Incidence and Clinical Features of Panic Related Posttraumatic Stress Tomer Shasha, MA,* Michael J. Dolgin, PhD,* Dana Tzur Bitan, PhD,* and Eli Somer, PhD† Abstract: The current study assessed the incidence and associated features of posttraumatic stress after the experience of panic. One hundred seventy-eight par- ticipants meeting diagnostic criteria for panic attacks (PAs) were assessed using standardized measures of posttraumatic symptoms and posttraumatic stress disor- der (PTSD) in specific reference to their experience of panic. Sixty-three (35.4%) participants scored above the cutoff for PTSD in reference to the worst PA they had experienced. Adjusted means for the four PTSD symptom clusters indicate that panic-related posttraumatic symptoms are, on average, experienced “moder- ately” to “quite a bit. ” Panic-related posttraumatic symptoms and PTSD were best predicted by specific features of the panic experience itself, including subjective levels of distress, fear of losing control, chest pain, agoraphobia, and number of PAs experienced. These findings are discussed in terms of the diagnostic, prog- nostic, and treatment implications for a subset of individuals presenting with panic who may also have panic-related PTSD. Key Words: Panic attacks, panic disorder, posttraumatic symptoms, PTSD (J Nerv Ment Dis 2018;206: 501–506) S tudies have demonstrated significant comorbidity between post- traumatic stress disorder (PTSD) and panic attacks/disorder (PAs/ PD) such that persons diagnosed with PTSD resulting from a traumatic experience are at increased risk for PAs/PD compared with the general population. PD incidence rates among males with PTSD range between 7% and 18% and between 12% and 17% for females, whereas PA inci- dence rates are as high as 53% and 62% for males and females with PTSD, respectively, rates significantly higher than in the general popu- lation (Brown et al., 2001; Feldner et al., 2009; Kessler et al., 1995; Leskin and Sheikh, 2002). Falsetti et al. (1995) reported an 18.3% rate of PAs in persons with a lifetime history of PTSD compared with a 5.5% rate among persons with no trauma history. PD rates among per- sons with PTSD were 9.8% compared with 3.2% among those with no trauma history. The mechanisms accounting for the high rates of PA/PD after trauma cut across several dimensions. In terms of cognition, panic symptoms are commonly triggered by memories of the traumatic events for which a person seeks treatment (Falsetti and Resnick, 1997). On the somatic level, heightened sensitivity to anxiety and anxious responses to physiological arousal are core features of both PA/PD and PTSD Olthuis et al. (2014). Common neurobiological mechanisms in these disorders, involving the dynamic interaction of the amygdala, hippo- campus, and cortex, have also been posited (Kent et al., 2000). Clini- cally, a study of the “Panic Attack–PTSD Model” focusing on how PAs worsen PTSD demonstrated that changes in PA/PD severity par- tially mediate changes in PTSD symptomatology (Hinton et al., 2008). In sum, the epidemiological, theoretical, and clinical literatures suggest pathways whereby PA/PD might be a sequela of PTSD. Approaching this association from another direction, the ques- tion arises whether the experience of panic itself might result in PTSD. PAs are defined as a surge of intense fear or discomfort in which 4 of 13 symptoms develop abruptly and peak rapidly in less than 10 minutes from symptom onset (American Psychiatric Association [APA], 2013). These symptoms include abnormal and distressing somatic sensations (e.g. , tachycardia, trembling, shortness of breath, chest pain, paresthesias) as well as the perception of existential threat (e.g., losing control, hav- ing a heart attack, going crazy). PD is characterized by recurrent, unex- pected PA, the frequency of which can vary from several attacks per day to only a few attacks per year, as well as a) persistent concern or worry about additional PAs or their consequences and/or b) significant maladap- tive change in behavior related to the attacks (e.g., behaviors designed to avoid having PAs, such as avoidance of exercise or unfamiliar situa- tions). Criterion A in the diagnosis of PTSD requires that a) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; and b) the person's response in- volved intense fear, helplessness, or horror (APA, 2013). That PAs are experienced as events that involve existential fears of threatened death or serious injury, or a threat to one's physical integrity, and that the person's response typically involves intense fear and helpless- ness (i.e., PTSD criterion A) are clinically apparent and also evidenced by the high rates at which PA/PD present in hospital emergency rooms (ERs) (Belleville et al., 2010). Indeed, cognitive theorists (e.g., Clark, 1986) suggest that panic only occurs concurrent to the perception of immediate danger. It is therefore plausible that the experience of panic itself can meet PTSD's criterion A and that it may result in PTSD, should the other diagnostic criteria be met, such as dissociative symptoms, reexperiencing, avoidance, and arousal. Ball et al. (1997) reported a 69% rate of derealization and depersonalization symptoms during panic in persons with PD. Hagenaars et al. (2009a) reported similar rates of dissociative symptoms during initial experiences of both trauma and panic, as well as during recollection of such events. In the same study, comparable rates of intrusive memories, reexperiencing, and disor- ganization were found among persons with PD and those with PTSD resulting from traumatic events. With regard to avoidance, as noted above, PD is characterized by maladaptive changes in behavior de- signed to avoid having PAs, the most dramatic of which is mani- fested in agoraphobia. Finally, somatic symptoms, autonomic reactivity, and physiological vulnerability are, by definition, core features and di- agnostic criteria of PA/PD (Brown and McNiff, 2009; Nixon and Bryant, 2003). Our review of the literature revealed a single study that addressed the question of whether the experience of severe panic itself can be a traumatogenic event leading to posttraumatic symptoms and PTSD. McNally and Luckach (1992) found that 5 (17%) of 30 individuals with PD, as assessed by the Structured Clinical Interview for DSM-III-R (SCID), also qualified for a diagnosis of PTSD in reference to the most frightening PA they had experienced. The perception of the likelihood (0%–100%) of impending death related to their worst PA was signifi- cantly higher for those who had developed panic-related PTSD (72%) compared with those who had not (56%). Although the five individuals with panic-related PTSD were found to endorse somewhat fewer *Department of Psychology, Ariel University, Ariel; and †School of Social Work, Uni- versity of Haifa, Haifa, Israel. Send reprint requests to Michael J. Dolgin, PhD, POB 1118, Kochav Yair 44864, Israel. E‐mail: mdolgin@netvision.net.il. Tomer Shasha and Michael J. Dolgin are co-first authors. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/18/20607–0501 DOI: 10.1097/NMD.0000000000000845 ORIGINAL ARTICLE The Journal of Nervous and Mental Disease • Volume 206, Number 7, July 2018 www.jonmd.com 501 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.