Panic Disorder With and Without Agoraphobia

Panic disorder is characterized by two components: recurrent panic attacks and anticipatory anxiety. Panic attacks within panic disorder are not caused by physical illness or certain substances and they are unexpected, at least initially; later in the course of the disorder, many attacks may be precipitated by certain situations or are more likely to occur in them. Anticipatory anxiety is an intense fear of having another panic attack, which is present between panic attacks. Some patients with panic disorder go on to develop agoraphobia, usually defined as fear and/or avoidance of the situations from which escape might be difficult or embarrassing or in which help might not be available in case of a panic attack; in such cases, patients are diagnosed with panic disorder with agoraphobia. Those who do not develop agoraphobia receive a diagnosis of panic disorder without agoraphobia. Components of panic disorder are presented in Figure 2—1. Patients with agoraphobia who have no history of panic disorder or whose agoraphobia is not related at least to panic attacks or symptoms of panic attacks are relatively rarely encountered in clinical practice. The diagnosis of agoraphobia without history of panic disorder has been a matter of some controversy, especially in view of the differences between American and European psychiatrists (and the DSM and ICD diagnostic and classification systems) in the conceptualization of the relationship between panic disorder and agoraphobia. The conceptualization adhered to here has for the most part been derived from the DSM system, as there is more empirical support for it. Although panic disorder (with and without agoraphobia) is a relatively well-defined psychopathological entity whose treatment is generally rewarding, there are important, unresolved issues. They are listed below and discussed throughout this chapter. …1. Are there different types of panic attacks based on the absence or presence of the context in which they appear (i.e., unexpected vs. situational attacks)? Should the ‘‘subtyping’’ of panic attacks be based on other criteria (e.g., symptom profile)? 2. Because panic attacks are not specific for panic disorder, should they continue to be the main feature of panic disorder? Can panic attacks occurring as part of panic disorder be reliably distinguished from panic attacks occurring as part of other disorders or in the absence of any psychopathology? 3. What is the relationship between panic attacks, panic disorder, and agoraphobia?