Panic Disorder (DSM-IV-R)
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Panic Disorder (DSM-IV-R)
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DIAGNOSTIC CRITERIA FOR PANIC ATTACK

A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

 

  1. palpitations, pounding heart, or accelerated heart rate
  2. sweating
  3. trembling or shaking
  4. sensations of shortness of breath or smothering
  5. feeling of choking
  6. chest pain or discomfort
  7. nausea or abdominal distress
  8. feeling dizzy, unsteady, lightheaded, or faint
  9. derealization (feelings of unreality) or depersonalization (being detached from oneself)
  10. fear of losing control or going crazy
  11. fear of dying
  12. paresthesias (numbness or tingling sensations)
  13. chills or hot flashes

 

A Panic Attack has a sudden onset and builds to a peak rapidly (usually 10 minutes or less) and is often accompanied by a sense of imminent danger or impending doom and an urge to escape. Attacks that meet all other criteria but that have fewer than 4 somatic or cognitive symptoms are referred to as limited-symptom attacks.

 

There are three characteristic types of Panic Attacks: unexpected (uncued), situationally bound (cued), and situationally predisposed.  

  •  Unexpected (uncued) Panic Attacks are defined as those for which the individual does not associate onset with an internal or external situational trigger (i.e., the attack is perceived as occurring spontaneously "out of the blue").  
  • Situational (cued) Panic Attacks are defined as thoswe that almost invariably occur immediately on exposure to, or in anticipation of, the situational cue or trigger (e.g., a person with Social Phobia having a Panic Attack upon entering into, or thinking about, a public speaking engagement).
  • Situationally Predisposed Panic Attacks are similar to situationally bound Panic Attacks but are not invariably associated with the cue and do not necessarily occur immediately after the exposure (e.g., the attacks are more likely to occur while driving, but there are times when the individual drives and does not have a Panic Attack or times when the Panic Attack occurs after driving for a half hour).

 

* The occurrence of unexpected Panic Attacks is required for a diagnosis of Panic Disorder.



DIAGNOSTIC FEATURES

The essential feature of Panic Disorder is the presence of recurrent, unexpected Panic Attacks followed by at least 1 month of persistent concern about having another Panic Attack, worry about the possible implications or consequences of the Panic Attacks, or a significant behavioral change related to the attacks.  The Panic Attacks are not due to the direct physiological effects of a substance (e.g., Caffeine Intoxication) or a general medical condition (e.g., hyperthyroidism).  Finally, the Panic Attacks are not better accounted for by another mental disorder (e.g., Specific or Social Phobia, Obsessive-Compulsive Disorder, etc.).


At least two unexpected Panic Attacks are required for the diagnosis, but most individuals have considerably more.  Individuals with Panic Disoder frequently also have situationally predisposed Panic Attacks.  The frequency and severity of the Panic Attacks vary widely.  Some individuals have moderately frequent attacks (e.g., once a week) that occur regularly for months at a time.  Others report short bursts of more frequent attacks (e.g., daily for a week) separated by weeks or months without any attacks or with less frequent attacks (e.g., two each month) over many years.

 

ASSOCIATED FEATURES AND DISORDERS

In addition to worry about Panic Attacks and their implications, many individuals with Panic Disorder also report constant or intermittent feelings of anxiety that are not focused on any specific situation or event.  Others become excessively apprehensive about the outcome of routine activities and experiences, particularly those related to health or separation from loved ones.  Individuals with Panic Disorder often anticipate a catastrophic outcome from a mild physical symptom or medication side effect.  Such individuals are also much less tolerant of medication side effects and generally need continued reassurance in order to take medication.

 

In some cases, loss or disruption of important interpersonal relationships is associated with the onset or exacerbation of Panic Disorder.  Demoralization is a common consequence, with many individuals becoming discouraged, ashamed, and unhappy about the difficulties of carrying out their normal routines.  They often attribute this problem to a lack of "strength" or "character".  This demoralization can become generalized to areas beyond specific panic-related problems.  These individuals may frequently be absent from work or school for doctor and emergency-room visits, which can lead to unemployment or dropping out of school.

