A discrete period (unexpected or spontaneous) intense fear  or discomfort, in which 4 or more symptoms develop abruptly and peak in 10 minutes.

• Palpitations, pounding heart or accelerated heart rate
• Trembling or shaking Feelings of choking
• Nausea or abdominal distress
• De - realization (feelings of unreality) or
• Depersonalization (being detached from oneself)
• Paraesthesia (numbness or tingling sensations)
• Sweating Sensations of shortness of breath or smothering
• Chest pain or discomfort Feeling dizzy, unsteady, light - headed or faint
• Fear of losing control or going crazy
• Fear of dying
• Chills or hot flushes

• Spontaneous PAs occur in the absence of a trigger.
• person does not associate onset with an internal or external situational trigger

• Situational bound PAs occur immediately on exposure to or in anticipation of, the situational cue/trigger 
• Ex. person with social phobia having a PA upon entering or thinking about a public speaking event.
• Prior to entering the phobic situations, anxiety known as anticipatory anxiety is experienced; the cause of this anxiety is whether a PA will occur.

• Situational predisposed PAs are not necessarily related to a cue, in that, the attack may or may not happen after exposure to a feared situation
• They are similar to Situational bound PAs
• The PAs are more likely to occur while driving  or not  or
• PAs could occur after driving  for 1/2hr.

• Limited symptom attacks are PAs in which there are fewer than four symptoms.
• The symptoms are similar to the full - blown attacks but are perceived as less intense.
• It is rare to experience limited symptom attacks in the absence of full - blown attacks.

• NPAs refer to wakening in a state of panic 1 to 3 hours after sleep onset.
• The attacks last from 2 to 8 minutes and
• the symptoms are similar to daytime PAs but often more severe.
• Up to 2/3 of those with Panic disorder, at sometime, experience a NPA and one third will have such attacks regularly.
• Some experience a NPA in the absence of a daytime PA.
• Following a NPA, a delay in returning to sleep is the norm.

• Anxiety about being in places or situations where escape is difficult,
• Where help may not be available in the event of an Unexpected or Situational predisposed PA or panic-like symptoms,
• Agoraphobic fears typically involve clusters of situations:
• being outside home alone,
• being in a crowd or standing in a line
• being on a bridge or
• traveling on a bus, train, car

• The situations are avoided: ex. travel is restricted 
• Endure situations with marked distress/anxiety about having a PA or panic-like symptoms or require a friend's company.
• Note: Consider Specific Phobia dx if the avoidance is limited to 1 or only a few specific situations
• Consider Social phobia dx if the avoidance is limited to social situations

• The anxiety or phobic avoidance can be not better accounted for by another mental disorder.
• Such as social phobia, specific phobia, OCD, PTSD, SAD

• The presence of recurrent Unexpected PAs.
• At least 1 of the attacks is followed by 1 month or more of these:
• Persistent concerns about having an additional attack
• Worrying about implications of the attack
• A significant change in behavior related to the attack,
• i.e., avoidance of situations

• PAs are not better accounted for another mental disorder
• Social/Specific phobia, OCD, PTSD, SAD

Panic Disorder w/Agoraphobia or w/out Agoraphobia is diagnosed if criteria for Agoraphobia are met. see p433

Differences:

1. PA:

• unexpected, spontaneous, no internal or external trigger
• 4 or more symptoms
• peak in 10 minutes
• greater morbidity with PAs
• presence of recurrent spontaneous PA initially or later in the course, Panic disorder will be diagnosed.

2. Limited-symptom PA:

• identical to full PA
• occur frequent/very common in Panic disorder
• have fewer than four symptoms of PA
• lesss intense than full blown PAs
  

 3 Situationally bound PA: 

• occur immediately on exposure to situational trigger or
• occur when anticipating the situational trigger
• occur in context  in other Anxiety disorders

4. Situationally predisposed PA:

• may or not associated with cue/trigger
• could be immediate occur after exposure
• occur in context in other Anxiety disorders

 Examples of Situationally bound/predisposed PAs:

• Social phobia PA cued by social situations,
• Specific phobia PA cued by phobic object/situation,
• OCD PA cued by thoughts of, or exposure to object/situation related to the obssession
• PTSD PA cued by stimuli recalling the stressor
• GAD cued by the worry

Similarities:

• PD w/Agoraphobia is characterized by
• initial onset of unexpected PAs and
• subsequent avoidance thought to be triggers of the PAs.

Social phobia is characterized by the avoidance of social situations in the absence of recurrent  unexpected PAs - when occur are in the form of situationally bound or predisposed PAs.

