Panic Attack Specifier 215
intensity is literally only a few minutes. A panic attack can arise from either a calm state or an
anxious state, and time to peak intensity shou ld be assessed independently of any preceding
anxiety. That is, the start of the panic attack is the point at which there is an abrupt increase in
discomfort rather than the point at which anxiet y first developed. Likew ise, a panic attack can
return to either an anxious state or a calm stat e and possibly peak again. A panic attack is dis-
tinguished from ongoing anxiety by its time to pe ak intensity, which occurs within minutes; its
discrete nature; and its typically greater severity. Attacks that meet all other criteria but have
fewer than four physical and/or cogn itive symptoms are referred to as limited-symptom attacks.  
There are two characteristic types of pa nic attacks: expected and unexpected. Expected
panic attacks  are attacks for which there is an obvious cue or trigger, such as situations in
which panic attacks have typically occurred. Unexpected panic attacks  are those for which
there is no obvious cue or trigger at the time  of occurrence (e.g., wh en relaxing or out of
sleep [nocturnal panic attack]). The determination of whether panic attacks are expected
or unexpected is made by the clinician, who makes this judgment based on a combination
of careful questioning as to the sequence of events preceding or leading up to the attack
and the individual’s own judgment of whether or not the attack seemed  to occur for no ap-
parent reason. Cultural interp retations may influence their determination as expected or
unexpected. Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncon-
trollable screaming or crying) may be seen; however, such symptoms  should not count as