects of a substance or another medical condition

d) not better explained by another mental disorder

Diagnostic Features

• unexpected panic attacks: no obvious cue / trigger when they happen (seems out of nowhere)

• can also have expected panic attacks, but only unexpected are required

  • approx. half of people w/ panic disorder have both

• frequency and severity of attacks can vary widely, with no obvious differences in what may cause this variance

• can have both full-symptom (4+) or limited-symptom (<4) panic attacks, but more than one full-symptom attack is required for diagnosis

• the number + type of panic attack symptoms frequently differs from one attack to another

• nocturnal panic attack: waking up in a state of panic

  • happens at least once to ¼ - 1/3 people w/ panic disorder

  • people w/ both nocturnal + daytime panic attacks tend to have more severe panic disorder

• worries about panic attacks + their consequences can be physical concerns (eg: panic attacks are happening bc of a life-threatening illness), social concerns (eg: people will judge me bc of visible panic attack symptoms), or losing control

• people who report fears of dying as a panic attack symptom usually have more severe presentations of panic disorder

Associated Features

• many people report constant or recurring health + mental health anxiety, often expecting terrible outcomes from mild physical symptoms

  • often relatively intolerant of medication side effects

• may have pervasive concerns about ability to complete daily tasks / withstand daily stressors

• potential excessive drug use to control panic attacks

• potential extreme behaviours aimed at controlling panic attacks

Prevalence

• 12-month prevalence in US adults + adolescents: 2 - 3%

• global lifetime prevalence: estimated 1.7%

• women more frequently affected than men, 2:1

  • differentiation happens before adolescence + can be observed by 14

• rates start low in children, gradually increase during adolescence, peak during adulthood, + decline in older individuals

Development and Course

• median onset age: 20 - 24 in US, 32 cross-nationally

• mean onset age: 34.7

• small number of cases begin in childhood

  • however, “fearful spells” may be retroactively dated back to childhood

• onset after 55 is rare

• if untreated, usual course is chronic, with waxing + waning

• typically course is complicated by presence of other disorders

• minority of people have full remission without a subsequent relapse in the next few years

• no difference in clinical presentation between adolescents + adults

• lower prevalence in older adults may be due to age-related dampening of automatic nervous system response

Etiology: Temperament

• negative affectivity (neuroticism), anxiety sensitivity, behavioural inhibition, + harm avoidance are risk factors for onset

• history of “fearful spells” (typically limited-symptom panic attacks) is a risk factor, esp. when experience was appraised as negative

• separation anxiet in childhood may precede development of panic disorder, but isn’t a consistent risk factor

Etiology: Environmental

• most people report identifiable stressors in the months before their first panic attack

• more chronic life stress is associated w/ a higher degree of panic disorder severity

• between 10 - 60% of people w/ panic disorder endorse a history of trauma

• stressful life experiences + childhood adversities are associated w/ more severe panic pathology

• risk factors for development: smoking, parental overprotection + low emotional warmth

• people w/ few economic resources are more likely to have symptoms that meet critieria

Etiology: Genetic

• multiple genes probably carry vulnerability to panic disorder, but we don’t know which ones

• people w/ parents that have anxiety, depressive, or bipolar disorders have increased risk for panic disorder

• respiratory disturbance may be associated w/ risk (past history, family history, comorbidity)

Culture-Related Diagnostic Issues

• rate of fears about mental + somatic symptoms of anxiety varies across cultural contexts, may influence the rate of panic disorder

• cultural expectations may influence classification of panic attacks as expected / unexpected

• cultural concepts of distress have an impact on symptoms + frequency of panic disorder

• specific worries about panic attacks + their consequences vary across ethnoracial groups + cultural contexts

  • panic disorder is associated w/ reports of ethnic discrimination + racism among Asian, Hispanic, + Black communities in the US

Sex + Gender-Related Diagnostic Issues

• adult women relapse from panic disorder more frequently than men, indicating they may have more unstable illness course

• has higher impact on health-related quality of life in women, suggesting that they have have greater anxiety sensitivity or higher comorbidities w/ agoraphobia + depression

• some evidence for sexual dimorphism

Functional Consequences

• panic attacks + diagnosis of panic disorder in the last 12 months → higher rate of suicidal thoughts + behaviour in the last 12 months

• approx. 25% of primary care patients w/ panic disorder report suicidal thoughts

• associated w/ high levels of social, occupational, + physical disability, considerable economic costs, + highest # of medical visits out of all the anxiety disorders

• may be frequently out of work / school for doctor + ER visits, potentially leading to unemployment or dropping out

• full-symptom panic attacks are associated w/ greater morbidity (more disability, lower quality of life, etc.) than limited-symptom panic attacks

Differential Diagnosis

• only limited-symptom panic attacks

• anxiety disorder due to another medical condition

• substance / medication-induced anxiety disorder

• other mental disorders with panic attacks as an associated feature

Differential Diagnosis: Only Limited-Symptom Panic Attacks

can’t be panic disorder if the patient has no history of full-symptom panic attacks. consider other specified anxiety disorder or unspecified anxiety disorder

Differential Diagnosis: Anxiety Disorder Due to Another Medical Condition

if panic attacks are the direct physiological consequence of another condition (eg: hyperthyroidism, seizure disorders, etc.), it’s not panic disorder

can be determined w/ help of lab tests + physical exams. onset after age 45 or atypical panic attack symptoms suggest possibility of medical condition as cause

Differential Diagnosis: Substance / Medication-Induced Anxiety Disorder

if panic attacks are direct physiological consequence of a substance, it’s not panic disorder — but panic disorder may be considered if the attacks continue outside of the context of substance use

since panic disorder can be the reason for substance use and can be associated with a higher rate of substance use, a detailed history should be taken to determine if panic attacks happened before the excessive substance use → potential comorbid diagnoses of substance use disorder + panic disorder

onset after age 45 or atypical panic attack symptoms suggest possibility of substances / medications as cause

Differential Diagnosis: Other Mental Disorders With Panic Attacks as an Associated Feature

panic attacks that are symptoms of other disorders are expected (triggered by specific situations associated w/ the disorder: social interactions → social anxiety, agoraphobic situations → agoraphobia, worries → generalised anxiety disorder, separation → separation anxiety, etc.) and don’t meet the criteria for panic disorder. if panic attacks only occur in response to those triggers, only the relevant anxiety disorder is diagnosed

however, if there are also unexpected panic attacks accompanied by persistent concern / worry about more attacks or their consequences, or a behavioural change due to the attacks, an additional diagnosis of panic disorder may be made

Comorbidity

• 80% of people w/ panic disorder have a lifetime comorbid mental health diagnosis

• prevalence of panic disorder is higher in people w/ anxiety disorders (esp. agoraphobia), major depressive disorder, bipolar I + II, + mild alcohol use disorder

• onset of panic disorder frequently occurs after the onset of the comorbid disorder + may be seen as a severity marker of that disorder

• lifetime comorbidity rates between panic disorder + major depressive disorder vary wildly, from 10 - 65%

  • 1/3 of people w/ both disorders had MDD first; 2/3 either developed them at the same time or had panic disorder first

• some develop a substance-use disorder in an attempt to treat their anxiety

• illness anxiety disorder + other anxiety disorder are very common comorbidities

• significantly comorbid w/ many general medical symptoms + conditions, including: dizziness, cardiac arrythmias, hyperthyroidism, asthma, COPD, + irritable bowel synrome

  • nature of association (eg: cause + effect) remains unknown