• PD is also characterized by recurrent unexpected PAs
• they are not limited to social situations
• social situations may be avoided b/c of the clt's fear of being seen while having the attack

 Examples:
- A clt who had no previous fear of public speaking, had a PA while giving a talk and begins to dread future presentations.

- If this clt has subsequent (situational bound/predisposed PAs) only in social performance situations (public speaking) (even if the focus is on the fear/panic), then SoP dx is appropriate.

-If this clt continues to experience unexpected PAs, then PD w/A is warranted p454.

- A clt has lifelong fear and avoidance of most social situations (SoP, Generalized) later develops PAs in nonsocial situations (unexpected PAs) and additional avoidance behaviors (PD w/A) would be diagnosed with both SoP and PD w/A as long as all criteria are met.

• Fears in A w/o PD hx typically involve characteristic cluster of situations that may or may involve scrutiny by others ex. being home alone, on a bridge, etc.
• The role of a companion may distinguish Social phobia from Agoraphobia (With and Without PD):
• Typically the clt with agoraphobic avoidance prefer to be with a trusted companion when in a feared situation (A w/PD & w/o PD)
• whereas clt with Social phobia may have marked anticipatory anxiety, but do not have PAs when alone.

• 5 or more symptoms occuring within a 2 week period;
• there is a visible change in functioning;
• at least 1 symptom shows a depressed mood or loss of interest/pleasure

1. depressed mood-most of the day reported by clt (subjectively)
2. markedly reduced interest in all or most activities during the day
3. significant weight loss or gain; or reduced/increased appetite nearly everyday
4. insomnia or hypersomnia nearly everyday
5. psychomotor agitation or retardation (also observed by others)
6. fatigue or loss of energy everyday
7.  feeling worthless and extreme/inappropriate guilt border on delusional daily
8. diminished ability to concentrate or think; indecisive daily
9.  recurrent thoughts of death, recurrent suicide ideation w/out a plan, or attempt or w/a plan

the symptoms are not due to direct physiological effects of a substance/drug or gmc ie. hypothyroidism

• the symptoms are not better accounted for by Bereavement-after a loss of loved one
• the symptoms persist for longer than 2 mths
• the symptoms are characterized by:
• marked functional impairment preoccupation w/death,
• feeling worthless,
• suicidal ideation,
• psychotic symptoms, or psychomotor retardation

a distinct period of abnormally persistent elevated, expansive, irritable mood - 1 wk in duration

3 or more symptoms present during mood disturbance with significant intensity:

1. inflated self-esteem or grandiosity

2. decreased need to sleep

3. more talkative than usual

4. flight of ideas or racing thoughts

5. easily distracted

6. increased goal-directed activity: psychomotor agitation or socially

7. excessive involvement in pleasurable things

• the mood is severe causing marked impairment:
• in occupational functioning
• in usual social activities/relationships
• to need to be hospitalized to prevent harm to self or others or
• there are psychotic features

• the mood is severe causing marked impairment:
• in occupational functioning
• in usual social activities/relationships
• to need to be hospitalized to prevent harm to self or others or
• there are psychotic features

the symptoms are not due to direct physiological effects of a substance/drug or gmc ie. hypothyroidism

• difference betw mixed episode and ADHD is early onset before age 7yrs;
• chronic course,
• lack or relatively clear onsets and offsets
• absence of expansive/elevated mood or psychotic features

• a distinct period of persistently elevated expansive, or irritable mood,
• lasting thru at least 4 dys
• clearly different from nondepressed mood

during  the period of mood disturbance, 3 or more of the following symptoms  have persisted, (4 if mood is irritable) and present:

1. inflated self-esteem or grandiosity
2. decrease need for sleep
3. more talkative or pressure to keep talking
4. flight of ideas or thoughts racing
5. easily distracted
6. increased goal-directed activities
7. excessive involvement in pleasurable activities
    

The episode is not severe enough

• to cause marked impairment in social or occupational functioning
• or is there a need for hospitalization 
• there are no psychotic features

Either obssessions or compulsions Obssessions defined by:

1. recurrent persistent thoughts, impulses, or images

• -experienced during some disturbances
• -which is intrusive and inappropriate
• -cause marked anxiety/distress

 2. these thoughts, impulses, or images are not simply worrying about real life problems

 3. the person attempts

• -to ignore to suppress such thoughts, impulses, images
• -to neuralize them with some other thought or action.

 4. the person recognizes that these thoughts, impulses, images are a product of his/her own mind.

Compulsions:

1. repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.

2. the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation.

The obssession or compulsions

• cause marked distress,
• are time consuming
• (take more than 1hr/day), or
• significantly interfere with the person's normal routine, occupational/academics functioning or usual social activities/relationships.

The disturbance is not due to the direct physiological effects of a substance (ie drug of abuse, medication) or gmc.