What are the changes in the diagnostic criteria for panic disorder across the Diagnostic and Statistical Manual of Mental Disorders (DSM) versions III, III‑R (Text Revision), IV, V, V‑TR (Text Revision), and the International Classification of Diseases (ICD) versions X and XI?

Evolution of Panic Disorder Diagnostic Criteria Across DSM and ICD Versions

DSM-III (1980): Initial Recognition as Distinct Entity

Panic disorder first appeared as a specific diagnostic entity in DSM-III (1980), marking the separation of classical anxiety neurosis into two distinct disorders: panic disorder and generalized anxiety disorder. 1

• The primary distinguishing criterion was the presence or absence of panic attacks in the patient's history 1
• Agoraphobia was classified as an independent anxiety disorder, defined by fear and avoidance of being alone or in public places from which escape might be difficult 2
• The diagnosis focused on recurrent panic attacks as the core feature 1

DSM-III-R (1987): Reclassification of Agoraphobia

• Agoraphobia was reclassified as a sequela of panic disorder rather than an independent entity, removing it as a separate classification 2
• This change reflected emerging research suggesting agoraphobia was a secondary response to panic disorder, with fear and avoidance primarily due to fear of developing panic-like symptoms 2
• Inter-rater reliability for specific phobia diagnoses was lower than in subsequent versions 2

DSM-IV (1994): Three-Category System

DSM-IV introduced three distinct diagnoses related to panic and agoraphobia: panic disorder without agoraphobia, panic disorder with agoraphobia, and agoraphobia without history of panic disorder. 2

• This revision acknowledged that agoraphobia could exist independently, though rarely, in the absence of panic symptoms 2
• Agoraphobia without history of panic disorder was characterized by avoidance resulting from "fear of incapacitation or humiliation due to unpredictable, sudden, panic-like symptoms rather than from fear of a full panic attack" 2
• The definition of panic attacks remained relatively constant across DSM versions 1
• Inter-rater reliability for principal diagnoses improved markedly to kappa = 0.86 2, 3
• The most frequent source of diagnostic disagreement (62%) involved clinicians' judgments about whether impairment and distress met diagnostic thresholds 2, 3

Key DSM-IV Criteria Evolution

• Panic disorder was redefined from simply recurrent panic attacks to a disorder characterized by chronic anxiety focused on the risk of future panic attacks with symptoms of autonomic dysregulation 1
• Required that at least one panic attack be followed by: persistent fear of additional attacks, concerns about implications or consequences of attacks, or major behavioral changes related to attacks 1
• Panic attacks were reconceptualized as a syndrome not specific to panic disorder 1

DSM-5 (2013): Major Criterion Refinements

DSM-5 eliminated the requirement that adults recognize their fear as excessive or unreasonable, acknowledging that insight varies and is not essential for diagnosis. 3

Specific Criterion Changes:

• Criterion A: Changed to require "marked (intense) fear," removing the ambiguous term "persistent" and operationalizing "marked" as "intense" 2, 3
• Criterion B: Replaced "anxiety response" with "fear response" and changed "phobic stimulus" to "phobic object or situation" to align with the acute fear characteristic of panic-related phobias 2, 3
• Criterion C: Restructured to state the phobic object or situation is "actively avoided or endured with intense fear," emphasizing active avoidance and substituting "fear" for "anxiety or distress" 2, 3
• Exclusionary criterion: Reworded to state fear/avoidance "is not restricted to another mental disorder" rather than "not better accounted for" 3

Duration Requirements:

• Maintained the 6-month minimum duration requirement for individuals under 18 years 3
• This sparked ongoing debate because 6 months represents a substantial portion of a child's life while no comparable duration threshold exists for adults, potentially creating diagnostic inconsistency 3

DSM-5-TR (2022): Minimal Changes

• The DSM-5-TR retained the same subtype specifiers and classification framework established in DSM-5 3
• No major criterion revisions were implemented for panic disorder 3

ICD-10: Conservative Approach

ICD-10 maintains a more conservative position, continuing to consider agoraphobia as a key symptom and listing agoraphobia and panic disorder as separate diagnoses that sometimes co-occur. 2

• When both conditions are present, the diagnostic coding is agoraphobia with panic disorder 2
• This contrasts with the DSM approach that prioritizes panic disorder as primary 2

ICD-11: Continued Separation

• ICD-11 continues to list agoraphobia and panic disorder as separate diagnoses that can co-occur 2
• This reflects ongoing international consensus that agoraphobia frequently occurs independently of panic disorder or panic-like symptoms 2

Critical Diagnostic Evolution: Agoraphobia Independence

Longitudinal research has demonstrated that over half of individuals with agoraphobia never meet criteria for panic disorder and fail to meet criteria even for liberally defined panic-like symptoms. 2

• A 10-year longitudinal study of 3,021 subjects found that while panic disorder and panic-like symptoms increase odds of developing agoraphobia, they are not necessary components 2
• Clinical reappraisal studies found that 72.8% of individuals reporting only one feared agoraphobic situation were actually better diagnosed with specific phobia rather than agoraphobia 2

Common Diagnostic Pitfalls

• Vague terms such as "marked," "persistent," and "excessive or unreasonable" in earlier DSM versions contributed to reliability problems; DSM-5's operationalization was intended to mitigate these issues 2, 3
• Requiring clinically significant functional impairment may overlook individuals who successfully avoid feared situations yet experience intense fear, raising concerns about under-diagnosis 2, 3
• Panic disorder is frequently undiagnosed in medical settings, particularly when presenting with prevalent somatic expression without cognitive symptoms, especially in cardiology contexts 4
• The distinction between panic disorder and generalized anxiety disorder can be difficult due to paucisymptomatic panic attacks whose paroxystic nature is hard to distinguish from fluctuations of generalized anxiety 4