Panic Disorder & Separation Anxiety - Quick Reference

Panic Disorder: DSM-5-TR Criteria

A. Recurrent unexpected panic attacks
- An abrupt surge of intense fear or discomfort that peaks within minutes, with at least 4 of the following symptoms:\
  1) Palpitations, pounding heart, or accelerated heart rate
  2) Sweating
  3) Trembling or shaking
  4) Shortness of breath or smothering
  5) Feelings of choking
  6) Chest pain or discomfort
  7) Nausea or abdominal distress
  8) Dizziness, unsteady, light-headed, or faint
  9) Chills or heat sensations
  10) Paresthesias (numbness/tingling)
  11) Derealization or depersonalization
  12) Fear of losing control or "going crazy"
  13) Fear of dying
- Note: The abrupt surge can occur from a calm or anxious state; culture-specific symptoms may occur but do not count toward the required four
B. At least one attack followed by one 1 month (or more) of one or both of the following:
- Persistent concern or worry about additional panic attacks or their consequences
- A significant maladaptive change in behavior related to the attacks (e.g., avoidance)
C. Disturbance not attributable to a substance or medical condition
D. Disturbance not better explained by another mental disorder
Pro Tip: DSM-5-TR criteria summarized; culture-specific symptoms may appear but do not count toward the threshold

Panic disorder and GAD share high lifetime prevalence; brain mechanisms not fully clear
Heritability estimated at about 43\%\to\48\%; family history and twin studies support genetic influence (no single gene consistently identified)
Fight-or-flight response appears poorly regulated; possible dysregulation of norepinephrine, serotonin, GABA, and CCK
Panic triggers can include hyperventilation, CO₂ inhalation, caffeine, breathing into a paper bag, and infusions of sodium lactate
Individuals with panic disorder may respond with full attacks to these physiological changes; others without history may experience only discomfort

Prone individuals tend to: (1) pay close attention to bodily sensations, (2) interpret sensations negatively, (3) engage in catastrophizing thinking
Example: misinterpretation of dizziness as imminent fainting or heart attack amplifies anxiety and physiology
Hypervigilance for bodily sensations between attacks; generalized worry about health and attacks
Anxiety sensitivity: belief that bodily symptoms have harmful consequences; linked to higher likelihood/severity of panic
Increased interoceptive awareness: cues signal coming attacks; interoceptive conditioning links mild symptoms to fear
Beliefs about controllability matter: perceived lack of control over CO₂ exposure precipitated more attacks; perceived control reduced attacks
Summary: cognitive bias, anxiety sensitivity, interoception, conditioning, and controllability beliefs contribute to panic

Biological vulnerability → hypersensitive fight-or-flight response to mild stimuli
Catastrophizing cognitions amplify symptoms to full panic attack; sustained hypervigilance increases anxiety
Conditioning and avoidance develop: contexts become associated with symptoms (agoraphobia via conditioned avoidance)
Contextual generalization explains broad situational anxiety and withdrawal from safe contexts
Contextual conditioning and generalization may underpin panic disorder and agoraphobia

First-line medications: affect serotonin and norepinephrine systems
- SSRIs: ext{Paxil}, ext{Prozac}, ext{Zoloft}
- SNRIs: ext{Effexor}
- TCAs
Benzodiazepines: fast-acting relief; suppress CNS via GABA; risk of dependence and withdrawal
Relapse risk: discontinuation without concurrent CBT often leads to relapse

Core approach: confront fear-provoking situations/thoughts; reduce irrational beliefs; extinguish anxious behaviors
Components:
- Relaxation and breathing training to gain symptom control
- Identify catastrophizing cognitions; use thought diaries between sessions
- In-session exposure to symptoms (therapist may induce symptoms safely to surface cognitions)
- Cognitive restructuring to challenge catastrophic beliefs about sensations
- Systematic desensitization: gradual exposure from least to most threatening contexts with skill use
Outcomes:
- Large-scale study: CBT and TCAs equally effective at symptom elimination
- About 85\%\text{--}90\% of patients achieve relief within 12\ weeks of CBT
- Follow-ups: ~90\% panic-free after >2\ years; CBT better at preventing relapse than antidepressants

A. Developmentally inappropriate and excessive fear/ anxiety concerning separation from attachment figures, evidenced by at least three of the following:
1) Recurrent distress with separation anticipation/experience
2) Persistent worry about losing figures or harm to them (illness, injury, disasters, death)
3) Persistent worry about untoward events causing separation (getting lost, kidnapping, accidents, illness)
4) Reluctance/refusal to leave home due to fear of separation
5) Fear/reluctance to be alone without attachment figures
6) Reluctance to sleep away from home or without near figure
7) Repeated nightmares with separation theme
8) Repeated physical symptoms (headaches, stomachaches, nausea, vomiting) with separation
B. Fear/ anxiety/ avoidance is persistent: at least 4\ weeks in children/adolescents; typically 6\ months or more in adults
C. Disturbance causes clinically significant distress or impairment
D. Not better explained by another mental disorder
Note: Separation anxiety can persist into adulthood; onset is often in adulthood with peak in early adulthood; prevalence roughly 5.3\% worldwide; comorbid with internalizing and externalizing disorders; substantial impairment if untreated
Additional points: May co-occur with various psychiatric conditions; can begin at any age; adult onset is common; lifelong impact on functioning if untreated