304 Panic Disorder and Agoraphobia
DSM-IV-TR Criteria
Of all the anxiety disorders, panic disorder is set to undergo the most changes in the proposed DSM-5. In the DSM-IV, there are three separate diagnoses, Panic Disorder with Agoraphobia, Panic Disorder without Agoraphobia, and Agoraphobia without History of Panic Disorder, while the DSM-5 proposes to have only two: Panic Disorder and Agoraphobia. As such, this section will be a bit different from the other anxiety disorders, in that I will detail information about DSM-IV panic attacks, agoraphobia, panic disorder, and then discuss the etiology, treatments, and DSM-5 changes that are proposed across all three.
Panic Attack
DSM-IV-TR Criteria
NOTE: A panic attack is not a codeable 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
- 2. Sweating
- 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. De-realization (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 sensation)
- 13. Chills or hot flashes
Associated Features
Panic attacks (PA) are actually fairly common across all the anxiety disorders, but are especially prevalent in the phobias and post-traumatic stress disorder. They usually last several minutes and can mimic signs of a heart-attack to those not familiar with them. The most commonly reported PA symptoms are heart-pounding and dizziness, although there is great variability among PA, even in the same person (as indicated by the large number of possible symptoms). The least common symptoms (paresthesias, choking, and fear of dying) are indicative of more severe PA problems and likelihood of reoccurrence. Also, the higher number of symptoms, the more severe the PA will be. In fact, one’s risk for suicide attempts and emergency room use was elevated by 20% for each additional PA symptom above the four. If a person has less than four of the PA symptoms listed above, it is referred to as a “limited panic attack.”
Recent research has shown that, contrary to previous beliefs, there are not significant differences in people who are “early peakers” (symptom severity reaches highest level prior to 10 minutes) and “late peakers” (those who have highest severity after 10 minutes). This is reflected in the proposed changes for DSM-5, as discussed below. Having a PA actually puts one at an increased risk for developing other anxiety disorders, even though they are relatively common (see “Epidemiology” below).
There are three