The mean age at onset for panic attacks in the United States is approximately 22—23 years among adults. However, the course of panic attacks is likely inﬂuenced by the course of any co-occurring mental disorder(s) and stressful life events. Panic attacks are uncommon, and unexpected panic attacks are rare, in preadolescent children. Adolescents might be less willing than adults to openly discuss panic attacks, even though they present with ep- isodes of intense fear or discomfort. Lower prevalence of panic attacks in older individuals may be related to a weaker autonomic response to emotional states relative to younger in- dividuals. Older individuals may be less inclined to use the word ”fear” and more inclined to use the word ”discomfort” to describe panic attacks. Older individuals with ”panicky feelings” may have a hybrid of limited-symptom attacks and generalized anxiety. In addition, older individuals tend to attribute panic attacks to certain situations that are stressful (e.g., medical procedures, social settings) and may retrospectively endorse expla- nations for the panic attack even if it was unexpected in the moment. This may result in un- der-endorsement of unexpected panic attacks in older individuals.
Temperamental. Negative affectivity (neuroticism) (i.e., proneness to experiencing neg- ative emotions) and anxiety sensitivity (i.e., the disposition to believe that symptoms of anxiety are harmful) are risk factors for the onset of panic attacks. History of "fearful spells” (i.e., limited-symptom attacks that do not meet full criteria for a panic attack) may be a risk factor for later panic attacks.
Environmental. Smoking is a risk factor for panic attacks. Most individuals report iden- tifiable stressors in the months before their first panic attack (e.g., interpersonal stressors and stressors related to physical well-being, such as negative experiences with illicit or prescription drugs, disease, or death in the family).
Cultural interpretations may inﬂuence the determination of panic attacks as expected or unexpected. Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, and un- controllable screaming or crying) may be seen; however, such symptoms should not count as one of the four required symptoms. Frequency of each of the 13 symptoms varies cross- culturally (e.g., higher rates of paresthesias in African Americans and of dizziness in sev- eral Asian groups). Cultural syndromes also inﬂuence the cross-cultural presentation of panic attacks, resulting in different symptom profiles across different cultural groups. Ex- amples include khyfil (wind) attacks, a Cambodian cultural syndrome involving dizziness, tinnitus, and neck soreness; and triing gié (wind-related) attacks, a Vietnamese cultural syndrome associated with headaches. Ataque de nervios (attack of nerves) is a cultural syn- drome among Latin Americans that may involve trembling, uncontrollable screaming or crying, aggressive or suicidal behavior, and depersonalization or derealization, and which may be experienced for longer than only a few minutes. Some clinical presentations of ataque de nervios fulfill criteria for conditions other than panic attack (e.g., other specified dissociative disorder). Also, cultural expectations may inﬂuence the classification of panic attacks as expected or unexpected, as cultural syndromes may create fear of certain situa- tions, ranging from interpersonal arguments (associated with atuque de nervios), to types of exertion (associated with khyfil attacks), to atmospheric wind (associated with tning gié at- tacks). Clarification of the details of cultural attributions may aid in distinguishing ex- pected and unexpected panic attacks. For more information about cultural syndromes, see ”Glossary of Cultural Concepts of Distress" in the Appendix to this manual.
Panic attacks are more common in females than in males, but clinical features or symp- toms of panic attacks do not differ between males and females.