B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following: 1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).
2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).
C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, car- diopulmonary disorders).
D. The disturbance is not better explained by another mental disorder (e.g., the panic at- tacks do not occur only in response to feared social situations, as in social anxiety dis- order; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to re- minders of traumatic events, as in posttraumatic stress disorder; or in response to sep- aration from attachment figures, as in separation anxiety disorder).
Panic disorder refers to recurrent unexpected panic attacks (Criterion A). A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four or more of a list of 13 physical and cognitive symptoms occur.
The term recurrent literally means more than one unexpected panic attack. The term unex— pected refers to a panic attack for which there is no obvious cue or trigger at the time of oc- currence—that is, the attack appears to occur from out of the blue, such as when the individual is relaxing or emerging from sleep (nocturnal panic attack). In contrast, expected panic attacks are attacks for which there is an obvious cue or trigger, such as a situation in which panic attacks typically occur. The determination of whether panic attacks are ex- pected or unexpected is made by the clinician, who makes this judgment based on a com- bination of careful questioning as to the sequence of events preceding or leading up to the attack and the individual’s own judgment of whether or not the attack seemed to occur for no apparent reason. Cultural interpretations may inﬂuence the assignment of panic at- tacks as expected or unexpected (see section ”Culture-Related Diagnostic Issues" for this disorder). In the United States and Europe, approximately one-half of individuals with panic disorder have expected panic attacks as well as unexpected panic attacks. Thus, the presence of expected panic attacks does not rule out the diagnosis of panic disorder. For more details regarding expected versus unexpected panic attacks, see the text accompa- nying panic attacks (pp. 214—217).
The frequency and severity of panic attacks vary widely. In terms of frequency, there may be moderately frequent attacks (e.g., one per week) for months at a time, or short bursts of more frequent attacks (e.g., daily) separated by weeks or months without any at- tacks or with less frequent attacks (e.g., two per month) over many years. Persons who have infrequent panic attacks resemble persons with more frequent panic attacks in terms of panic attack symptoms, demographic characteristics, comorbidity with other disorders, family history, and biological data. In terms of severity, individuals with panic disorder four symptoms) attacks, and the number and type of panic attack symptoms frequently differ from one panic attack to the next. However, more than one unexpected full—symp- tom panic attack is required for the diagnosis of panic disorder.