A panic attack is a period of intense fear or discomfort, typically with an abrupt onset and usually lasting no more than thirty minutes. Symptoms include trembling, shortness of breath, heart palpitations, sweating, nausea, dizziness, hyperventilation, paresthesia (tingling sensations), and sensations of choking or smothering. The disorder is strikingly different from other types of anxiety, in that panic attacks are very sudden, appear to be unprovoked, and are often disabling. Most who have one attack will have others. People who have repeated attacks, or feel severe anxiety about having another attack are said to have panic disorder. ==Introduction== Most sufferers of panic attacks report a fear of dying, "going crazy", or losing control of emotions or behavior. The experiences generally provoke a strong urge to escape or flee the place where the attack begins ("fight or flight" reaction) and, when associated with chest pain or shortness of breath, a feeling of impending doom and/or tunnel vision, frequently resulting in seeking aid from a hospital emergency room or other type of urgent assistance. The panic attack is distinguished from other forms of anxiety by its intensity and its sudden, episodic nature. Panic attacks are often experienced by sufferers of anxiety disorders, agoraphobia, and other psychological conditions involving anxiety, though panic attacks are not always indicative of a mental disorder. Up to 10 percent of otherwise healthy people experience an isolated panic attack per year. A person with a phobia will often experience a panic attack as a direct result of exposure to their trigger. These panic attacks are usually short-lived and rapidly relieved once the trigger is escaped. In conditions of chronic anxiety one panic attack can often roll into another one, leading to nervous exhaustion over a period of days. ==Symptoms== The symptoms of a panic attack appear suddenly, without any apparent cause. They may include: * Racing or pounding heart rate or palpitations * Sweats * Chest pains * Dizziness, lightheadedness, nausea * Difficulty breathing (dyspnea) * Paresthesia in the hands, face, feet or mouth * Flushes to the face and chest or chills * Dreamlike sensations or perceptual distortions (derealization) * Disassociation, the perception that one is not connected to the body or even disconnected from space and time (depersonalization) * Terror, a sense that something unimaginably horrible is about to occur and one is powerless to prevent it * Fear of losing control and doing something embarrassing or of going crazy * Fear of death * Feeling of impending doom * Trembling or "shivering" * Crying A panic attack typically lasts for several minutes and is one of the most distressing conditions that a person can experience in everyday life. The various symptoms of a panic attack can be understood as follows. First comes the sudden onset of fear with little or no provoking stimulus. This then leads to a release of adrenaline (epinephrine) which cause the so-called fight-or-flight response where the person's body prepares for major physical activity. This leads to an increased heart rate (tachycardia), rapid breathing (hyperventilation), and sweating (which increases grip and aids heat loss). Because strenuous activity rarely ensues, the hyperventilation leads to carbon dioxide levels lowering in the lungs and then the blood. This leads to shifts in the pH of the blood which then leads to many of the other symptoms such as paresthesia, dizziness, and lightheadedness. Anyone who hyperventilates for a while can demonstrate this. For the person with a panic attack who does not know this, these symptoms are often seen as further evidence of how serious the condition is. An ensuing vicious cycle of adrenaline release fuels worsening physical symptoms and psychological distress. ==Induced phobias== People who have had a panic attack — for example while driving, shopping in a crowded retailer, or riding in an elevator — may develop irrational fears, called phobias, about these situations and begin to avoid them. Eventually, the pattern of avoidance and level of anxiety about another attack may reach the point where individuals with panic disorder may be unable to drive or even step out of the house. At this stage, the person is said to have panic disorder with agoraphobia. Thus panic disorder can have as serious an impact on a person's daily life as other major disease. ==Occurrence== Panic disorder is a serious health problem in the United States. It is estimated that 1.6 percent of the American population has panic disorder. It typically strikes in young adulthood; roughly half of all people who have panic disorder develop the condition before age 24. Women are twice as likely as men to develop panic