Clinical staging in panic disorder

Fava and Kellner in 1993 described a staging model for panic disorder with agoraphobia based on the fact that, in a substantial proportion of patients, agoraphobia, hypochondriacal fears and beliefs, and generalized anxiety precede the first panic attack. However, for some patients the first panic attack can apparently occur without conspicuous prodromal symptoms, while anticipatory anxiety, phobic avoidance, and hypochondriasis may develop subsequently. For this reason, it is noteworthy to mention the hypothesis formulated by Sheehan and Sheehan in 1982-1983 which outlined a different staging process: stage 1 (sub-panic) characterized by panic attacks with limited symptoms; stage 2 (panic); stage 3 (hypochondriasis); stage 4 (single phobia, that is the setting in which panic occurs); stage 5 (social phobia); stage 6 (agoraphobia); stage 7 (depression). An updated version of the staging model of panic disorder is here proposed as well as a staging model of treatment resistance when panic is treated.