The worries about panic attacks or their consequences usually pertain to physical con- cerns, such as worry that panic attacks reﬂect the presence of life-threatening illnesses (e.g., cardiac disease, seizure disorder); social concerns, such as embarrassment or fear of being judged negatively by others because of visible panic symptoms; and concerns about mental functioning, such as "going crazy" or losing control (Criterion B). The maladaptive changes in behavior represent attempts to minimize or avoid panic attacks or their conse- quences. Examples include avoiding physical exertion, reorganizing daily life to ensure that help is available in the event of a panic attack, restricting usual daily activities, and avoiding agoraphobia-type situations, such as leaving home, using public transportation, or shopping. If agoraphobia is present, a separate diagnosis of agoraphobia is given.
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). In the United
States, this type of panic attack has been estimated to occur at least one time in roughly one-quarter to one-third of individuals with panic disorder, of whom the majority also have daytime panic attacks. In addition to worry about panic attacks and their conse- quences, many individuals with panic disorder report constant or intermittent feelings of anxiety that are more broadly related to health and mental health concerns. For example, individuals with panic disorder often anticipate a catastrophic outcome from a mild phys- ical symptom or medication side effect (e.g., thinking that they may have heart disease or that a headache means presence of a brain tumor). Such individuals often are relatively in- tolerant of medication side effects. In addition, there may be pervasive concerns about abilities to complete daily tasks or withstand daily stressors, excessive use of drugs (e.g., alcohol, prescribed medications or illicit drugs) to control panic attacks, or extreme behav- iors aimed at controlling panic attacks (e.g., severe restrictions on food intake or avoidance of specific foods or medications because of concerns about physical symptoms that pro- voke panic attacks).
In the general population, the 12-month prevalence estimate for panic disorder across the
United States and several European countries is about 2%—3% in adults and adolescents. In the United States, significantly lower rates of panic disorder are reported among Latinos,
African Americans, Caribbean blacks, and Asian Americans, compared with non-Latino whites; American Indians, by contrast, have significantly higher rates. Lower estimates have been reported for Asian, African, and Latin American countries, ranging from 0.1% to 0.8%. Females are more frequently affected than males, at a rate of approximately 2:1. The gender differentiation occurs in adolescence and is already observable before age 14 years.
Although panic attacks occur in children, the overall prevalence of panic disorder is low before age 14 years (<0.4%). The rates of panic disorder show a gradual increase during ad- olescence, particularly in females, and possibly following the onset of puberty, and peak dur- ing adulthood. The prevalence rates decline in older individuals (i.e., 0.7% in adults over the age of 64), possibly reﬂecting diminishing severity to subclinical levels.
The median age at onset for panic disorder in the United States is 20—24 years. A small number of cases begin in childhood, and onset after age 45 years is unusual but can occur.
The usual course, if the disorder is untreated, is chronic but waxing and waning. Some in- dividuals may have episodic outbreaks with years of remission in between, and others may have continuous severe symptomatology. Only a minority of individuals have full remission without subsequent relapse within a few years. The course of panic disorder typically is complicated by a range of other disorders, in particular other anxiety disor- ders, depressive disorders, and substance use disorders (see section ”Comorbidity" for this disorder).