disorder. Panic disorder tends to continue for months or years. If left untreated, it may worsen to the point where the person's life is seriously affected by panic attacks and by attempts to avoid or conceal them. In fact, many people have had problems with personal relationship and family or unemployment while struggling to cope with panic disorder. It does not usually go away unless the person receives treatments designed specifically to help people with panic disorder. ==Treatment== Panic disorder is real and potentially disabling, but it can be controlled with specific treatments. Because of the disturbing symptoms that accompany panic disorder, it may be mistaken for coronary heart disease or some other life-threatening medical illness. People frequently go to hospital emergency rooms when they are having a panic attack, and extensive medical tests may be performed to rule out these other conditions. Others often try to reassure persons having a panic attack that they are not in great danger. Expressions such as "nothing serious," "all in your head," or "nothing to worry about" may give the incorrect impression that there is no real problem and that treatment is not possible or necessary. Treatment for panic disorder includes medications and a type of psychotherapy known as cognitive-behavioral therapy, which teaches people how to view panic attacks differently and demonstrates ways to reduce anxiety. Appropriate treatment by an experienced professional can reduce or prevent panic attacks in 70 to 90 percent of people with panic disorder. Most patients show significant progress after a few weeks of therapy. Relapses may occur, but they can often be effectively treated just like the initial episode. Medications are often used to break the psychological connection between a specific phobia and panic attacks, reducing future panic attacks. Medications can include antidepressants (selective serotonin reuptake inhibitor's, Monoamine oxidase inhibitors's, etc.) taken every day, or anti-anxiety drugs (benzodiazepines, e.g. -- Valium, Ativan, Xanax, etc.) during or in anticipation of panic attacks. Exposure to the phobia trigger multiple times without a resulting panic attack (due to medication) can often break the phobia-panic pattern, allowing people to fuction around their phobia without the help of medications. In addition, people with panic disorder may need treatment for other emotional problems. Clinical depression has often been associated with panic disorder, as have alcoholism and drug addiction. About 30% of people with panic disorder use alcohol and 17% use drugs such as cocaine or marijuana to alleviate the anguish and distress caused by their condition. Recent research also suggests that Suicide#Attempted suicide are more frequent in people with panic disorder. ==Causes== Panic disorder has been found to run in families, and this may mean that inheritance (genetics) plays a strong role in determining who will get it. However, many people who have no family history of the disorder develop it. Heredity, other biological factors, stressful life events, and thinking in a way that exaggerates relatively normal bodily reactions are all believed to play a role in the onset of panic disorder. Often the first attacks are triggered by physical illnesses, a major life stress, or certain medications. PTSD patients also show a much higher rate of Panic Disorder than the general population; 60% of women with Panic Disorder were sexually abused as children. The exact cause or causes of panic disorder are unknown and are the subject of intense scientific investigation. Studies in animals and humans have focused on pinpointing the specific brain areas involved in anxiety disorders such as panic disorder. Fear, an emotion that evolved to deal with danger, causes an automatic, rapid protective response that occurs without the need for conscious thought. It has been found that the body's fear response is coordinated by a small but complicated structure deep inside the brain called the amygdala. Hypoglycemia may also cause panic attacks. In this condition the receptor (biochemistry) for insulin do not respond properly to insulin, interfering with the transport of glucose across the membranes of cell (biology). The brain depends on a steady supply of glucose — its only source of energy. When there is a sudden fall in blood sugar levels the brain sends a hormonal signal to the adrenal glands to produce adrenaline. This hormone functions to raise blood sugar levels by converting glycogen into glucose, thus preventing brain starvation, but it is also a panic hormone that is responsible for attacks of fear. The non-drug treatment for this is the adoption of the hypoglycemic diet. [http://www.hypoglycemia.asn.au/articles/beating_anxiety.html] ==See