should be taken to determine if the individual had panic at tacks prior to excessive sub-
stance use. If this is the case, a diagnosis of pa nic disorder should be considered in addition
to a diagnosis of substance use disorder. Features such as onset after age 45 years or the
presence of atypical symptoms during a panic attack (e.g., vertigo, loss of consciousness,
loss of bladder or bowel control, slurred speech, amnesia) suggest the possibility that an-
other medical condition or a substance may be causing the panic attack symptoms.
Other mental disorders with panic attacks as an associated feature (e.g., other anxiety
disorders and psychotic disorders). Panic attacks that occur as a symptom of other anx-
iety disorders are expected (e.g., triggered by social situations in social anxiety disorder, by
phobic objects or situations in specific phobia  or agoraphobia, by worry in generalized anx-
iety disorder, by separation from home or atta chment figures in separation anxiety disorder)
and thus would not meet crit eria for panic disorder. ( Note: Sometimes an unexpected panic
attack is associated with the onset of another anxi ety disorder, but then the attacks become
expected, whereas panic disorder is characterized by recurrent unexpected panic attacks.) If
the panic attacks occur only in response to spec ific triggers, then only the relevant anxiety
disorder is assigned. However,  if the individual experiences unexpected panic attacks as
well and shows persistent concern and worry or  behavioral change because of the attacks,
then an additional diagnosis of pa nic disorder should be considered.
Comorbidity
Panic disorder infrequently occurs in clinic al settings in the absence of other psychopa-
thology. The prevalence of panic disorder is elevated in individuals with other disorders,
particularly other anxiety disorders (and espe cially agoraphobia), major depression, bipo-