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DSM-III

Diagnostic Criteria

A. At least three panic attacks within a three-week period in circumstances other than during marked physical exertion or in a life-threatening situation. The attacks are not precipitated only by exposure to a circumscribed phobic stimulus.

B. Panic attacks are manifested by discrete periods of apprehension or fear, and at least four of the following symptoms appear during each attack:

  1. dyspnea
  2. palpitations
  3. chest pain or discomfort
  4. choking or smothering sensations
  5. dizziness, vertigo, or unsteady feelings
  6. feelings of unreality
  7. paresthesias (tingling in hands or feet)
  8. hot and cold flashes
  9. sweating
  10. faintness
  11. trembling or shaking
  12. fear of dying, going crazy, or doing something uncontrolled during an attack

C. Not due to a physical disorder or another mental disorder, such as Major Depression, Somatization Disorder, or Schizophrenia.

D. The disorder is not associated with Agoraphobia.

Differential Diagnosis

Physical disorders

Physical disorders such as hypoglycemia, pheochromocytoma, and hyperthyroidism, all of which can cause similar symptoms, must be ruled out.

Substance-induced Organic Mental Disorder

In Withdrawal from some substances, such as barbiturates, and in some Substance Intoxication, such as due to caffeine or amphetamines, there may be panic attacks. Panic Disorder should not be diagnosed when the panic attacks are due to Substance-induced Organic Mental Disorder.

Schizophrenia, Major Depression, and Somatization Disorder

In Schizophrenia, Major Depression, and Somatization Disorder panic attacks may occur. However, the diagnosis of Panic Disorder is not made if the panic attacks are due to these other disorders.

Generalized Anxiety Disorder

Generalized Anxiety Disorder may be confused wit the chronic anxiety that often develops between panic attacks in Panic Disorder. A history of recurrent panic attacks precludes Generalized Anxiety Disorder.

Simple or Social Phobia

In Simple or Social Phobia, the individual may develop panic attacks if exposed to the phobic stimulus. However, in Panic Disorder, the individual is never certain which situations provoke panic attacks.

DSM-IV

Diagnostic Criteria

Panic Disorder Without Agoraphobia

A. Both (1) and (2):

  1. recurrent unexpected Panic Attacks
  2. at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:
  • a. persistent concern about having additional attacks
  • b. worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")
  • c. a significant change in behavior related to the attacks

B. Absence of Agoraphobia.

C. The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

D. The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobia situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).

Panic Disorder With Agoraphobia

A. Both (1) and (2):

  1. recurrent unexpected Panic Attacks
  2. at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:
  • a. persistent concern about having additional attacks
  • b. worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")
  • c. a significant change in behavior related to the attacks

B. The presence of Agoraphobia.

C. The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

D. The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).

Differential Diagnosis

Anxiety Disorder Due to a General Medical Condition and Substance-Induced Anxiety Disorder

Panic Disorder is not diagnosed if the Panic Attacks are judged to be a direct physiological consequence of a general medical condition, in which case an Anxiety Disorder Due to a General Medical Condition is diagnosed. Examples of general medical conditions that can cause Panic Attacks include hyperthyroidism, hyperparathyroidism, pheochromocytoma, vestibular dysfunctions, seizure disorders, and cardiac conditions (e.g., arrhythmias, supraventricular tachycardia). Appropriate laboratory tests (e.g., serum calcium levels for hyperparathyroidism) or physical examinations (e.g., for cardiac conditions) may be helpful in determining the etiological role of a general medical condition. Panic Disorder is not diagnosed if the Panic Attacks are judged to be a direct physiological consequence of a substance (i.e., a drug of abuse, a medication), in which case a Substance-Induced Anxiety Disorder is diagnosed. Intoxication with central nervous system stimulants (e.g., cocaine, amphetamines, caffeine) or cannabis and withdrawal from central nervous system depressants (e.g., alcohol, barbiturates) can precipitate a Panic Attack. However, if Panic Attacks continue to occur outside of the context of substance use (e.g., long after the effects of intoxication or withdrawal have ended), a diagnosis of Panic Disorder should be considered. Features such as onset after age 45 years or the presence of atypical symptoms during a Panic Attack (e.g., vertigo, loss of consciousness, loss of bladder or bowel control, headaches, slurred speech, or amnesia) suggest the possibility that a general medical condition or a substance may be causing the Panic Attack symptoms.

