AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

In 1994, the American Psychiatric Association included panic disorder with agoraphobia and panic disorder without agoraphobia in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). In prior DSM editions, the terms panic disorder and agoraphobia with panic attacks had been used to describe similar conditions. The presence of recurrent panic attacks is an essential feature of panic disorder. According to the DSM-IV, a panic attack is a discrete episode during which a person experiences intense fear or discomfort. They also must have at least 4 of the following symptoms:

• Accelerated heart rate
• Sweating
• Trembling
• Shortness of breath
• Feeling of choking
• Chest pain
• Nausea or abdominal distress
• Dizziness
• Feelings of unreality
• Fear of losing control
• Fear of dying
• Numbness or tingling
• Chills or hot flashes

The attack has a sudden onset and typically reaches a peak within 10 minutes. Panic attacks can be (1) unexpected, that is, not associated with a specific trigger; (2) situationally bound, that is, almost always occurring on exposure to, or in anticipation of, a specific trigger; or (3) situationally predisposed, which means they are more likely to occur on exposure to a trigger but are not invariably associated with that trigger. Situationally bound panic disorder is very similar to specific phobia except for the degree of the reaction. Unexpected and situationally predisposed panic attacks are the most frequent types in panic disorder.

As indicated above, 2 types of panic disorder exist and are distinguished based on whether agoraphobia is present. The essential feature of agoraphobia is anxiety about being in a situation in which escape would be difficult or help unavailable should a panic attack or paniclike symptoms occur. Patients with agoraphobia often try to avoid a number of situations and activities; for example, children may be reluctant to go to school or be separated from parents. In severe cases, the child or adolescent may be too scared to leave home or be home alone. Refusal to leave home or one's bedroom despite encouragement is the most serious outcome of severe agoraphobia.

Panic attacks and agoraphobia can occur with several anxiety disorders. Although panic disorder is more frequent in older adolescents and adults, it does occur in children. It is an important disorder to consider because unrecognized and untreated panic disorder can have a devastating impact on a child's life and can interfere with normal development, schoolwork, and relationships.

Pathophysiology

Currently, no consistent physiologic findings have been identified as diagnostic for panic disorder. However, adults with panic disorder have been found to differ from adults without the disorder. For example, panic disorder sometimes is associated with signs of compensated respiratory alkalosis. An increased frequency of panic attack response in reaction to sodium lactate infusion or carbon dioxide inhalation has been reported in research settings.

Frequency

United States

Prevalence before puberty is unknown, but somatic symptoms consistent with panic attacks are reported. Panic disorder is considered most frequent in late adolescence and young adulthood, with peak onset from age 15-19 years. The rate of panic disorder for adolescents is approximately 0.6%.

Mortality/Morbidity

Panic disorder may be a marker for increased risk of suicide in individuals with co-occurring depressive disorder. Panic disorder leads to psychological morbidity when the spontaneous attacks become associated with some place or event such that the patient develops increased anticipatory anxiety or phobic avoidance. (This is different from specific phobia, in which no spontaneous attacks are experienced and in which the phobic avoidance is confined to one thing or situation.) Panic disorder is associated with a lifetime risk of increased morbidity and mortality from stress-related physical problems. Comorbidity with other disorders is common. Multiple coexisting disorders compound morbidity.

Race

No differences based on race or ethnicity are known.

Sex

In anecdotally reported childhood cases, sex distribution appears equal. Panic disorder is more common in postpubertal girls than in postpubertal boys. Before puberty, the sex ratio is equal.

