Panic Disorder

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Course

The age of onset of panic disorder varies, but is usually in the early 20s. Onset in children and in people in middle age is unusual but does occur. The frequency of panic attacks varies. Some people experience them every week. Some experience a series of episodes during a week or over a period of months and then go for months or years before they experience another series of episodes.

People with panic disorder sometimes experience limited symptom attacks. This means that only two or three of the symptoms associated with a panic attack occur. Spontaneous panic attacks are the hallmark of panic disorder.

Because there's no clear cause, people with panic disorder frequently visit their doctor or hospital emergency rooms in search of a medical reason for their symptoms.

Anticipatory anxiety and avoidance of potentially anxiety-causing situations develop. Agoraphobia develops in 40% of people with panic disorder. Depression often results because of the disruption of normal daily routines, shame, and embarrassment association with panic disorder.

There is no laboratory test for panic disorder. The personal account of the patient is used to diagnose the condition.

The American Psychiatric Association (APA) provides the criteria for panic disorder diagnosis (with and without agoraphobia) in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition.

Criteria for Panic Disorder Without Agoraphobia

• A. Both (1) and (2) are present:
  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:
     • Persistent concern about having additional attacks
     • Worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")
     • 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., occurring on exposure to a specific phobic situation), Obsessive-Compulsive 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).

Criteria for Panic Disorder With Agoraphobia
All of the criteria above, except B., are present.

Differential Diagnosis
Because panic attacks occur in other anxiety disorders and in some medical conditions, it is necessary to rule out other possible diagnoses, such as the following: Other anxiety disorders in which panic attacks occur

• Generalized anxiety disorder
• Phobias
• Posttraumatic stress disorder
• Substance-induced anxiety disorder (caffeine, amphetamine, cocaine intoxication)

Organic disorders that cause symptoms associated with panic attacks

• Heart disease
• Heart attack (chest pain)
• Mitral valve prolapse (rapid heart rate)
• Paroxysmal atrial tachycardia (recurrent, sudden attacks of rapid heartbeat)
• Pulmonary embolism (sudden shortness of breath and chest pain)
• Hypothyroidism (tremor)
• Hypoglycemia (sweating, tremor, palpitation)
• Pheochromacytoma (sudden attacks of palpitations, anxiety, sweating)
• Postconcussion syndrome (dizziness)

Stimulant use

• Amphetamines
• Asthma medication
• Caffeine

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