216 Anxiety Disorders
to use the word “discomfort” to describe pa nic attacks. Older individuals with “panicky
feelings” may have a hybrid of limited-sym ptom attacks and generalized anxiety. In
addition, older individuals tend  to attribute panic attacks to  certain situations that are
stressful (e.g., medical procedures, social se ttings) and may retrospectively endorse expla-
nations for the panic attack even if it was un expected in the moment. This may result in un-
der-endorsement of unexpected panic attacks in older individuals. 
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. History of “fearful
spells” (i.e., limited-symptom attacks that do not meet full criteria for a panic attack) may
be a risk factor for later panic attacks. 
Environmental. Smoking is a risk factor for panic atta cks. Most individu als report iden-
tifiable stressors in the months before their first panic attack (e.g., interpersonal stressors
and stressors related to physical well-being,  such as negative experiences with illicit or
prescription drugs, disease,  or death in the family). 
Culture-Related Diagnostic Issues
Cultural interpretations may in fluence the determination of panic attacks as expected or
unexpected. Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, and un-
controllable screaming or crying) may be seen ; however, such symptoms should not count
as one of the four required symptoms. Frequency of each of the 13 symptoms varies cross-