Because Panic Attacks can occur in the context of any Anxiety Disorder as well as other mental disorders (e.g., Mood Disorders, Substance-Related Disorders) and some general medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal), the text and criteria set for a Panic Attack are provided separately in this section.
The essential feature of a Panic Attack is a discrete period of intense fear or discomfort in the absence of real danger that is accompanied by at least 4 of 13 somatic or cognitive symptoms. Symptoms can be somatic or cognitive in nature and include palpitations, sweating, trembling or shaking, sensations of shortness of breath or smothering, feeling of choking, chest pain or discomfort, nausea or abdominal distress, dizziness or lightheadedness, derealization or depersonalization, fear of losing control or “going crazy,” fear of dying, paresthesias, and chills or hot flushes. The attack has a sudden onset and builds to a peak rapidly (usually in 10 minutes or less) and is often accompanied by a sense of imminent danger or impending doom and an urge to escape. The anxiety that is characteristic of a Panic Attack can be differentiated from generalized anxiety by its discrete, almost paroxysmal, nature and its typically greater severity. 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. Each type of Panic Attack is defined by a different set of relationships between the onset of the attack and the presence or absence of situational triggers that can include cues that are either external (e.g., an individual with claustrophobia has an attack while in a elevator stuck between floors) or internal (e.g., catastrophic cognitions about the ramifications of heart palpitations). 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”). Situationally bound (cued) Panic Attacks are defined as those 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., 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).
Individuals seeking care for unexpected Panic Attacks will usually describe the fear as intense and report that they thought they were about to die, lose control, have a heart attack or stroke, or “go crazy.” They also usually report an urgent desire to flee from wherever the attack is occurring. With recurrent unexpected Panic Attacks, over time the attacks typically become situationally bound or predisposed, although unexpected attacks may persist.
The occurrence of unexpected Panic Attacks is required for a diagnosis of Panic Disorder (with or without Agoraphobia). Situationally bound and situationally predisposed attacks are frequent in Panic Disorder but also occur in the context of other Anxiety Disorders and other mental disorders. For example, situationally bound Panic Attacks are experienced by a majority of individuals with Social Phobia (e.g., the person experiences a Panic Attack each and every time she must speak in public) and Specific Phobias (e.g., the person with a Specific Phobia of dogs experiences a Panic Attack each and every time he encounters a barking dog), whereas situationally predisposed Panic Attacks most typically occur in Generalized Anxiety Disorder (e.g., after watching television news programs that warn of an economic slowdown, the person becomes overwhelmed with worries about his finances and escalates into a Panic Attack) and Posttraumatic Stress Disorder (e.g., a rape victim sometimes experiences Panic Attacks when faced with reminders of the traumatic event, such as seeing a man who reminds her of the assailant).
In determining the differential diagnostic significance of a Panic Attack, it is important to consider the context in which the Panic Attack occurs. The distinction between unexpected Panic Attacks and both situationally bound and situationally predisposed Panic Attacks is critical, since recurrent unexpected attacks are required for a diagnosis of Panic Disorder. Determining whether a history of Panic Attacks warrants a diagnosis of Panic Disorder is, however, complicated by the fact that an exclusive relationship does not always exist between the type of Panic Attack and the diagnosis. For instance, although a diagnosis of Panic Disorder definitionally requires that at least some of the Panic Attacks be unexpected, individuals with Panic Disorder frequently report also having situationally bound or situationally predisposed attacks. As such, careful consideration of the focus of anxiety associated with the Panic Attacks is also important in differential diagnosis. To illustrate, consider a woman who has a Panic Attack prior to a public speaking engagement. If this woman indicates that the focus of her anxiety was that she might die from an impending heart attack, then assuming other diagnostic criteria are met, she may have Panic Disorder. If on the other hand, this woman identifies the focus of anxiety as not the Panic Attack itself, but of being embarrassed and humiliated, then she may be more likely to have Social Phobia. The diagnostic issues for boundary cases are discussed in the “Differential Diagnosis” sections of the texts for the disorders in which Panic Attacks may appear.
Criteria for Panic Attack
Note: A Panic Attack is not a codable disorder. Code the specific diagnosis in which the Panic Attack occurs (e.g., 300.21 Panic Disorder With Agoraphobia).
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
(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 flushes