Anxiety Disorders: Panic Disorder With and Without Agoraphobia

Anxiety Disorders: Panic Disorder With and Without Agoraphobia

Definitions and Diagnostic Criteria

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) (Ameri-can Psychiatric Association, 2000), panic disorder is defined by recurrent and unexpected panic attacks. At least one of these at-tacks must be followed by one month or more of:

·        persistent concern about having more attacks;

·        worry about the implications or consequences of the attack; or

·        changes to typical behavioral patterns (e.g., avoidance of work or school activities) as a result of the attack

In addition, the panic attacks must not stem solely from the direct effects of illicit substance use, medication, or a general medical condition (e.g., hyperthyroidism, vestibular dysfunction) and are not better explained by another mental disorder (e.g., such as social phobia for attacks that occur only in social situations). A diagnosis of panic disorder with agoraphobia is warranted when the criteria for panic disorder are satisfied and accompanied by agoraphobia.

Although panic attacks are a cardinal feature of panic dis-order and in combination with agoraphobia (i.e., anxiety about be-ing in a place or a situation that is not easily escaped or where help is not easily accessible if panic occurs) are essential to a diagno-sis of panic disorder with agoraphobia, the criteria sets for panic attacks and for agoraphobia are listed separately as standalone noncodable conditions that are referred to by the diagnostic cri-teria for panic disorder and agoraphobia without history of panic disorder. Notwithstanding, accurate diagnosis is difficult without a proficient understanding of these features. Tables 49.1 and 49.2 show the DSM-IV-TR criteria for panic attack and agoraphobia, respectively. While the criteria for agoraphobia are generally straightforward, panic attacks can be difficult to understand.

A number of investigations indicate that people report hav-ing what they consider to be a panic attack during or in association with actual physical threat (i.e., a true alarm situation). It is, how-ever, important to distinguish between a fear reaction in response to actual threat and a panic attack. In an attempt to do so, the DSM-IV-TR has clarified that panic attacks occur “in the absence of real danger”. Such attacks involve a paroxysmal occurrence of intense fear or discomfort accompanied by a minimum of four of the 13 symptoms shown in Table 49.1. The DSM-IV-TR recognizes three characteristic types of panic attacks, including those that are unex-pected (i.e., not associated with an identifiable internal or external trigger and appear to occur “out of the blue”), situationally bound

(i.e., almost invariably occur when exposed to a situational trigger or when anticipating it) and situationally predisposed (i.e., usually, but not necessarily, occur when exposed to a situational trigger or when anticipating it). The term limited symptom attacks is used to refer to panic-like episodes comprising fewer than four symptoms.

Although unexpected panic attacks are required for a diag-nosis of panic disorder, not all panic attacks that occur in panic dis-order are unexpected. The occurrence of unexpected attacks can wax and wane and over the developmental course of the disorder they tend to become situationally bound or predisposed. Moreo-ver, unexpected panic attacks as well as those that are situationally bound or predisposed can occur in the context of other psychiatric disorders, including all of the other anxiety disorders, e.g., a per-son with social phobia might have an occasional unexpected panic attack without the other feature required to diagnose panic disor-der; a dog phobic might panic whenever a large dog is encountered) and some general meda conditions. A clear understanding of the

distinction between types of panic attacks outlined in the DSM-IV-TR provides a foundation for diagnosis and differential diag-nosis. However, consideration of other characteristics of panic – including duration of attacks, frequency of attacks, number and intensity of symptoms, nature of catastrophic thinking and mech-anism responsible for termination of an attack – can be important in identifying exacerbating and controlling factors.