The essential feature of 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 13 physical and cog- nitive symptoms occur. Eleven of these 13 symptoms are physical (e.g., palpitations, sweat- ing), while two are cognitive (i.e., fear of losing control or going crazy, fear of dying). ”Fear of going crazy” is a colloquialism often used by individuals with panic attacks and is not in- tended as a pejorative or diagnostic term. The term within minutes means that the time to peak intensity is literally only a few minutes. A panic attack can arise from either a calm state or an anxious state, and time to peak intensity should be assessed independently of any preceding anxiety. That is, the start of the panic attack is the point at which there is an abrupt increase in discomfort rather than the point at which anxiety first developed. Likewise, a panic attack can return to either an anxious state or a calm state and possibly peak again. A panic attack is dis- tinguished from ongoing anxiety by its time to peak intensity, which occurs within minutes; its discrete nature; and its typically greater severity. Attacks that meet all other criteria but have fewer than four physical and / or cognitive symptoms are referred to as limited—symptom attacks.
There are two characteristic types of panic attacks: expected and unexpected. Expected panic attacks are attacks for which there is an obvious cue or trigger, such as situations in which panic attacks have typically occurred. Unexpected panic attacks are those for which there is no obvious cue or trigger at the time of occurrence (e.g., when relaxing or out of sleep [nocturnal panic attack]). The determination of whether panic attacks are expected or unexpected is made by the clinician, who makes this judgment based on a combination 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 ap- parent reason. Cultural interpretations may inﬂuence their determination as expected or unexpected. Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncon- trollable screaming or crying) may be seen; however, such symptoms should not count as one of the four required symptoms. Panic attacks can occur in the context of any mental disorder (e.g., anxiety disorders, depressive disorders, bipolar disorders, eating disorders, obsessive-compulsive and related disorders, personality disorders, psychotic disorders, substance use disorders) and some medical conditions (e.g., cardiac, respiratory, vestibu- lar, gastrointestinal), with the majority never meeting criteria for panic disorder. Recur- rent unexpected panic attacks are required for a diagnosis of panic disorder.
One type of unexpected panic attack is a nocturnal panic attack (i.e., waking from sleep in a state of panic), which differs from panicking after fully waking from sleep. Panic attacks are related to a higher rate of suicide attempts and suicidal ideation even when comorbid- ity and other suicide risk factors are taken into account.
In the general population, 12-month prevalence estimates for panic attacks in the United
States is 11.2% in adults. Twelve-month prevalence estimates do not appear to differ sig- nificantly among African Americans, Asian Americans, and Latinos. Lower 12-month prevalence estimates for European countries appear to range from 2.7% to 3.3%. Females are more frequently affected than males, although this gender difference is more pro- nounced for panic disorder. Panic attacks can occur in children but are relatively rare until the age of puberty, when the prevalence rates increase. The prevalence rates decline in older individuals, possibly reﬂecting diminishing severity to subclinical levels.