African Americans, Caribbean blacks, and As ian Americans, compared with non-Latino
whites; American Indians, by contrast, have significantly higher rates. Lower estimates
have been reported for Asian,  African, and Latin American countries, ranging from 0.1%
to 0.8%. Females are more frequently affected than males, at a rate of approximately 2:1. The
gender differentiation occurs in adolescence and is already observable before age 14 years.
Although panic attacks occur in children, the overall prevalence  of panic disorder is low
before age 14 years (<0.4%). The rates of panic disorder show a gradua l increase during ad-
olescence, particularly in females, and possibly following the onset of puberty, and peak dur-
ing adulthood. The prevalence rates decline in older individuals (i.e., 0.7% in adults over
the age of 64), possibly reflecting diminishing severity to subclinical levels. 
Development and Course
The median age at onset for panic disorder in the United States is 20–24 years. A small
number of cases begin in childhood, and onse t after age 45 years is unusual but can occur.
The usual course, if the disorder is untreated,  is chronic but waxing and waning. Some in-
dividuals may have episodic outbreaks with years of remission in between, and others
may have continuous severe symptomatology. Only a minority of individuals have full
remission without subsequent relapse within a few years. The course of panic disorder
typically is complicated by a range of other disorders, in particular other anxiety disor-
ders, depressive disorders, and substance us e disorders (see section “Comorbidity” for
this disorder). 
Although panic disorder is very rare in child hood, first occurrence of “fearful spells” is