also== * hyperventilation syndrome ==External links== * [http://www.pueblo.gsa.gov/cic_text/health/panic/panfly.htm Public domain NIMH panic disorder page] * [http://www.fda.gov/bbs/topics/CONSUMER/CON00134.html Panic Disorder: The Heart That Goes Thump in the Night -- and Day] * [http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec2.html Mental Health : A Report of the Surgeon General] * [http://counsellingresource.com/distress/anxiety-disorders/panic-disorder-symptoms.html Panic Disorder Symptoms] * [http://www.hypoglycemia.asn.au/articles/beating_anxiety.html Beating Anxiety and Panic Attacks] * [http://www.remedyfind.com/HC-Anxiety.asp A review of treatments commonly used for panic disorder and other anxiety disorders] * [http://www.anxietyzone.com Anxiety Zone - Anxiety Disorders Support] ---- ''Some text in this article was taken from the public domain NIMH web pages at http://www.pueblo.gsa.gov/cic_text/health/panic/panfly.htm and http://www.nimh.nih.gov/publicat/panicfacts.cfm'' Anxiety disorders
What's an "adrenal overload"? Is this an orthodox medical term? Please provide cites for this usage. Any doctors in the house? ---- * Added some text from the public domain NIMH web page at http://www.pueblo.gsa.gov/cic_text/health/panic/panfly.htm * Removed most of the "adrenal overload" stuff. * Added more public domain stuff from http://www.nimh.nih.gov/anxiety/panicfacts.cfm and the public domain Report of the Surgeon-General on Mental Health at http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec2.html ---- This article now consists of three public-domain articles aimed at audiences with different levels of understanding, and a paragraph of lead-in from an earlier article. It now needs copyediting and merging. Any volunteers? : I've taken some of the heavy technical stuff from lower down & lightened up (like egg white! fluffy!) to give an introduction which states what a PA actually ''is''. I'm not sure we can include people's testimonials (GFDL...), so I suggest we remove them. We have a list of what people report as the sensations anyway. -- User:Tarquin 17:25 Dec 24, 2002 (UTC) : The triple redundancy in the article confused me until I read this talk page. If noone plans to merge the three source articles soon, I'd like to put a notice at the top along the lines of "this page contains three articles, please help us merge them." I don't have the patience to merge the articles myself. The subject matter is too sensitive for me. -- User:Crag 02:19, 2004 May 1 (UTC) It isn't necessary to have so much repeated information. Would you find such an article in a normal encyclopedia? The section I've moved here has little information beyond that contained in the other sections, and isn't written for an audience of laypeople. --User:Eequor 19:49, 22 Jun 2004 (UTC) I've listed this on Wikipedia:Pages needing attention. --User:Eequor 20:02, 22 Jun 2004 (UTC) In my opinion, this article ought to be rewritten from scratch. The language the government uses to make its documents accessible tends to sound uneducated. --User:Eequor 20:07, 22 Jun 2004 (UTC) ---- ==Panic attacks and panic disorder== A panic attack is a discrete period of intense fear or discomfort that is associated with numerous somatic and cognitive symptoms (DSM-IV). These symptoms include palpitations, sweating, trembling, shortness of breath, sensations of choking or smothering, chest pain, nausea or gastrointestinal distress, dizziness or lightheadedness, tingling sensations, and chills or blushing and "hot flashes." The attack typically has an abrupt onset, building to maximum intensity within 10 to 15 minutes. Most people report a fear of dying, "going crazy," or losing control of emotions or behavior. The experiences generally provoke a strong urge to escape or flee the place where the attack begins and, when associated with chest pain or shortness of breath, frequently results in seeking aid from a hospital emergency room or other type of urgent assistance. Yet an attack rarely lasts longer than 30 minutes. Current diagnostic practice specifies that a panic attack must be characterized by at least four of the associated somatic and cognitive symptoms described above. The panic attack is distinguished from other forms of anxiety by its intensity and its sudden, episodic nature. Panic attacks may be further characterized by the relationship between the onset of the attack and the presence or absence of situational factors. For example, a panic attack may be described as unexpected, situationally bound, or situationally predisposed (usually, but not invariably occurring in a particular situation). There are also attenuated or "limited symptom" forms of panic attacks. Panic attacks are not always indicative of a mental