282 TREATMENT OF SPECIFIC ANXIETY DISORDERS
behavioral explanation, studies have found an increase in physiological changes in the
minutes before panicky awaking (Hauri et al., 1989; Roy-Byrne, Mellman, & Uhde,
1988) and experimental manipulation of individuals’ expectations and interpretations
of the physiological arousal symptoms associated with sleep can influence their level
of anxiety and presence of panic attacks upon abrupt awaking (Craske et al., 2002;
see also Craske & Freed, 1995, for similar results). In addition Craske et al. (2005)
reported significant posttreatment gains at 9-month follow-up in a sample of panic
disorder patients with recurrent NPs who were offered 11 sessions of CBT. NPs, then,
are common in panic disorders and can be accommodated within the cognitive per-
spective.
Limited- Symptom Panic
DSM-IV-TR recognizes that limited- symptom attacks are common in panic disorder
and are identical to full-blown attacks except they involve fewer than 4 of 13 symptoms
(APA, 2000). The usual profile is for individuals to experience full-blown panic attacks
interspersed with frequent minor attacks, with both showing similar functional and
phenomenological characteristics (Barlow, 2002; McNally, 1994).
Nonclinical Panic
Contrary to expectations, panic attacks are actually quite common in the general
population. Questionnaire studies indicate that over one-third of nonclinical young
adults experience at least one panic attack within the past year (Norton, Dorward, &
Cox, 1986; Norton, Harrison, Hauch, & Rhodes, 1985), but only 1–3% report three
or more panic attacks in the last 3 weeks (i.e., Salge et al., 1988). Unexpected panic
attacks are less common, ranging from 7 to 28%, and far fewer (approximately 2%)
meet diagnostic criteria for panic disorder (Norton et al., 1986; Telch, Lucas, & Nel-
son, 1989). Structured interviews produce much lower rates (i.e., 13%) of nonclinical
panic (Brown & Deagle, 1992; Eaton, Kessler, Wittchen, & Magee, 1994; Hayward
et al., 1997; Norton, Cox, & Malan, 1992). However, the infrequent panic attacks of
infrequent nonclinical panickers are less severe, less pathological, and more situation-
ally predisposed than the unexpected, “crippling” attacks found in diagnosable panic
disorder (Cox, Endler, Swinson, & Norton, 1992; Norton et al., 1992; Telch et al.,
1989), leading to the possibility that a history of infrequent panic attacks might be
a possible risk factor for panic disorder (e.g., Antony & Swinson, 2000a; Brown &
Deagle, 1992; Ehlers, 1995).
Clinician Guideline 8.3
The dimensional quality to panic attacks should be recognized when assessing this clinical
phenomenon. Clients should be evaluated for past and current experiences with less severe,
“partial” panic episodes as well as the occurrence of nocturnal panic attacks. An exclusive
focus on “full-blown” panic attacks may not capture the total impact of panic experiences
on individual clients.