264 CHAPTER 7
Table 7.4 • DSM-IV-TR Diagnostic Criteria for Panic Disorder (Without Agoraphobia)
A. Both (1) and (2):
(1) recurrent unexpected Panic Attacks
(2) at least one of the attacks has been followed by 1 month (or more) of one (or more) of the
following:
(a) persistent concern about having additional attacks
(b) worry about the implications of the attack or its consequences (e.g., losing control, having
a heart attack, “going crazy”)
(c) a signifi cant change in behavior related to the attacksB. Absence of Agoraphobia [discussed later in this section].C. The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition (e.g., hyperthyroidism).D. The Panic Attacks are not better accounted for by another mental disorder, such as Social
Phobia (e.g., occurring on exposure to feared social situations [discussed later in this chapter]),
Specifi c Phobia (e.g., on exposure to a specifi c phobic situation [discussed later in this chapter]),
Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about
contamination [discussed later in this chapter]), Posttraumatic Stress Disorder (e.g., in response
to stimuli associated with a severe stressor [discussed later in this chapter]), or Separation Anxi-
ety Disorder (e.g., in response to being away from home or close relatives [Chapter 14]).
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Text Revision,
Fourth Edition, (Copyright 2000) American Psychiatric Association.CASE 7.2 • FROM THE OUTSIDE: Panic Disorder
S was a 28-year-old married woman with two children, aged 3 and 5 years. S had experi-
enced her fi rst panic attack approximately 1 year prior to the time of the initial assessment.
Her father had died 3 months before her fi rst panic attack; his death was unexpected, the
result of a stroke. In addition to grieving for her father, S became extremely concerned
about the possibility of herself having a stroke. S reported [that before her father’s death,
she’d never had a panic attack nor been concerned about her health.] Apparently, the loss
of her father produced an abrupt change in the focus of her attention, and a cycle of anxi-
ety began [which led to a heightened] awareness of the imminence of her own death, given
that “nothing in life was predictable.”... S became increasingly aware of different bodily
sensations. Following her fi rst panic attack, S was highly vigilant for tingling sensation in
her scalp, pain around her eyes, and numbness in her arms and legs. She interpreted all
of these symptoms as indicative of impending stroke. Moreover, because her concerns be-
came more generalized, she began to fear any signs of impending panic, such as shortness
of breath and palpitations.
Her concerns led to signifi cant changes in her lifestyle [and she avoided] unstructured
time in the event she might dwell on “how she felt” and, by so doing, panic.... S felt that her
life revolved around preventing the experience of panic and stroke.
(Craske, Barlow, & Meadows, 2000, pp. 45–46)Symptoms of panic disorder are similar across cultures, but in some cultures,
the symptoms focus on fear of magic or witchcraft (American Psychiatric Associa-
tion, 2000); in other cultures, the physical symptoms may be expressed differently.
For example, among Cambodian refugees, symptoms of panic disorder include a
fear that “wind-and-blood pressure” (referred to as wind overload) may increase to
the point of bursting the neck area, and patients may complain of a sore neck, along
with headache, blurry vision, and dizziness (Hinton, Um, & Ba, 2001).
In some cultures, people experience symptoms that are similar—but not identical—
to the classic symptoms of a panic attack. In the Caribbean, Puerto Rico, and some
areas of Latin America, an anxiety-related problem called ataque de nervios can
occur (usually in women). The most common symptoms are uncontrollable screaming
and crying attacks, together with palpitations, shaking, and numbness. An ataque