disorder, and up to 10 percent of otherwise healthy people experience an isolated panic attack per year (Barlow, 1988; Klerman et al., 1991). Panic attacks also are not limited to panic disorder. They commonly occur in the course of social phobia, generalized anxiety disorder, and major depressive disorder (DSM-IV). Panic disorder is diagnosed when a person has experienced at least two unexpected panic attacks and develops persistent concern or worry about having further attacks or changes his or her behavior to avoid or minimize such attacks. Whereas the number and severity of the attacks varies widely, the concern and avoidance behavior are essential features. The diagnosis is inapplicable when the attacks are presumed to be caused by a drug or medication or a general medical disorder, such as hyperthyroidism. Lifetime rates of panic disorder of 2 to 4 percent and 1-year rates of about 2 percent are documented consistently in epidemiological studies (Kessler et al., 1994; Weissman et al., 1997) (Table 4-1). Panic disorder is frequently complicated by major depressive disorder (50 to 65 percent lifetime comorbidity rates) and alcoholism and substance abuse disorders (20 to 30 percent comorbidity) (Keller & Hanks, 1994; Magee et al., 1996; Liebowitz, 1997). Panic disorder is also concomitantly diagnosed, or co-occurs, with other specific anxiety disorders, including social phobia (up to 30 percent), generalized anxiety disorder (up to 25 percent), specific phobia (up to 20 percent), and obsessive-compulsive disorder (up to 10 percent) (DSM-IV). As discussed subsequently, approximately one-half of people with panic disorder at some point develop such severe avoidance as to warrant a separate description, panic disorder with agoraphobia. Panic disorder is about twice as common among women as men (American Psychiatric Association, 1998). Age of onset is most common between late adolescence and midadult life, with onset relatively uncommon past age 50. There is developmental continuity between the anxiety syndromes of youth, such as separation anxiety disorder. Typically, an early age of onset of panic disorder carries greater risks of comorbidity, chronicity, and impairment. Panic disorder is a familial condition and can be distinguished from depressive disorders by family studies (Rush et al., 1998).
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Panic attack
A panic attack is a period of intense fear or discomfort, typically with an abrupt onset and usually lasting no more than thirty minutes. Symptoms include trembling, shortness of breath, heart palpitations, sweating, nausea, dizziness, hyperventilation, paresthesia (tingling sensations), and sensations of choking or smothering. The disorder is strikingly different from other types of anxiety, in that panic attacks are very sudden, appear to be unprovoked, and are often disabling. Most who have one attack will have others. People who have repeated attacks, or feel severe anxiety about having another attack are said to have panic disorder. ==Introduction== Most sufferers of panic attacks report a fear of dying, "going crazy", or losing control of emotions or behavior. The experiences generally provoke a strong urge to escape or flee the place where the attack begins ("fight or flight" reaction) and, when associated with chest pain or shortness of breath, a feeling of impending doom and/or tunnel vision, frequently resulting in seeking aid from a hospital emergency room or other type of urgent assistance. The panic attack is distinguished from other forms of anxiety by its intensity and its sudden, episodic nature. Panic attacks are often experienced by sufferers of anxiety disorders, agoraphobia, and other psychological conditions involving anxiety, though panic attacks are not always indicative of a mental disorder. Up to 10 percent of otherwise healthy people experience an isolated panic attack per year. A person with a phobia will often experience a panic attack as a direct result of exposure to their trigger. These panic attacks are usually short-lived and rapidly relieved once the trigger is escaped. In conditions of chronic anxiety one panic attack can often roll into another one, leading to nervous exhaustion over a period of days. ==Symptoms== The symptoms of a panic attack appear suddenly, without any apparent cause. They may include: * Racing or pounding heart rate or palpitations * Sweats * Chest pains * Dizziness, lightheadedness, nausea * Difficulty breathing (dyspnea) * Paresthesia in the hands, face, feet or mouth * Flushes to the face and chest or chills * Dreamlike sensations or perceptual distortions (derealization) * Disassociation, the perception that one is not connected to the body or even disconnected from space and time (depersonalization) * Terror, a