Age

The estimated age of onset varies among studies. A recent study (Ost, 2001) reported a mean age of onset for panic disorder across several studies to be 11.6-15.6 years. However, panic disorder tends to be most frequent in late adolescence and young adulthood, with a mean peak onset of 15-19 years.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Children with panic disorder may experience the following somatic symptoms during discrete panic attacks:
• • Dyspnea and/or palpitations with or without tachycardia
  • Diaphoresis
  • Nausea and/or diarrhea
  • Urinary urgency
  • Cold and clammy hands
  • Dry mouth
  • Dysphagia or complaint of a "lump in the throat"
• Patients also may have the above symptoms, to some degree, as symptoms of anticipatory anxiety or comorbid generalized anxiety disorder. Anxious muscle tension also can occur with trembling, twitching, feeling shaky, and experiencing muscle soreness or aches. Stomachaches and headaches may be the most frequent symptoms.
• The DSM-IV (1994) requires the following "A" criteria to be used when diagnosing panic disorder without agoraphobia:
• • Panic attacks are recurrent and unexpected.
  • At least one of the attacks has been followed by a minimum of 1 month of one or more of the following:
    • Persistent concern about having more attacks
    • Worry about the implications of the attack or its consequences
    • Significant behavioral changes related to the attacks
• The other DSM-IV criteria used when diagnosing panic disorder without agoraphobia include the following:
• • Agoraphobia is absent.
  • The panic attacks are not caused by the direct physiologic effects of a substance or a general medical condition.
  • The panic attacks are not better accounted for by another mental disorder.
• The DSM-IV (1994) requires the following "A" criteria to satisfy a diagnosis of panic disorder with agoraphobia:
• • Panic attacks are recurrent and unexpected.
  • At least one of the attacks has been followed by a minimum of 1 month of one or more of the following:
    • Persistent concern about having more attacks
    • Worry about the implications of the attack or its consequences
    • Significant behavioral changes related to the attacks
• The other DSM-IV criteria used when diagnosing panic disorder with agoraphobia include the following:
  • Agoraphobia is present.
  • The panic attacks are not caused by the direct physiologic effects of a substance or a general medical condition.
  • The panic attacks are not better accounted for by another mental disorder.

Physical

Children with panic disorder may have few physical findings because the attacks rarely occur in the presence of a physician. Hyperventilation to the point of carpal-pedal spasm is rare.

Causes

• Biological vulnerability in combination with stressful circumstances or events is hypothesized to contribute to the development of panic disorder. Behavioral inhibition, a temperamental style associated with avoidance of new stimuli, has been found to place children at risk for anxiety disorders. Likewise, children with parents who struggle with anxiety are at higher risk of developing anxiety. A possible genetic link in the development of anxiety also has been supported through twin studies. Parents who are anxious may contribute further to higher anxiety levels in their children by modeling anxious behavior and maladaptive coping.
• Researchers do not believe that all children of parents who are anxious also become anxious. Other factors that may contribute are insecure attachment patterns, high levels of stress in the home, and the presence of stressful life events. Some evidence suggests that children and adolescents who develop panic disorder tend to be hypersensitive to certain bodily sensations and interpret these sensations as dangerous when they may be harmless. The first panic attack often is preceded by a stressful event, such as the death of a parent or other significant person, a move to a new school, or any other significant emotionally traumatic experience. Early studies suggest a link between separation anxiety and later development of panic disorder, but this appears to be a nonspecific risk factor for panic disorder or depressive disorder.
• Prospective studies looking to predict which adolescents will develop panic disorders are lacking. One prospective survey suggested an association between development of major depression and panic disorder (and vice-versa).

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Anxiety disorder caused by a general medical condition
Substance-induced anxiety disorder
Delusional disorder
Psychotic disorder

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Excessive medical workup without clear indication by history and physical examination is contraindicated because it can exacerbate anxiety.
• The relatively rare medical causes of panic in pediatric patients, such as hyperinsulinemia or hyperthyroidism, should be documented with appropriate laboratory studies.

Other Tests

• A structured interview, such as the Anxiety Disorders Interview Schedule for DSM-IV Child and Parent Versions (ADIS-C/P), can be employed.
• Questionnaires, such as the Revised Children's Manifest Anxiety Scale (RCMAS), the Multidimensional Anxiety Scale for Children (MASC), and the Screen for Child Anxiety Related Emotional Disorders (SCARED), child and parent versions, can be used to further assess anxiety symptoms.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Support for individual and family-based cognitive-behavioral treatment approaches for childhood anxiety disorders has been demonstrated in recent randomized controlled trials (Barrett, 1996; Kendall, 1994; Kendall, 1997). Behavioral techniques often discussed in association with the treatment of panic disorder include deep breathing and relaxation, development of a systematic desensitization program, prolonged and carefully monitored exposure to negatively perceived stimuli, adaptive modeling, and contingency management. These techniques seek to change the way the child acts and reduce avoidance and the subjective experience of anxiety. Complementary cognitive techniques include developing a fear hierarchy, learning to identify and monitor feelings and bodily sensations, making accurate interpretations of situations and bodily sensations, and improving problem-solving skills.

Treatment may include developing a coping regimen and practicing using this regimen in the office and/or in vivo. The importance of parental involvement in the treatment of childhood anxiety disorders recently has received attention, and such involvement is a necessary component to ensure success. The family-based component in the treatment of panic disorder can include contingency management, improved communication and problem-solving skills at the family level, and encouragement of effective coping through modeling.

