What are the diagnostic criteria for Panic Disorder, Episodic, in a patient with mellow anxiety and nocturnal panic attacks?

Diagnostic Criteria for Panic Disorder

To diagnose Panic Disorder, the patient must have recurrent unexpected panic attacks followed by at least one month of persistent concern about additional attacks, worry about their implications, or significant behavioral changes related to the attacks. 1

Core Diagnostic Requirements

Panic Attack Definition

• A panic attack is an abrupt surge of intense fear or discomfort that reaches a peak within minutes, accompanied by four or more of the following symptoms: 2

  • Palpitations 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)
  • Derealization or depersonalization
  • Fear of losing control or "going crazy"
  • Fear of dying

• The abrupt surge can occur from either a calm state or an anxious state, clarifying that panic attacks may arise from baseline anxiety or worry episodes 2

Panic Disorder Specific Criteria

The diagnosis requires recurrent panic attacks where at least one attack is followed by one month or more of:1, 3

1. Persistent concern or worry about having additional panic attacks 1
2. Worry about the implications or consequences of the panic attacks (e.g., losing control, having a heart attack, "going crazy") 1
3. Significant maladaptive behavioral changes related to the attacks (e.g., avoidance of exercise, unfamiliar situations) 1

The "Unexpected" Attack Criterion

• At least one panic attack must be unexpected (uncued) to distinguish Panic Disorder from other anxiety disorders 2
• Unexpected attacks occur "out of the blue" without an obvious trigger or situational cue 2
• This distinguishes Panic Disorder from situationally-bound panic attacks seen in specific phobias or social anxiety disorder 2

Important caveat: Cultural factors may influence whether patients perceive their attacks as expected versus unexpected, as cultural syndromes can create anticipatory anxiety that makes attacks seem cued 2

Episodic Specifier

The term "episodic" in your question likely refers to the course pattern rather than a formal DSM specifier. Panic Disorder is inherently episodic by nature, characterized by discrete panic attacks rather than continuous anxiety 1, 4

Differential Diagnosis Considerations

Rule Out Medical Conditions

• Cardiac symptoms (chest pain, tachycardia), neurologic symptoms (headache, dizziness, syncope), and gastrointestinal symptoms are the most common presentations that require medical workup 5
• However, diagnosis should be made positively by identifying diagnostic symptoms rather than negatively by eliminating other conditions 6

Distinguish From Other Anxiety Disorders

• Panic attacks can occur in multiple anxiety disorders, but Panic Disorder specifically requires unexpected attacks 2
• In specific phobias, attacks are situationally bound to the phobic stimulus 2
• In social anxiety disorder, attacks are triggered by social scrutiny situations 7
• In PTSD, attacks are typically triggered by trauma reminders 2

Assess for Comorbidities

• Screen for major depression using PHQ-9, as 50-60% of panic disorder patients have comorbid depression 8
• Evaluate for alcohol abuse and substance use disorders, which frequently complicate panic disorder 5, 8
• Assess for other anxiety disorders, as approximately 50-60% of patients with one anxiety disorder meet criteria for another 8

Clinical Presentation in Your Case

For a patient with "mellow anxiety and nocturnal panic attacks":

• The nocturnal panic attacks (occurring during sleep) are classic unexpected panic attacks, as they have no obvious situational trigger 1
• The "mellow anxiety" between attacks likely represents the persistent concern about future attacks required for Panic Disorder diagnosis 1
• Nocturnal panic attacks are particularly distressing and strongly suggest Panic Disorder rather than situationally-triggered anxiety 4

Functional Impairment Requirement

• The panic attacks and associated anxiety must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 1, 4
• This impairment distinguishes clinically significant Panic Disorder from isolated panic attacks that may occur in the general population 1

Common Diagnostic Pitfalls

• Do not wait to exclude all medical conditions before making a positive diagnosis—if the symptom pattern clearly fits panic disorder criteria, diagnose it positively 6
• Do not miss comorbid depression—systematically screen with PHQ-9 or direct questioning about depressive symptoms 8
• Do not overlook substance use, particularly alcohol, which patients may use to self-medicate panic symptoms 5, 8
• Recognize that patients often focus on one frightening somatic symptom (chest pain, dizziness) rather than reporting the full panic syndrome, leading to misdiagnosis 5