History and exam

Key diagnostic factors

common

presence of risk factors

Age 20 to 30 years, female sex, white ethnicity, positive family history, other psychological factors, major life stressors or a history of recent trauma, asthma, comorbid disorders.

unexpected onset

Brief period of intense physical and psychological symptoms that occur unexpectedly.

Up to 70% of patients report at least 1 nocturnal panic attack.

apprehension and worry

Excessive concern about the dangers of somatic (e.g., fear of having heart attack or dying) and psychological (e.g., fear of losing control) symptoms.

Worry about recurrence of attacks.

behavioural avoidance

Avoidance of external situations (e.g., crowds) and internal sensations (e.g., exercising) due to fears of provoking panic attacks.

tachycardia

Increased heart rate on exposure or anticipated exposure to phobic cue.

Most commonly reported panic symptom.

positive PRIME-MD panic screen

The PRIME-MD panic screen contains 4 'yes or no' questions to assess the presence of panic attacks within the last 4 weeks. Responding 'yes' to all 4 questions indicates likely presence of panic disorder. The panic screen also includes 11 somatic and cognitive symptoms, with endorsement of at least 4 of these symptoms indicative of likely panic disorder.[73]

Panic Disorder Severity Scale (PDSS)

A 7-item measure assessing the frequency, avoidance, degree of distress, and functional impairment of panic attacks. Items are scored on a 0-4 scale, with higher scores indicative of greater panic severity. Among patients with panic disorders without agoraphobia, scores of 0-1 are considered normal, 2-5 borderline ill, 6-9 slightly ill, 10-13 moderately ill, 14-16 markedly ill, and 17+ severely ill.[74]

GAD-7 cute score ≥10

The GAD-7 is a brief self-report measure for assessing anxiety severity in primary care. In total, 7 items are scored on a 0 to 3 scale, with a cut score of ≥10 indicative of a likely anxiety disorder.[10][75] Although designed as a measure of generalised anxiety, the GAD-7 is sensitive in detecting panic-related symptoms.

Other diagnostic factors

common

palpitations; chest pain and discomfort

May present with atypical chest pain and a pounding heart.

Cardiac work-up is unremarkable.

nausea and abdominal pain

Gastrointestinal symptoms are more commonly reported among men.

dizziness

Patient may experience dizziness, lightheadedness, instability, and feeling faint.

perceptual abnormality

Feelings of de-realisation (i.e., feeling detached from one's surroundings) and depersonalisation (i.e., feeling detached from oneself).

respiratory symptoms

Hyperventilation, shortness of breath, smothering sensations, and a feeling of choking.

reliance on safety cues

Venturing out with trusted companions, holding on to objects to stabilise oneself, always carrying a mobile phone, having rescue medications readily available, or using medication when entering social situations.

paraesthesias

Numbing or tingling sensations in extremities.

Typically more common with more intense panic sensations.

muscle shaking

Muscle trembling or shaking in extremities.

May contribute to imbalance fears.

uncommon

sweating

May be localised (palms) or diffuse.

fainting

Fear of fainting common during panic attacks.

Actual fainting episodes are uncommon.

chills or hot flushes

May report independent or co-occurring chills and hot flushes.

Risk factors

strong

history in first-degree relatives

Familial heritability among first-degree relatives with panic disorder confers a fivefold elevation in risk.

30% to 50% of twin heritability is accounted for by shared genetics.[22][24]

Multiple genes are likely to contribute to panic vulnerability.[24][25]

age 18 to 39 years

Panic attacks are most likely to develop during the early to mid-20s, with the highest rates between 30 and 39 years of age, and may be preceded by significant negative life events.[2][29]

female sex

Approximately 2 to 3 times more common among women than men.[47][48]

white and Native American ethnicity

Risk higher among Native Americans and lower among Asian, Hispanic, and black people relative to white people.[47][48]

major life events

Major negative life events prior to panic onset are reported in approximately 80% of patients.[29]

A history of trauma is common, especially in women.[30]

comorbid disorders

Highly comorbid with other anxiety, mood, and substance use disorders.[8][16][49] Comorbidity with depression may signify a more severe and longer-term course of illness, with panic attacks being independently associated with an increased risk of suicidal thoughts and suicide attempts.[20][21]

psychological factors

Anxiety sensitivity may predispose individuals to overly monitor somatic functioning and catastrophically misinterpret physical sensations as dangerous.[37]

Learned escape, avoidance, and safety behaviours contribute to increasing anticipatory anxiety and functional impairments.[34]

Early temperamental factors, such as behavioural inhibition and childhood anxiety disorders, are associated with elevated panic risk in adulthood.[35][36]

asthma and respiratory variability

Asthma severity appears to be associated with an incremental risk for panic disorder.[50] Respiratory variability may also increase risk for later onset panic disorder.[51]

cigarette smoking

Nicotine use and dependence is disproportionately high among patients with panic disorder, and may be temporally related to elevated risk for developing panic disorder.[52]

caffeine use

Caffeine use has been found to be positively associated with increased anxiety symptoms and risk of inducing panic attacks among panic disorder patients.[53]

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