Consultations

Consultation with a child psychologist, psychiatrist, or behavioral-developmental pediatrician is important for the evaluation and treatment of this disorder.

Diet

Avoid or limit caffeine.

Activity

Children and adolescents with this disorder may need help learning to interpret physical reactions in response to exercise as normal and not a sign of an imminent panic attack.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medication is adjunctive to psychological treatment of panic disorder.

Selective serotonin reuptake inhibitors (SSRIs) are currently the antidepressants of choice. These antidepressants are powerful anxiolytics with a broader spectrum, such that comorbid affective disorders may also respond to treatment. Tricyclic antidepressants are not generally recommended for the treatment of panic disorder in children and adolescents because of their potential cardiotoxicity. In rare patients in whom symptoms are resistant to treatment, these drugs may be considered. The dosage and use of these agents for panic disorder is similar to their use in depressive disorder.

Benzodiazepines have a relatively favorable adverse effect profile but are not considered first-line medications in the treatment of panic disorder in children and adolescents. In some young children, these agents may cause behavioral disinhibition. Also, a potential withdrawal syndrome can occur after prolonged use. Some benzodiazepines also have "street value" as drugs of abuse. Buspirone (BuSpar), which is an anxiolytic unrelated chemically and pharmacologically to benzodiazepines, does not suppress panic attacks.

Monoamine oxidase inhibitors (MAOIs) are the most effective agents to manage panic attacks in adults. They are not used as first- or second-line agents in adults for the same reasons that they are not used in children or adolescents (ie, risk of hypertensive crisis, dietary restrictions).

Antihistamines and antipsychotics are not recommended for treatment of childhood-onset anxiety disorders.

Drug Category: Selective serotonin reuptake inhibitors

These agents inhibit neuronal uptake of serotonin, thus potentiating serotonergic activity in the brain and down-regulating the potential for panic attacks. Fluoxetine is presented as an example. Several SSRIs are now available.

SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.

Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

On October 15, 2004 the US Food and Drug Administration (FDA) issued a directive to all pharmaceutical companies, instructing them to include a black box warning label on all antidepressant medications (such as SSRIs). This decision was based on an analysis demonstrating that children and adolescents on antidepressant medications may have a small, but statistically significant risk of suicidal ideation. Initially, this risk was thought to increase during the first few months after initiating treatment. However, a recent study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants. This is the largest study to date to address this issue.

Currently, evidence does not exist to associate obsessive-compulsive disorder (OCD) and other anxiety disorders treated with SSRIs with an increased risk of suicide.

Physicians who consider prescribing these medications must remember that the drugs are not currently approved for the treatment of panic disorder in the pediatric and adolescent (<18 y) population. Therefore, they must balance the risks of suicidal ideation with the medications' potential benefits, as demonstrated in adults. Once the patient starts therapy, the physician, parents, and caregivers must closely monitor the patient for any signs of irritability, agitation, behavioral changes, and/or suicidality.

Drug Category: Benzodiazepines

These agents depress all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of gamma-aminobutyric acid (GABA). Several benzodiazepines have been used in children for a variety of indications, including reduction of anticipatory or acute situational anxiety. Note the importance of caution and use only in conjunction with psychotherapy aimed at reducing the patient's time using benzodiazepines.

Many pediatricians are most familiar with diazepam (Valium), and no particular reason exists to prefer another benzodiazepine in children because diazepam is available as a generic preparation and has a smooth, longer action that may be advantageous. Lorazepam (Ativan) has the advantage of being quite short acting in the event of disinhibition, but it is not as useful for treatment of panic disorder because of the frequent dosing. Clonazepam (Klonopin) has been studied in panic disorder but has been noted anecdotally to have some increased risk of behavioral disinhibition.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Outpatient psychotherapy may be required for a few weeks to a year or longer.
• Follow-up care during medical treatment with an SSRI (eg, fluoxetine) includes monitoring pulse and paying particular attention to symptoms of hepatic dysfunction, seizures, and movement disorder. Anorexia, gastrointestinal dysfunction, and headache tend to be possible transient adverse effects of SSRIs. Rashes may not be reported until they already have passed and tend to be coincidental with viral illness; thus, they should be assessed by a primary care physician familiar with the rash-producing illnesses currently occurring in the community.