 

ASSOCIATED LABORATORY FINDINGS

No laboratory findings have been identified that are diagnostic of Panic Disorder.  However, a variety of laboratory finding have been noted to be abnormal in groups of individuals with Panic Disorder relative to control subjects.  Some individuals with Panic Disorder show signs of compensated respiratory alkalosis (i.e., decreased carbon dioxide and decreased bicarbonate levels with an almost normal pH).  Panic Attacks in response to panic provocation procedures such as sodium lactate infusion or carbon dioxide inhalation are more common in individuals with Panic Disorder than in control subjects or individuals with Generalized Anxiety Disorder.

 

ASSOCIATED PHYSICAL EXAMINATION AND GENERAL MEDICAL CONDITIONS

Transient tachycardia and moderate elevation of systolic blood pressure may occur during some Panic Attacks.  Studies have identified significant comorbidity between Panic Disorder and numerous general medical symptoms and conditions, including, but not limited to, dizziness, cardiac arrhythmias, hyperthyroidism, asthma, chronic obstructive pulmonary disease, and irritable bowel syndrome.  However, the nature of the association (e.g., cause-and-effect) between Panic Disorder and these conditions remains unclear.  Although studies have suggested that both mitral valve prolapse and thyroid disease are more common among individuals with Panic Disorder than in the general population, others have found no differences in prevalence.

 

COURSE

Age at onset for Panic Disorder varies considerably, but is most typically between late adolescence and mid-30s.  There may be a bimodal distribution, with one peak in late adolescence and a second smaller peak in the mid-30s.  A small number of cases begin in childhood, and onset after age 45 years is unusual but can occur.  Some individuals may have episodic outbreaks with years of remission in between, and others may have continuous sever symptomatology.  Limited symptom attacks may come to be eperienfced with greater frequency if the course of the Panic Disorder is chronic.

 

FAMILIAL PATTERN

First-degree biological relatives of individuals with Panic Disorder are up to 8 times more likely to develop Panic Disorder.  If the age at onset of the Panic Disorder is before 20, first-degree relatives have been found to be up to 20 times more likely to have Panic Disorder.  However, in clinical settings, as many as one-half to three-quarters of individuals with Panic Disorder do not have an affected first-degree biological relative.  Twin studies indicate a genetic contribution to the development of Panic Disorder.

 

DIFFERENTIAL DIAGNOSIS

Panic Disorder is not diagnosed if the Panic Attacks are judge 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.  Appropriate laboratory tests or physical examinations may be helpful in determining the etiological role of a general medical condition.

 

Panic Attacks are also not diagnosed if the Panic Attacks are judge to be a direct result physiological consequence of a substance (i.e., drug abuse, or medication), in which case a Substance-Induced Anxiety Disorder is diagnosed.  Intoxication with central nervous system stimulants or cannabis and withdrawal from central nervous system depressants can precipitate a Panic Attack.  However, if Panic Attacks continue to occur outside of the context of substance use, 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 for purpose of self-medication, a detailed history should be taken to determine if the individual had Panic Attacks prior to excessive substance abuse.  If this is the case, a diagnosis of Panic Disorder should be considered in addition to a diagnosis of Substance Dependence or Abuse.

 

In summary, there are three parts to the Panic Attack syndrome:

  1. The panic attack itself as defined above.
  2. Anticipartory anxiety about when and where the next attack will occur.
  3. Avoidance behavior due to severe anticipatory anxiety.

 



THE BRAIN AND MOOD


PanicImage

The Limbic System is a motivational system.  The Limbic System tries to motivate our DLPC to plan and execute tasks to satisfy our instinctive needs.  For example, if one lost a million dollars in the stock market, he/she would be depressed and/or anxious.

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Another example of Limbic assignment of emotional form is guilt.  If a person deviates from social norms, the Limbic system will assign the emotional form of guilt.

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When the Limbic System fails, it creates emotional forms independent of personality and content of life.

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