The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) is a guide to the diagnosis of mental disorders in the United States. The following are a list of the criteria for Panic Disorder. Please note: although these criteria are designed to provide a guideline to diagnosis they cannot substitute a visit to a doctor or mental health practitioner. These guidelines are provided for information purposes only.

DIAGNOSTIC CRITERIA FOR A PANIC ATTACK

Note: a Panic Attack is not a codable disorder.

sweating

trembling or shaking

sensations of shortness of breath or smothering

feeling of choking

chest pain or discomfort

nausea or abdominal distress

feeling dizzy, unsteady, lightheaded, or faint

derealization (feelings of unreality) or depersonalization (being detached from oneself)

fear of losing control or going crazy

fear of dying

paresthesias (numbing or tingling sensations)

chills or hot flushes

DIAGNOSTIC CRITERIA FOR PANIC DISORDER WITHOUT AGORAPHOBIA

A. Both (1) and (2):

Recurrent unexpected Panic Attacks

At least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:

persistent concern about having additional attacks

worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")

a significant change in behavior related to the attacks

B. Absence of Agoraphobia

C. The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

D. The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).

Diagnostic Features

The essential feature of Panic Disorder is the presence of recurrent, unexpected Panic Attacks followed by at least 1 month of persistent concern about having another Panic Attack, worry about the possible implications or consequences of the Panic Attacks, or a significant behavioral change related to the attacks (Criterion A). The Panic Attacks are not due to the direct physiological effects of a substance (e.g., Caffeine Intoxication) or a general medical condition (e.g., hyperthyroidism) (Criterion C). Finally, the Panic Attacks are not better accounted for by another mental disorder (e.g., Specific or Social Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, or Separation Anxiety Disorder) (Criterion B).

An unexpected (spontaneous, uncued) Panic Attack is defined as one that is not associated with a situational trigger (i.e., it occurs "out of the blue"). At least two unexpected Panic Attacks are required for the diagnosis, but most individuals have considerably more. Individuals with Panic Disorder frequently also have situationally predisposed Panic Attacks (i.e., those more likely to occur on, but not invariably associated with, exposure to a situational trigger). Situationally bound attacks (e.g., those that occur almost invariably and immediately on exposure to a situational trigger) can occur but are less common.

The frequency and severity of the Panic Attacks vary widely. For example, some individuals have moderately frequent attacks (e.g., once a week) that occur regularly for months at a time. Others report short bursts of more frequent attacks (e.g., daily for a week) separated by weeks or months without any attacks or with less frequent attacks (e.g., two each month) over many years. Limited-symptom attacks (i.e., attacks that are identical to "full" Panic Attacks except that the sudden fear or anxiety is accompanied by fewer than 4 of the 13 additional symptoms) are very common in individuals with Panic Disorder. Although the distinction between full Panic Attacks and limited-symptom attacks is somewhat arbitrary, full Panic Attacks are associated with greater morbidity. Most individuals who have limited-symptom attacks have full Panic Attacks at some time during the course of the disorder.

Individuals with Panic Disorder display characteristic concerns or attributions about the implications or consequences of the Panic Attacks. Some fear that the attacks indicate the presence of an undiagnosed, life-threatening illness (e.g., cardiac diseases, seizure disorder). Despite repeated medical testing and reassurance, they may remain frightened and unconvinced that they do not have a life-threatening illness. Others fear that the Panic Attacks are an indication that they are "going crazy" or losing control or are emotionally weak. Some individuals with recurrent Panic Attacks significantly change their behavior (e.g., quit a job) in response to the attacks, but deny either fear of having another attack or concerns about the consequences of their Panic Attacks. Concerns about the next attack, or its implications, are often associated with development of avoidant behavior that may meet criteria for Agoraphobia, in which case Panic Disorder With Agoraphobia is diagnosed.

Prevalence

Epidemiological studies throughout the world consistently indicate the lifetime prevalence of Panic Disorder (With or Without Agoraphobia) to be between 1.5% and 3.5%. One-year prevalence rates are between 1% and 2%. Approximately one-third to one-half of individuals diagnosed with Panic Disorder in community samples also have Agoraphobia, although a much higher rate of Agoraphobia is encountered in clinical samples.

