What are the diagnostic criteria and treatment options for Panic Disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5 TR)?

DSM-5-TR Diagnostic Criteria for Panic Disorder

Panic Disorder is diagnosed when recurrent unexpected panic attacks are followed by at least one month of persistent concern about additional attacks, worry about their implications, or significant maladaptive behavioral changes related to the attacks. 1

Core Diagnostic Requirements

A panic attack is defined as an abrupt surge of intense fear or discomfort that reaches a peak within minutes, during which four or more of the following symptoms occur: 1

• Palpitations, pounding heart, or accelerated heart rate
• Sweating
• Trembling or shaking
• Sensations of shortness of breath or smothering
• Feelings of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, lightheaded, or faint
• Chills or heat sensations
• Paresthesias (numbness or tingling sensations)
• Derealization (feelings of unreality) or depersonalization (being detached from oneself)
• Fear of losing control or "going crazy"
• Fear of dying

For Panic Disorder diagnosis, at least one panic attack must be followed by one or more of the following for at least one month: 1

• Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, "going crazy")
• Significant maladaptive change in behavior related to the attacks (e.g., avoidance of exercise or unfamiliar situations)

Critical Distinction: Expected vs. Unexpected Attacks

The diagnosis requires that at least some panic attacks are unexpected (uncued), meaning they occur without an obvious trigger or cue. 1 This distinguishes Panic Disorder from panic attacks that occur exclusively in response to specific phobic objects or situations, which would suggest a different anxiety disorder diagnosis. 2

Essential Exclusion Criteria

The panic attacks and subsequent anxiety cannot be attributable to: 3, 4

• Medical conditions that must be systematically ruled out include hyperthyroidism, hypoglycemia, cardiac arrhythmias, asthma, migraines, and other endocrine, cardiac, or respiratory disorders 4
• Substance/medication effects including caffeine excess, illicit drug use, alcohol withdrawal, or medication side effects 4
• Another mental disorder that better explains the presentation, such as social anxiety disorder (panic only in social situations), specific phobia (panic only with phobic stimulus), OCD (panic only in response to obsessions), PTSD (panic only with trauma reminders), or separation anxiety disorder 3, 4

Relationship with Agoraphobia

Panic Disorder and Agoraphobia are now separate diagnoses in DSM-5 and can be coded independently or as comorbid conditions. 5 Agoraphobia involves fear or anxiety about situations where escape might be difficult or help unavailable should panic-like symptoms occur, and can exist with or without Panic Disorder. 3, 4

Duration and Impairment Requirements

The disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 3, 4 Unlike some other anxiety disorders, there is no specific 6-month duration requirement for Panic Disorder; the one-month criterion for persistent concern or behavioral change following attacks is sufficient. 1

Systematic Comorbidity Assessment

Clinicians must systematically evaluate for commonly co-occurring conditions: 3, 4

• Major depressive disorder (very common comorbidity)
• Other anxiety disorders (generalized anxiety disorder, social anxiety disorder, specific phobias)
• Agoraphobia (present in approximately 30-50% of Panic Disorder cases)
• Substance use disorders
• PTSD, bipolar disorder, ADHD, OCD

Structured Diagnostic Approach

Use structured diagnostic interviews to confirm DSM-5 criteria, with the Anxiety Disorders Interview Schedule (ADIS) considered the gold standard for anxiety disorder assessment. 2, 4 The K-SADS-PL DSM-5 is a freely available alternative that includes comprehensive panic disorder assessment sections. 2

For initial screening, the GAD-7 can be used, with scores ≥10 indicating moderate to severe anxiety requiring comprehensive diagnostic evaluation. 3, 4

Cultural Considerations

The "unexpectedness" criterion for panic attacks may have limited cross-cultural validity, as some cultural contexts may interpret panic symptoms differently. 2 The 10-minute crescendo criterion and emphasis on psychological symptoms may not capture all culturally valid presentations of panic. 2

Common Diagnostic Pitfalls

Avoid misdiagnosing medical conditions as Panic Disorder: Cardiac arrhythmias, hyperthyroidism, and other medical conditions can present identically to panic attacks and must be ruled out through appropriate medical evaluation. 4

Do not diagnose Panic Disorder if attacks occur exclusively in specific situations: If panic attacks only occur in social situations, consider social anxiety disorder; if only with specific objects/situations, consider specific phobia. 3, 4

Recognize that panic attacks can occur as a specifier across multiple DSM-5 diagnoses: The presence of panic attacks does not automatically indicate Panic Disorder—the pattern of unexpected attacks with subsequent persistent concern is essential. 1