Panic Disorder 211
tend to attribute their panic attacks to certai n stressful situations, such as a medical pro-
cedure or social setting. Older individuals may retrospectively endorse explanations for
the panic attack (which would preclude the diagnosis of panic disorder), even if an attack
might actually have been unexpected in the moment (and thus qualify as the basis for a
panic disorder diagnosis). This may result in under-endorsem ent of unexpected panic at-
tacks in older individuals. Thus, careful questioning of older adults is required to assess
whether panic attacks were expected before entering the situation,  so that unexpected
panic attacks and the diagnosis of panic disorder are not overlooked.
While the low rate of panic disorder in child ren could relate to difficulties in symptom
reporting, this seems unlikely given that child ren are capable of reporting intense fear or
panic in relation to separation and to phobic objects or phobic si tuations. Adolescents
might be less willing than adul ts to openly discuss panic a ttacks. Therefore, clinicians
should be aware that unexpected  panic attacks do occur in adolescents, much as they do in
adults, and be attuned to this possibility when encountering adolescents presenting with
episodes of intense fear or distress. 
Risk and Prognostic Factors
Temperamental. Negative affectivity (neuroticism) (i .e., proneness to experiencing neg-
ative emotions) and anxiety sensitivity (i.e., the disposition to believe that symptoms of
anxiety are harmful) are risk factors for the onset of panic attacks and, separately, for
worry about panic, although thei r risk status for the diagnosis of panic disorder is un-
known. History of “fearful spe lls” (i.e., limited-symptom atta cks that do not meet full cri-