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 (Criterion A). 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).(Criterion C). Finally, the Panic Attacks are not better accounted for by another mental disorder (e.g., Specific or Social Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, or Separation Anxiety Disorder) (Criterion D). Depending on whether criteria are also met for agoraphobia, 300.21 Panic Disorder With Agoraphobia or 300.01 Panic Disorder Without Agoraphobia is diagnosed (Criterion B).

An unexpected (spontaneous, uncued) Panic Attack is defined as one that is not associated with a situational trigger (i.e., it occurs "out of the blue"). At least two unexpected Panic Attacks are required for the diagnosis, but most individuals have considerable more. Individuals with Panic Disorder frequently also have situationally predisposed Panic Attacks (i.e., those more likely to occur on, but not invariably associated with, exposure to a situational trigger). Situationally bound attacks (i.e., those that occur almost invariably and immediately on exposure to a situational trigger) can occur but are less common.

The frequency and severity of Panic Attacks vary widely. For example, 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 a month) over many years. Limited-symptom attacks(i.e., attacks that are identical to "full" Panic Attacks except that the sudden fear or anxiety is accompanied by fewer than 4 of the 13 additional symptoms) are very common in individuals with Panic Disorder.

Although the distinction between full Panic Attacks and limited- symptom attacks is somewhat arbitrary, full Panic Attacks are associated with greater morbidity. Most individuals who have limited-symptom attacks have had full Panic Attacks at some time during the course of the disorder.

Individuals with Panic Disorder display characteristic concerns or attributions about the implications or consequences of the Panic Attacks.  Some fear that the attacks indicate the presence of an undiagnosed, life-threatening illness (e.g., cardiac disease, seizure disorder). Despite repeated medical testing and reassurance, they may remain frightened and unconvinced that they do not have a life-threatening illness. Others fear that the Panic Attacks are an indication that they are "going crazy" or

losing control or are emotionally weak. Some individuals with recurrent Panic Attacks significantly change their behavior (e.g., quit a job) in response to the attacks, but deny either fear of having another attack or concerns about the consequences of their Panic Attacks. Concerns about the next attack, or its implications, are often associated with development of avoidance behaviors that may meet criteria for Agoraphobia, in which case Panic Disorder with Agoraphobia is diagnosed.

ASSOCIATED FEATURES AND DISORDERS

Associated descriptive features and mental disorders In addition to worry about Panic Attacks and their imnplications, 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. For example, individuals with Panic Disorder often anticipate a catastrophic outcome from a mild physical symptom or medication side effect (e.g., thinking that a headache indicates a brain tumor or a hypertensive crisis). Such individuals are also much less tolerant of medication side effects and generally need continued reassurance in order to take medication. In individuals whose Panic Disorder has not been treated or was misdiagnosed, the belief that they have an undetected life-threatening illness may lead to both chronic debilitating anxiety and excessive visits to health care facilities. This pattern can be both emotionally and financially disruptive. In some cases, loss or disruption of important interpersonal relationships (e.g., leaving home to live on one's own, divorce) 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 or emergency-room

visits, which can lead to unemployment or dropping out of school. Major Depressive Disorder occurs frequently (50%-65%) in individuals with Panic Disorder. In approximately one-third of individuals with both disorders, the depression precedes the onset of Panic Disorder. In the remaining two-thirds, depression occurs coincident with or following the onset of Panic Disorder. A subset of individuals, some of whom may develop a Substance-Related Disorder as a consequence, treat their anxiety with alcohol and medications. Comorbidity with other Anxiety Disorders is also common, especially in

clinical settings and in individuals with more severe Agoraphobia (Social Phobia has been reported in 15%-30% of individuals with Panic Disorder; Obsessive-Compulsive Disorder in 8%-10%; Specific Phobia in 10%-20%; and Generalized Anxiety Disorder in 25%). Separation Anxiety Disorder in childhood has been associated with this disorder.

Associated laboratory findings. No laboratory findings have been identified that are diagnostic of Panic Disorder. However, a variety of laboratory findings 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 sodium lactate infusion or carbon dioxide inhalation are more common in Panic Disorder than in other Anxiety Disorders.

Associated physical examination findings and general medical conditions.  Transient tachycardia and moderate elevation of systolic blood pressure may occur during some Panic Attacks. Although studies have suggested both mitral valve prolapse and thyroid disease are more common among individuals with Panic Disorder than inthe general population, others have found no difference in prevalence.

SPECIFIC CULTURE AND GENDER FEATURES

In some cultures, Panic Attacks may involve intense fear of witchcraft or magic. Panic Disorder as described here has been found in epidemiological studies throughout the world. Moreover, a number of conditions included in the "Glossary of Culture-Bound Syndromes" (see Appendix I) may be related to Panic Disorder.  Some cultural or ethnic groups restrict the participation of women in public life, and this must be distinguished from Agoraphobia. Panic Disorder Without Agoraphobia is diagnosed twice as often and Panic Disorder With Agoraphobia three times as often in women as in men.

PREVALENCE

Epidemiological studies throughout the world consistently indicate the lifetime prevalence of Panic Disorder (With or Without Agoraphobia) to be between 1.5% and 3.5%. One-year prevalence rates are between 1% and 2%.  Approximately one-third to one-half of individuals diagnosed with Panic Disorder in community samples also have Agoraphobia, although a much higher rate of Agoraphobia is encountered in clinical samples.

COURSE

Age at onset for Panic Disorder varies considerably, but is most typically between late adolescence and the 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. Retrospective descriptions by individuals seen in clinical settings suggest that the usual course is chronic but waxing and waning. Some individuals may have episodic

outbreaks with years of remission in between, and others may have continuous severe symptomatology. Although Agoraphobia may develop at any point, its onset is usually within the first year of occurrence of recurrent Panic Attacks. The course of Agoraphobia and its relationship to the course of Panic Attacks are variable. In some cases, a decrease or remission of Panic Attacks may be followed closely by a corresponding decrease in agoraphobic avoidance and anxiety. In others, Agoraphobia may become chronic regardless of the presence or absence of Panic Attacks. Some individuals report that they can reduce the frequency of Panic Attacks by avoiding certain situations. Naturalistic follow-up studies of individuals treated in tertiary care settings (which may select for poor-prognosis group) suggest that, at 6-10 years posttreatment, about 30% of individuals are well, 40%-50% are improved but symptomatic, and the remaining 20%-30% have symptoms that are the same or slightly worse.

FAMILIAL PATTERN

First-degree biological relatives of individuals with Panic Disorder have a four to seven times greater chance of developing 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 relative. Twin studies indicate a genetic contribution to the development of Panic Disorder.

Hosted by www.Geocities.ws