Other mental disorders

Panic Disorder must be distinguished from other mental disorders (e.g., other Anxiety Disorders and Psychotic Disorders) that have Panic Attacks as an associated feature. By definition, Panic Disorder is characterized by recurrent, unexpected (spontaneous, uncued, "out of the blue") Panic Attacks. There are three types of Panic Attacks - unexpected, situationally bound, and situationally predisposed. The presence of recurrent unexpected Panic Attacks either initially or later in the course is required for the diagnosis of Panic Disorder. In contrast, Panic Attacks that occur in the context of other Anxiety Disorders are situationally bound or situationally predispose (e.g., in Social Phobia cued by social situations; in Specific Phobia cued by an object or situation; in Obsessive-Compulsive Disorder cued by exposure to the object of an obsession [e.g., exposure to dirt in someone with an obsession about contamination]; in Posttraumatic Stress Disorder cued by stimuli recalling the stressor).

The focus of the anxiety also helps to differentiate Panic Disorder With Agoraphobia from other disorders characterized by avoidant behaviors. Agoraphobic avoidance is associated with the fear of having a Panic Attack, whereas avoidance in other disorders is associated with specific situations (e.g., fears of scrutiny, humiliation, and embarrassment in Social Phobia; fears of heights, elevators, or crossing bridges in Specific Phobia; separation concerns in Separation Anxiety Disorder; persecution fears in Delusional Disorder).

Specific Phobia

Differentiation of Specific Phobia, Situational Type, from Panic Disorders With Agoraphobia may be particularly difficult because both disorders may include Panic Attacks and avoidance of similar types of situations (e.g., driving, flying, public transportation, enclosed places). Prototypically, Panic Disorder With Agoraphobia is characterized by the initial onset of unexpected Panic Attacks and the subsequent avoidance of multiple situations thought to be likely triggers of the Panic Attacks. Prototypically, Specific Phobia, Situational Type, is characterized by situational avoidance in the absence of recurrent unexpected Panic Attacks. Some presentations fall between these prototypes and require clinical judgement in the selection of the most appropriate diagnosis. Four factors can be helpful in making this judgment: the focus of fear, the type of number of Panic Attacks, the number of situations avoided, and the level of intercurrent anxiety. For example, an individual who had not previously feared or avoided elevators has a Panic Attack in an elevator and begins to dread going to work because of the need to take the elevator to his office on the 24th floor. If this individual subsequently has Panic Attacks only in elevators (even if the focus of fear is on the Panic Attack), then a diagnosis of Specific Phobia may be appropriate. If, however, the individual experiences unexpected Panic Attacks in other situations and begins to avoid or endure with dread other situations because of fear of a Panic Attack, then a diagnosis of Panic Disorder With Agoraphobia would be warranted. Furthermore, the presence of pervasive apprehension about having a Panic Attack even when not anticipating exposure to a phobic situation also supports a diagnosis of Panic Disorder With Agoraphobia. If the individual has additional unexpected Panic Attacks in other situations but no additional avoidance or endurance with dread develops, then the appropriate diagnosis would be Panic Disorder Without Agoraphobia. if the focus of avoidance is not related to having a Panic Attack but concerns some other catastrophe (e.g., injury due to the elevator cable breaking), then an additional diagnosis of Specific Phobia may be considered.

Social Phobia

Similarly, distinguishing between Social Phobia and Panic Disorder With Agoraphobia can be difficult, especially when there is avoidance only of social situations. The focus of fear and the type of Panic Attacks can be helpful in making this distinction. For example, and individual who had not previously had a fear of public speaking has a Panic Attack while giving a talk and begins to dread giving presentations. If this individual subsequently has Panic Attacks only in social performance situations (even if the focus of fear is on the possibility of having another Panic Attack), then a diagnosis of Social Phobia may be appropriate. If, however, the individual continues to experience unexpected Panic Attacks in other situations, then a diagnosis of Panic Disorder With Agoraphobia would be warranted. Individuals with Social Phobia fear scrutiny and rarely have a Panic Attack when alone, whereas individuals with Panic Disorder With Agoraphobia may be more anxious in situations where they must be without a trusted companion. In addition, nocturnal Panic Attacks that awaken an individual from sleep are characteristic of Panic Disorder.

