212 Anxiety Disorders
of panic attacks. Some c linical presentations of ataque de nervios  fulfill criteria for condi-
tions other than panic attack (e.g., other spec ified dissociative disorder). These syndromes
impact the symptoms and frequency of panic disorder, including the individual’s attribu-
tion of unexpectedness, as cultural syndromes may create fear of certain situations, rang-
ing from interpersonal arguments (associated with ataque de nervios), to types of exertion
(associated with khyâl  attacks), to atmospheri c wind (associated with trúng gió  attacks).
Clarification of the details of cultural attributions may aid in distinguishing expected and
unexpected panic attacks. For more information regarding cultural syndromes, refer to the
“Glossary of Cultural Concepts of Distress” in the Appendix.
The specific worries about panic attacks or their consequences are likely to vary from
one culture to another (and across different age groups and gender). For panic disorder,
U.S. community samples of non- Latino whites have significantly less functional impair-
ment than African Americans. There are also hi gher rates of objectively defined severity in
non-Latino Caribbean blacks with panic disord er, and lower rates of panic disorder over-
all in both African American and Afro-Carib bean groups, suggesting that among individ-
uals of African descent, the criteria for pa nic disorder may be met only when there is
substantial severity and impairment.
Gender-Related Diagnostic Issues 
The clinical features of panic disorder do not appear to differ between males and females.
There is some evidence for sexual dimorphi sm, with an association between panic disor-
der and the catechol-O-methyltransferase (COMT) gene in females only.
Diagnostic Markers