sense that something unimaginably horrible is about to occur and one is powerless to prevent it * Fear of losing control and doing something embarrassing or of going crazy * Fear of death * Feeling of impending doom * Trembling or "shivering" * Crying A panic attack typically lasts for several minutes and is one of the most distressing conditions that a person can experience in everyday life. The various symptoms of a panic attack can be understood as follows. First comes the sudden onset of fear with little or no provoking stimulus. This then leads to a release of adrenaline (epinephrine) which cause the so-called fight-or-flight response where the person's body prepares for major physical activity. This leads to an increased heart rate (tachycardia), rapid breathing (hyperventilation), and sweating (which increases grip and aids heat loss). Because strenuous activity rarely ensues, the hyperventilation leads to carbon dioxide levels lowering in the lungs and then the blood. This leads to shifts in the pH of the blood which then leads to many of the other symptoms such as paresthesia, dizziness, and lightheadedness. Anyone who hyperventilates for a while can demonstrate this. For the person with a panic attack who does not know this, these symptoms are often seen as further evidence of how serious the condition is. An ensuing vicious cycle of adrenaline release fuels worsening physical symptoms and psychological distress. ==Induced phobias== People who have had a panic attack — for example while driving, shopping in a crowded retailer, or riding in an elevator — may develop irrational fears, called phobias, about these situations and begin to avoid them. Eventually, the pattern of avoidance and level of anxiety about another attack may reach the point where individuals with panic disorder may be unable to drive or even step out of the house. At this stage, the person is said to have panic disorder with agoraphobia. Thus panic disorder can have as serious an impact on a person's daily life as other major disease. ==Occurrence== Panic disorder is a serious health problem in the United States. It is estimated that 1.6 percent of the American population has panic disorder. It typically strikes in young adulthood; roughly half of all people who have panic disorder develop the condition before age 24. Women are twice as likely as men to develop panic disorder. Panic disorder tends to continue for months or years. If left untreated, it may worsen to the point where the person's life is seriously affected by panic attacks and by attempts to avoid or conceal them. In fact, many people have had problems with personal relationship and family or unemployment while struggling to cope with panic disorder. It does not usually go away unless the person receives treatments designed specifically to help people with panic disorder. ==Treatment== Panic disorder is real and potentially disabling, but it can be controlled with specific treatments. Because of the disturbing symptoms that accompany panic disorder, it may be mistaken for coronary heart disease or some other life-threatening medical illness. People frequently go to hospital emergency rooms when they are having a panic attack, and extensive medical tests may be performed to rule out these other conditions. Others often try to reassure persons having a panic attack that they are not in great danger. Expressions such as "nothing serious," "all in your head," or "nothing to worry about" may give the incorrect impression that there is no real problem and that treatment is not possible or necessary. Treatment for panic disorder includes medications and a type of psychotherapy known as cognitive-behavioral therapy, which teaches people how to view panic attacks differently and demonstrates ways to reduce anxiety. Appropriate treatment by an experienced professional can reduce or prevent panic attacks in 70 to 90 percent of people with panic disorder. Most patients show significant progress after a few weeks of therapy. Relapses may occur, but they can often be effectively treated just like the initial episode. Medications are often used to break the psychological connection between a specific phobia and panic attacks, reducing future panic attacks. Medications can include antidepressants (selective serotonin reuptake inhibitor's, Monoamine oxidase inhibitors's, etc.) taken every day, or anti-anxiety drugs (benzodiazepines, e.g. -- Valium, Ativan, Xanax, etc.) during or in anticipation of panic attacks. Exposure to the phobia trigger multiple times without a resulting panic attack (due to medication) can often break the phobia-panic pattern, allowing people to fuction around their phobia without the help of medications. In addition, people with panic disorder may need