Anxiety and Mood Disorders

When criteria are met for both Panic Disorder and another Anxiety or Mood Disorder, both disorders should be diagnosed. However, if unexpected Panic Attacks occur in the context of another disorder (e.g., Major Depressive Disorder or Generalized Anxiety Disorder) but are not accompanied by a month or more of fear of having additional attacks, associated concerns, or behavior change, the additional diagnosis of Panic Disorder is not made. Because individuals with Panic Disorder may self-medicate their symptoms, comorbid Substance-Related Disorders (most notably related to cannabis, alcohol, and cocaine) are not uncommon.

DSM-5

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: (Note: The abrupt surge can occur from a calm state or an anxious state.)

  1. Palpitations, pounding heart, or accelerated heart rate.
  2. Sweating.
  3. Trembling or shaking.
  4. Sensations of shortness of breath or smothering.
  5. Feelings of choking.
  6. Chest pain or discomfort.
  7. Nausea or abdominal distress.
  8. Feeling dizzy, unsteady, light-headed, or faint.
  9. Chills or heat sensations.
  10. Paresthesias (numbness or tingling sensations).
  11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
  12. Fear of losing control or "going crazy."
  13. Fear of dying.

Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

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).

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, an other specified anxiety disorder or unspecified anxiety diagnosis should be considered.

Anxiety disorder due to another medical condition

Panic disorder is not diagnosed if the panic attacks are judged to be a direct physiological consequence of another medical condition. Examples of medical conditions that can cause panic attacks include hyperthyroidism, hyperparathyroidism, pheochromocytoma, vestibular dysfunctions, seizure disorders, and cardiopulmonary conditions (e.g., arrhythmias, supraventricular tachycardia, asthma, chronic obstructive pulmonary disease [COPD]). Appropriate laboratory tests (e.g., serum calcium levels for hyperparathyroidism; Holter monitor for arrhythmias) or physical examinations (e.g., for cardiac conditions) may be helpful in determining the etiological role of another medical condition.

Substance/medication-induced anxiety disorder

Panic disorder is not diagnosed if the panic attacks are judged to be a direct physiological consequence of a substance. Intoxication with central nervous system stimulants (e.g., cocaine, amphetamines, caffeine) or cannabis and withdrawal from central nervous system depressants (e.g., alcohol, barbiturates) can precipitate a panic attack. However, if panic attacks continue to occur outside of the context of substance use (e.g., long after the effects of intoxication or withdrawal have ended), a diagnosis of panic disorder should be considered. In addition, because panic disorder may precede substance use in some individuals and may be associated with increased substance use, especially for purposes of self-medication, a detailed history should be taken to determine if the individual had panic attacks prior to excessive substance use. If this is the case, a diagnosis of panic disorder should be considered in addition to a diagnosis of substance use disorder. Features such as onset after age 45 years or the presence of atypical symptoms during a panic attack (e.g., vertigo, loss of consciousness, loss of bladder or bowel control, slurred speech, amnesia) suggest the possibility that another medical condition or a substance may be causing the panic attack symptoms.

Other mental disorders with panic attacks as an associated feature (e.g., other anxiety disorders and psychotic disorders)

Panic attacks that occur as a symptom of other anxiety disorders are expected (e.g., triggered by social situations in social anxiety disorder, by phobic objects or situations in specific phobia or agoraphobia, by worry in generalized anxiety disorder, by separation from home or attachment figures in separation anxiety disorder) and thus would not meet criteria for panic disorder. (Note: Sometimes an unexpected panic attack is associated with the onset of another anxiety disorder, but then the attacks become expected, whereas panic disorder is characterized by recurrent unexpected panic attacks.) If the panic attacks only occur in response to specific triggers, then only the relevant anxiety disorder is assigned. However, if the individual experiences unexpected panic attacks as well and shows persistent concern and worry or behavioral change because of the attacks, then an additional diagnosis of panic disorder should be considered.