In/Out Patient Meds

• For patients for whom medication is prescribed, regular follow-up care with a child and adolescent psychiatrist or developmental-behavioral pediatrician is necessary for the duration of treatment.

Deterrence/Prevention

• A consistent, stable, supportive home environment with parenting practices that promote self-confidence, self-esteem, and effective coping skills are important preventive measures. Minimize psychosocial stressors or traumatic events when possible and provide rapid psychological intervention. Parents and other significant people in the child's life should model adaptive problem-solving and coping skills.

Complications

• Somatic symptoms may lead to excessive and invasive examinations when appropriate mental health professional assessment is delayed.
• Reluctance to go to school or engage in other age-appropriate activities may result.
• Comorbid depression is not uncommon, and, in severe cases, children and adolescents may become suicidal.
• Adolescents may self-medicate, leading to substance abuse.

Prognosis

• The prognosis may be worsened when parents are unable to assist in the child's treatment or model adaptive coping/anxiety management because of their own untreated anxiety (or other psychiatric conditions).
• In a clinical sample, 10 of 23 children met Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) criteria for panic disorder. During a 3-4-year follow-up period, the recovery rate was 70%, but 30% of the children had developed new psychiatric disorders (Last, 1996). This constitutes the worst prognosis for an anxiety disorder with onset in childhood or adolescence, but the prognosis with ongoing treatment is unknown and may be more favorable with recent developments in psychopharmacology and psychotherapy.

Patient Education

• Psychoeducation should be part of the treatment process. Patient and parents should have a good understanding of the contributing and maintaining factors of anxiety. Also, they should be clear on the treatment goals, process, and expectations.
• For excellent patient education resources, visit eMedicine's Anxiety Center. Also, see eMedicine's patient education articles, Anxiety, Panic Attacks, and Hyperventilation.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Because literature describes the risk of suicide in patients with comorbid depression and because risks are associated with unwarranted diagnostic procedures, consideration of this diagnosis is important when a child presents with the symptoms described earlier.
• In the event that further nonpsychiatric medical evaluation is warranted, early mental health professional consultation is important to obtain assistance in excluding this diagnosis.
• The FDA has not approved the use of antidepressants for treating panic disorder in children and adolescents. Physicians considering this off-label option must document that the child and parents received sufficient informed consent regarding the use of these medications.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Barrett PM, Rapee RM, Dadds MM, Ryan SM. Family enhancement of cognitive style in anxious and aggressive children. J Abnorm Child Psychol. Apr 1996;24(2):187-203. [Medline].
• Birmaher B, Brent DA, Chiappetta L, et al. Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study. J Am Acad Child Adolesc Psychiatry. Oct 1999;38(10):1230-6. [Medline].
• Green WH. Child and Adolescent Clinical Psychopharmacology. 3rd ed. Philadelphia:. Lippincott Williams & Wilkins;2001.
• Hayward C, Killen JD, Kraemer HC. Predictors of panic attacks in adolescents. J Am Acad Child Adolesc Psychiatry. Feb 2000;39(2):207-14. [Medline].
• Kendall PC. Treating anxiety disorders in children: results of a randomized clinical trial. J Consult Clin Psychol. Feb 1994;62(1):100-10. [Medline].
• Kendall PC, Sugarman A. Attrition in the treatment of childhood anxiety disorders. J Consult Clin Psychol. Oct 1997;65(5):883-8. [Medline].
• Last CG, Perrin S, Hersen M, Kazdin AE. A prospective study of childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry. Nov 1996;35(11):1502-10. [Medline].
• March JS, Parker JD, Sullivan K, et al. The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry. Apr 1997;36(4):554-65. [Medline].
• Ost L, Treffers PD. Onset, course, and outcome for anxiety disorders in children. In: Silverman W, Treffers PD, eds. Anxiety Disorders in Children & Adolescent. 2001:293-312.
• Reynolds CR, Richmond BO. What I think and feel: a revised measure of children''s manifest anxiety. J Abnorm Child Psychol. Jun 1978;6(2):271-80. [Medline].
• Silverman WK, Albano AM. The Anxiety Disorders Interview Schedule for Children (DSM-IV). San Antonio, TX:. Psychological Corporation;1997.
• Simon GE, Savarino J, Operskalski B, Wang PS. Suicide risk during antidepressant treatment. Am J Psychiatry. Jan 2006;163(1):41-7. [Medline]. [Full Text].

Article Last Updated: May 24, 2006