treatment for other emotional problems. Clinical depression has often been associated with panic disorder, as have alcoholism and drug addiction. About 30% of people with panic disorder use alcohol and 17% use drugs such as cocaine or marijuana to alleviate the anguish and distress caused by their condition. Recent research also suggests that Suicide#Attempted suicide are more frequent in people with panic disorder. ==Causes== Panic disorder has been found to run in families, and this may mean that inheritance (genetics) plays a strong role in determining who will get it. However, many people who have no family history of the disorder develop it. Heredity, other biological factors, stressful life events, and thinking in a way that exaggerates relatively normal bodily reactions are all believed to play a role in the onset of panic disorder. Often the first attacks are triggered by physical illnesses, a major life stress, or certain medications. PTSD patients also show a much higher rate of Panic Disorder than the general population; 60% of women with Panic Disorder were sexually abused as children. The exact cause or causes of panic disorder are unknown and are the subject of intense scientific investigation. Studies in animals and humans have focused on pinpointing the specific brain areas involved in anxiety disorders such as panic disorder. Fear, an emotion that evolved to deal with danger, causes an automatic, rapid protective response that occurs without the need for conscious thought. It has been found that the body's fear response is coordinated by a small but complicated structure deep inside the brain called the amygdala. Hypoglycemia may also cause panic attacks. In this condition the receptor (biochemistry) for insulin do not respond properly to insulin, interfering with the transport of glucose across the membranes of cell (biology). The brain depends on a steady supply of glucose — its only source of energy. When there is a sudden fall in blood sugar levels the brain sends a hormonal signal to the adrenal glands to produce adrenaline. This hormone functions to raise blood sugar levels by converting glycogen into glucose, thus preventing brain starvation, but it is also a panic hormone that is responsible for attacks of fear. The non-drug treatment for this is the adoption of the hypoglycemic diet. [http://www.hypoglycemia.asn.au/articles/beating_anxiety.html] ==See also== * hyperventilation syndrome ==External links== * [http://www.pueblo.gsa.gov/cic_text/health/panic/panfly.htm Public domain NIMH panic disorder page] * [http://www.fda.gov/bbs/topics/CONSUMER/CON00134.html Panic Disorder: The Heart That Goes Thump in the Night -- and Day] * [http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec2.html Mental Health : A Report of the Surgeon General] * [http://counsellingresource.com/distress/anxiety-disorders/panic-disorder-symptoms.html Panic Disorder Symptoms] * [http://www.hypoglycemia.asn.au/articles/beating_anxiety.html Beating Anxiety and Panic Attacks] * [http://www.remedyfind.com/HC-Anxiety.asp A review of treatments commonly used for panic disorder and other anxiety disorders] * [http://www.anxietyzone.com Anxiety Zone - Anxiety Disorders Support] ---- ''Some text in this article was taken from the public domain NIMH web pages at http://www.pueblo.gsa.gov/cic_text/health/panic/panfly.htm and http://www.nimh.nih.gov/publicat/panicfacts.cfm'' Anxiety disorders
Panic attack
What's an "adrenal overload"? Is this an orthodox medical term? Please provide cites for this usage. Any doctors in the house? ---- * Added some text from the public domain NIMH web page at http://www.pueblo.gsa.gov/cic_text/health/panic/panfly.htm * Removed most of the "adrenal overload" stuff. * Added more public domain stuff from http://www.nimh.nih.gov/anxiety/panicfacts.cfm and the public domain Report of the Surgeon-General on Mental Health at http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec2.html ---- This article now consists of three public-domain articles aimed at audiences with different levels of understanding, and a paragraph of lead-in from an earlier article. It now needs copyediting and merging. Any volunteers? : I've taken some of the heavy technical stuff from lower down & lightened up (like egg white! fluffy!) to give an introduction which states what a PA actually ''is''. I'm not sure we can include people's testimonials (GFDL...), so I suggest we remove them. We have a list of what people report as the sensations anyway. -- User:Tarquin 17:25 Dec 24, 2002 (UTC) : The triple redundancy in the article confused me until I read this talk page. If noone plans to merge the three source articles soon, I'd like to put a notice at the top along the lines of "this page contains three articles, please