Quick Reference Guide: DSM-5 Diagnosis of Panic Attacks and Anxiety Disorders
Panic Attack Criteria (DSM-5)
A panic attack is an abrupt surge of intense fear or discomfort that peaks within minutes, accompanied by at least 4 of the following 13 symptoms: 1
- Palpitations, pounding heart, or accelerated heart rate 1
- Sweating 1
- Trembling or shaking 1
- Sensations of shortness of breath or smothering 1
- Feelings of choking
- Chest pain or discomfort 1
- Nausea or abdominal distress 1
- Feeling dizzy, unsteady, lightheaded, or faint 1
- 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
Psychiatric Differentials: Diagnostic Algorithm
Step 1: Screen for Panic Disorder vs. Generalized Anxiety Disorder
Ask the key screening question: "Do you have sudden episodes where intense fear or discomfort comes on abruptly and peaks within minutes?" 1
If YES → Consider Panic Disorder
Panic Disorder diagnostic criteria: 1, 2
- Recurrent, unexpected panic attacks that arise abruptly without identifiable triggers 1
- Attacks are brief and peak within minutes 1
- At least one month of one or both of the following:
- Persistent concern or worry about additional panic attacks or their consequences
- Significant maladaptive behavioral change related to the attacks (e.g., avoidance)
- Autonomic hyperactivity dominates: palpitations, sweating, trembling, rapid breathing, tachycardia, sweaty palms 1
- The disturbance is not attributable to substances, medical conditions, or better explained by another mental disorder 3
Note: In DSM-5, panic disorder and agoraphobia are separate diagnoses and can be coded independently; comorbidity is disclosed by double diagnosis 2, 4
If NO → Consider Generalized Anxiety Disorder
Administer GAD-7 screening tool: 5, 6
| GAD-7 Score | Interpretation | Action |
|---|---|---|
| 0–4 | None/mild | Reassess as clinically indicated [5] |
| 5–9 | Moderate | Further evaluation; consider treatment [5] |
| ≥10 | Moderate-to-severe | Warrants full diagnostic assessment for GAD [5,1] |
GAD diagnostic criteria (DSM-5): 3
- Excessive anxiety and worry about multiple events or activities on most days for ≥6 months 3
- Difficulty controlling the worry 3
- At least 3 of the following 6 symptoms (only 1 required in children): 3
- Restlessness or feeling keyed up/on edge
- Being easily fatigued
- Difficulty concentrating or mind going blank
- Irritability
- Muscle tension
- Sleep disturbance
- Clinically significant distress or functional impairment in social, occupational, or other areas 3
- Not attributable to substances, medical conditions, or better explained by another mental disorder 3
Clinical pearl: GAD patients may not present with "anxiety" per se—look for multiple excessive worries, concerns, or fears that are disproportionate to actual risk (e.g., excessive fear of recurrence, worry about multiple symptoms) 5
Step 2: Evaluate for Post-Traumatic Stress Disorder (PTSD)
PTSD is now classified separately from anxiety disorders in DSM-5 but remains a critical differential 2, 7
Screen for trauma exposure and characteristic symptom clusters:
- Criterion A: Exposure to actual or threatened death, serious injury, or sexual violence 7
- Intrusion symptoms (e.g., recurrent distressing memories, nightmares, flashbacks)
- Avoidance of trauma-related stimuli
- Negative alterations in cognitions and mood
- Alterations in arousal and reactivity (e.g., hypervigilance, exaggerated startle)
- Duration >1 month with significant distress or impairment
Key distinguisher: PTSD anxiety is trauma-linked and includes re-experiencing phenomena, whereas GAD worry is generalized across multiple domains and panic disorder features unexpected attacks without clear triggers 1, 3
Medical Rule-Outs: Essential Workup
Before confirming a primary anxiety diagnosis, exclude substance- or medication-induced anxiety and medical mimics: 1, 3
Hyperthyroidism
Order: Thyroid-stimulating hormone (TSH) and free T4 8
Clinical clues favoring hyperthyroidism over GAD: 8
- Heat intolerance and weight loss despite normal/increased appetite
- Tremor (fine, rapid)
- Tachycardia at rest (often >100 bpm)
- Warm, moist skin
- Exophthalmos or lid lag (in Graves' disease)
- Absence of excessive worry across multiple domains
Symptom overlap: Both conditions share anxiety, restlessness, fatigue, difficulty concentrating, and irritability 8
Discriminant analysis: Four Hyperthyroid/Anxiety Indices have been developed with up to 100% sensitivity and specificity when carefully assessing symptom profiles; however, laboratory confirmation remains the gold standard 8
Cardiac Arrhythmias
Order: 12-lead electrocardiogram (ECG); consider 24-hour Holter monitor if paroxysmal arrhythmia suspected 9
Clinical clues favoring arrhythmia over panic disorder:
- Palpitations with documented irregular pulse or syncope
- Symptoms triggered by exertion rather than arising "out of the blue"
- Abnormal ECG findings (e.g., atrial fibrillation, supraventricular tachycardia, prolonged QT)
- Absence of psychological fear or dread during episodes
- Family history of sudden cardiac death or inherited arrhythmia syndromes
Physiologic distinction: Panic disorder exhibits lower autoregressive heart rate stability and more nonspecific heart rate accelerations during sleep compared to healthy controls, but these are research findings, not diagnostic tests 10
Other Medical Mimics to Consider
Rule out the following with targeted history and testing: 3, 9
- Substance-induced anxiety: Caffeine excess, stimulants (amphetamines, cocaine), cannabis, alcohol or benzodiazepine withdrawal 1, 3
- Medication-induced anxiety: Corticosteroids, bronchodilators, decongestants
- Hypoglycemia: Check fasting glucose or glucose during symptomatic episode
- Pheochromocytoma: 24-hour urine metanephrines if episodic hypertension, headache, sweating triad
- Vestibular disorders: Dizziness with positional triggers, nystagmus
- Seizure disorders: Temporal lobe epilepsy can mimic panic attacks
- Chronic obstructive pulmonary disease (COPD) or asthma: Dyspnea with objective pulmonary findings
Screening Tools Summary
| Tool | Purpose | Cutoff | Sensitivity/Specificity | Citation |
|---|---|---|---|---|
| GAD-7 | Screen for GAD | ≥10 | High validity in primary care | [5,6,1] |
| GAD-2 | Ultra-short GAD screen | ≥3 | Sens 89%, Spec 90% (LR+ 5.1) | [6] |
| Patient Health Questionnaire for PD | Screen for panic disorder | Validated | Aids diagnosis and severity | [9] |
| APA Level 1 Cross-Cutting Symptom Measures | Systematic screening for both PD and GAD | Multiple domains | Comprehensive assessment | [1] |
Common Pitfalls and Clinical Safeguards
- Do not diagnose GAD when worry is better explained by another disorder (e.g., worry about having panic attacks should be diagnosed as panic disorder, not GAD) 3
- Panic disorder requires unexpected attacks—if attacks are situationally bound (e.g., only in social situations), consider social anxiety disorder with panic attack specifier 1, 11
- Assess for comorbid substance use disorders, which are common and should be treated concurrently 9
- Cultural considerations: Somatic symptoms (palpitations, shortness of breath, dizziness, indigestion) may predominate in non-Western cultures; bilingual patients may emphasize somatic complaints in certain languages 3
- Pediatric modifications: Children require only 1 associated symptom (not 3) for GAD diagnosis; anxiety may manifest as crying, tantrums, freezing, or clinging 3
- Benzodiazepines are not recommended for first-line or long-term therapy due to adverse reactions, dependence risk, and higher mortality 9