Course

Age at onset for Panic Disorder varies considerably, but is most typically between late adolescence and the mid-30s. There may be a bimodal distribution, with one peak in late adolescence and a second smaller peak in the mid-30s. A small number of cases begin in childhood, and onset after age 45 years is unusual but can occur. Retrospective descriptions by individuals seen in clinical settings suggest that the usual course is chronic but waxing and waning. Some individuals may have episodic outbreaks with years of remission in between, and others may have continuous severe symptomatology. Although Agoraphobia may develop at any point, its onset is usually within the first year of occurrence of recurrent Panic Attacks. The course of Agoraphobia and its relationship to the course of Panic Attacks are variable. In some cases, a decrease or remission of Panic Attacks may be followed closely by a corresponding decrease in agoraphobic avoidance and anxiety. In others, Agoraphobia may become chronic regardless of the presence or absence of Panic Attacks by avoiding certain situations. Naturalistic follow-up studies of individuals treated in tertiary care settings (which may select for a poor-prognosis group) suggest that, at 6-10 years post-treatment, about 30% of individuals are well, about 30% of individuals are well, 40%-50% are improved but symptomatic, and the remaining 20%-30% have symptoms that are the same or slightly worse.

Anxiety relief: natural treatments for anxiety

Relief from chronic anxiety comes from restoring your body’s natural, healthy equilibrium. You can do that through change in a number of factors: lifestyle, diet, allergies, exercise levels, hormonal balance, general physical health, and your emotional history.

At our practice, we treat anxiety with nutrition and nutritional supplements, some prescription medications, emotional work and bodywork. Let’s review these methods for anxiety relief in detail.

Good nutrition is the foundation of natural treatment for anxiety. If you are serotonin-deficient you will crave sugar and simple carbohydrates. But those foods cause your insulin levels to spike and crash, further destabilizing your mood and creating that “bottoming out” feeling. Eat real whole foods, organic when possible, that will help maintain stable blood sugar levels. Avoid all processed, artificial products, trans fats, artificial additives, simple sugars and carbohydrates (or “white” food). Add multiple servings of fiber-rich vegetables or fruit to every meal and drink plenty of filtered water.

Take a medical-grade nutritional supplement to fill in any nutritional gaps. A daily supplement that includes essential fatty acids is an important part of supporting natural neurotransmitter balance and general good health.

Take our hormonal balance profile (it’s free). It will help you understand if your anxiety is actually a symptom of perimenopause or menopause. Using progesterone cream or bioidentical HRT may be a useful way to rebalance your hormones and soothe your anxiety.

Talk to your doctor about taking a neurotransmitter test and discuss the results. Ask to see the results for yourself. At Women to Women we often supplement with certain amino acids and other nutrients that are important precursors to neurotransmitters and can be hard to eat in sufficient quantities. But don’t self-medicate with supplements to balance your neurotransmitters except under medical supervision.

Examine your diet for potential food allergies or sensitivities. If you are experiencing anxiety-related gastrointestinal problems, you may want to follow an elimination diet. To learn more, you may also want to read our articles on detox and IBS.

Physical activity is the single best anxiety medication I know. It’s just essential to hormonal balance. In one study, people who engaged in 30–60 minutes of moderate exercise every day reported less anxiety than a similar group on anti-anxiety meds who did not exercise. Start slow and build up to at least 30 minutes a day. Find a friend or a neighborhood group to exercise with — it’s more fun and you’ll be more likely to stick with it.

Get enough sunlight and fresh air. Fifteen minutes of sun exposure (without sunscreen) in the early morning and late afternoon stimulates the production of vitamin D in your body. Vitamin D deficiency is related to depression, SAD, and other mood disorders. Deep breathing helps calm the senses and relax the mind — so combine both!

Get enough sleep. Adequate sleep is paramount to brain health. Women should get 7–9 hours a night. If you have trouble sleeping, avoid all caffeine (including chocolate and green tea) and set a bedtime for yourself that you stick to. Practice a calming technique like meditation or deep breathing before bed.

If you can afford it, find a counselor to talk to about your emotional experience. Ask for a referral from a doctor, family member or friend.  Interview several to make sure you find someone you really like and trust.

Try using the Emotional Freedom Techniques, widely known as EFT.  EFT gets at the root causes of anxiety rather than masking them.

Investigate integrative manual therapy (IMT) . Using gentle applied pressure, IMT opens up blocked energy channels to help the body do what it does best — heal itself. Anxiety is in a sense blocked energy, and bodywork helps redirect that energy constructively.

If you are paralyzed by catastrophic thoughts and debilitating physical symptoms of anxiety, talk to your healthcare professional about the usefulness of short-term medication. If your doctor does not offer additional support techniques to help you in the long term, look around for an alternative or integrative medical practitioner. Long-term use of anti-anxiety medication will not cure you.

It’s my hope that some of this advice will help you get a handle on your feelings of anxiety before they manifest into health concerns. If you are already in the grips of chronic anxiety, don’t worry! By supporting your body, examining your past, and rebalancing your body and mind, your anxiety will get better.

Just imagine how powerful you could feel if all that energy that is consumed by anxiety and fear were unleashed in a life-affirming, positive way!