help us merge them." I don't have the patience to merge the articles myself. The subject matter is too sensitive for me. -- User:Crag 02:19, 2004 May 1 (UTC) It isn't necessary to have so much repeated information. Would you find such an article in a normal encyclopedia? The section I've moved here has little information beyond that contained in the other sections, and isn't written for an audience of laypeople. --User:Eequor 19:49, 22 Jun 2004 (UTC) I've listed this on Wikipedia:Pages needing attention. --User:Eequor 20:02, 22 Jun 2004 (UTC) In my opinion, this article ought to be rewritten from scratch. The language the government uses to make its documents accessible tends to sound uneducated. --User:Eequor 20:07, 22 Jun 2004 (UTC) ---- ==Panic attacks and panic disorder== A panic attack is a discrete period of intense fear or discomfort that is associated with numerous somatic and cognitive symptoms (DSM-IV). These symptoms include palpitations, sweating, trembling, shortness of breath, sensations of choking or smothering, chest pain, nausea or gastrointestinal distress, dizziness or lightheadedness, tingling sensations, and chills or blushing and "hot flashes." The attack typically has an abrupt onset, building to maximum intensity within 10 to 15 minutes. Most people report a fear of dying, "going crazy," or losing control of emotions or behavior. The experiences generally provoke a strong urge to escape or flee the place where the attack begins and, when associated with chest pain or shortness of breath, frequently results in seeking aid from a hospital emergency room or other type of urgent assistance. Yet an attack rarely lasts longer than 30 minutes. Current diagnostic practice specifies that a panic attack must be characterized by at least four of the associated somatic and cognitive symptoms described above. The panic attack is distinguished from other forms of anxiety by its intensity and its sudden, episodic nature. Panic attacks may be further characterized by the relationship between the onset of the attack and the presence or absence of situational factors. For example, a panic attack may be described as unexpected, situationally bound, or situationally predisposed (usually, but not invariably occurring in a particular situation). There are also attenuated or "limited symptom" forms of panic attacks. Panic attacks are not always indicative of a mental disorder, and up to 10 percent of otherwise healthy people experience an isolated panic attack per year (Barlow, 1988; Klerman et al., 1991). Panic attacks also are not limited to panic disorder. They commonly occur in the course of social phobia, generalized anxiety disorder, and major depressive disorder (DSM-IV). Panic disorder is diagnosed when a person has experienced at least two unexpected panic attacks and develops persistent concern or worry about having further attacks or changes his or her behavior to avoid or minimize such attacks. Whereas the number and severity of the attacks varies widely, the concern and avoidance behavior are essential features. The diagnosis is inapplicable when the attacks are presumed to be caused by a drug or medication or a general medical disorder, such as hyperthyroidism. Lifetime rates of panic disorder of 2 to 4 percent and 1-year rates of about 2 percent are documented consistently in epidemiological studies (Kessler et al., 1994; Weissman et al., 1997) (Table 4-1). Panic disorder is frequently complicated by major depressive disorder (50 to 65 percent lifetime comorbidity rates) and alcoholism and substance abuse disorders (20 to 30 percent comorbidity) (Keller & Hanks, 1994; Magee et al., 1996; Liebowitz, 1997). Panic disorder is also concomitantly diagnosed, or co-occurs, with other specific anxiety disorders, including social phobia (up to 30 percent), generalized anxiety disorder (up to 25 percent), specific phobia (up to 20 percent), and obsessive-compulsive disorder (up to 10 percent) (DSM-IV). As discussed subsequently, approximately one-half of people with panic disorder at some point develop such severe avoidance as to warrant a separate description, panic disorder with agoraphobia. Panic disorder is about twice as common among women as men (American Psychiatric Association, 1998). Age of onset is most common between late adolescence and midadult life, with onset relatively uncommon past age 50. There is developmental continuity between the anxiety syndromes of youth, such as separation anxiety disorder. Typically, an early age of onset of panic disorder carries greater risks of comorbidity, chronicity, and impairment. Panic disorder is a familial condition and can be distinguished from depressive disorders by family studies (Rush et al., 1998).
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