Pediatric Panic Disorder

The presence of recurrent panic attacks is an essential feature of panic disorder. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), panic attacks feature prominently within the anxiety disorders, of which panic disorder is one. ^[1]

In panic disorder, the individual experiences recurrent unexpected panic attacks and is persistently concerned or worried about having more panic attacks or changes his or her behavior in maladaptive ways because of the panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time 4 or more of the following symptoms occur: ^[1]  

• Accelerated heart rate

• Sweating

• Trembling

• Shortness of breath

• Feelings of choking

• Chest pain

• Nausea

• Feeling dizzy or faint

• Chills or heat sensations

• Paresthesias

• Derealization

• Fear of losing control or "going crazy"

• Fear of dying

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. (See Etiology and History.)

In 1994, the American Psychiatric Association included panic disorder with agoraphobia and panic disorder without agoraphobia in the DSM-IV. (In prior DSM editions, the terms panic disorder and agoraphobia with panic attacks had been used to describe similar conditions.) In DSM-5, panic disorder and agoraphobia are two separate and distinct disorders. ^[1]

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. (See Epidemiology and Prognosis.)

Complications

Somatic symptoms of panic disorder 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 from panic disorder.

Comorbid depression is not uncommon, and, in severe cases, children and adolescents may become suicidal.

Adolescents with panic disorder may self-medicate, leading to substance abuse.

Biologic vulnerability in combination with stressful circumstances or events is hypothesized to contribute to the development of panic disorder. Studies have suggested a possible link between certain mutations of the gene for catechol-O-methyltransferase and the development of panic or anxious reactions in response to aversive stimuli, although no causational link has been proven. ^[2] There has been speculation that carriers of such polymorphisms may benefit from targeted interventions to prevent the development of panic pathology in adversarial situations. ^[2]  

In addition, children with parents who struggle with anxiety are at higher risk of developing anxiety. A possible genetic link to 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. Behavioral inhibition, a temperamental style associated with avoidance of new stimuli, has been found to place children at risk for anxiety disorders.

Researchers do not believe, however, that all children of parents who are anxious also become anxious.

Other factors that may contribute to panic disorder are insecure attachment patterns, high levels of stress in the home, and the presence of stressful life events. In fact, 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.

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. ^[3]  There have been studies of fMRI imaging in panic disorder patients that demonstrate differential activation of the insula and brainstem neural circuitry. Such neurological findings suggest that the fear of cardiovascular and respiratory symptoms may represent a core feature of panic disorder. ^[4]  

However, 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). ^[5]

In the general population, the 12-month prevalence estimate for panic disorder across the United States and several European countries is about 2%-3% in adults and adolescents. ^[1]

The median age at onset for panic disorder in the United States is 20-24 years. A small number of cases begin in childhood; the overall prevalence is low before age 14 years (< 0.4%). ^[1]

Females are more frequently affected than males.

The prognosis may be worsened when parents are unable to assist in their child's treatment or model adaptive coping/anxiety management because of their own untreated anxiety (or other psychiatric conditions).

In a clinical sample of 10 children who met the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) criteria for panic disorder, the recovery rate was 70% during a 3- to 4-year follow-up period. However, 30% of the children developed new psychiatric disorders. ^[6] This constitutes the worst prognosis for an anxiety disorder with onset in childhood or adolescence; nonetheless, the prognosis with ongoing treatment is unknown and may have become more favorable owing to developments in psychopharmacology and psychotherapy.

Without effective intervention, adolescent patients, especially those with comorbid agoraphobia, may experience an exacerbation of symptoms in adulthood. Serious adverse consequences include interpersonal, academic, and occupational impairments. ^[7]

Mortality and morbidity

Isolated panic disorder is uncommon in the pediatric population. ^[8] A careful screening for other anxiety, mood, trauma-related, and substance use disorders is particularly essential. Multiple coexisting disorders compound 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 1 thing or situation.)

Panic disorder is associated with a lifetime risk of increased morbidity and mortality from stress-related physical problems.

Psychoeducation should be part of the treatment process for panic disorder. 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 patient education information, see the Anxiety Center, as well as Anxiety, Panic Attacks, and Hyperventilation.