Pediatric Panic Disorder

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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.)

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]

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.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013.

Asselmann E, Hertel J, Beesdo-Baum K, Schmidt CO, Homuth G, Nauck M, et al. Interplay between COMT Val158Met, childhood adversities and sex in predicting panic pathology: Findings from a general population sample. J Affect Disord. 2018 Jul. 234:290-296. [Medline].

Meuret AE, Rosenfield D, Hofmann SG, Suvak MK, Roth WT. Changes in respiration mediate changes in fear of bodily sensations in panic disorder. J Psychiatr Res. 2009 Mar. 43(6):634-41. [Medline].

Feldker K, Heitmann CY, Neumeister P, Brinkmann L, Bruchmann M, Zwitserlood P, et al. Cardiorespiratory concerns shape brain responses during automatic panic-related scene processing in patients with panic disorder. J Psychiatry Neurosci. 2018 Jan. 43 (1):26-36. [Medline].

Hayward C, Killen JD, Kraemer HC. Predictors of panic attacks in adolescents. J Am Acad Child Adolesc Psychiatry. 2000 Feb. 39(2):207-14. [Medline].

Last CG, Perrin S, Hersen M, Kazdin AE. A prospective study of childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry. 1996 Nov. 35(11):1502-10. [Medline].

Queen AH, Ehrenreich-May J, Hershorin ER. Preliminary Validation of a Screening Tool for Adolescent Panic Disorder in Pediatric Primary Care Clinics. Child Psychiatry Hum Dev. 2011 Sep 22. [Medline].

Geronazzo-Alman L, Guffanti G, Eisenberg R, Fan B, Musa GJ, Wicks J, et al. Comorbidity classes and associated impairment, demographics and 9/11-exposures in 8,236 children and adolescents. J Psychiatr Res. 2018 Jan. 96:171-177. [Medline].

Kulason KO, Schneider JR, Rahme R, Pramanik B, Chong D, Boockvar JA. Lesional Temporal Lobe Epilepsy: Beware the Deceitful “Panic Attack”. World Neurosurg. 2018 Mar. 111:197-200. [Medline].

Agency for Healthcare Research and Quality. Guideline summary: Practice parameter for the psychiatric assessment and management of physically ill children and adolescents. Accessed December 7, 2011. National Guideline Clearinghouse (NGC). [Full Text].

Doerfler LA, Connor DF, Volungis AM, Toscano PF Jr. Panic disorder in clinically referred children and adolescents. Child Psychiatry Hum Dev. 2007 Jun. 38(1):57-71. [Medline].

Agency for Healthcare Research and Quality (AHRQ). Guideline summary: Practice guideline for the treatment of patients with panic disorder. Accessed December 7, 2011. National Guideline Clearinghouse (NGC). [Full Text].

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. 1997 Apr. 36(4):554-65. [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. 1999 Oct. 38(10):1230-6. [Medline].

Barrett PM, Rapee RM, Dadds MM, Ryan SM. Family enhancement of cognitive style in anxious and aggressive children. J Abnorm Child Psychol. 1996 Apr. 24(2):187-203. [Medline].

Kendall PC. Treating anxiety disorders in children: results of a randomized clinical trial. J Consult Clin Psychol. 1994 Feb. 62(1):100-10. [Medline].

Kendall PC, Sugarman A. Attrition in the treatment of childhood anxiety disorders. J Consult Clin Psychol. 1997 Oct. 65(5):883-8. [Medline].

Chavira DA, Stein MB, Golinelli D, Sherbourne CD, Craske MG, Sullivan G, et al. Predictors of clinical improvement in a randomized effectiveness trial for primary care patients with panic disorder. J Nerv Ment Dis. 2009 Oct. 197(10):715-21. [Medline].

Teachman BA, Marker CD, Smith-Janik SB. Automatic associations and panic disorder: trajectories of change over the course of treatment. J Consult Clin Psychol. 2008 Dec. 76(6):988-1002. [Medline]. [Full Text].

Masi G, Toni C, Mucci M, Millepiedi S, Mata B, Perugi G. Paroxetine in child and adolescent outpatients with panic disorder. J Child Adolesc Psychopharmacol. 2001 Summer. 11(2):151-7. [Medline].

Lepola UM, Wade AG, Leinonen EV, et al. A controlled, prospective, 1-year trial of citalopram in the treatment of panic disorder. J Clin Psychiatry. 1998 Oct. 59(10):528-34. [Medline].

Ost L, Treffers PD. Onset, course, and outcome for anxiety disorders in children. Silverman W, Treffers PD, eds. Anxiety Disorders in Children & Adolescent. 2001. 293-312.

Jeffrey S Forrest, MD 

Disclosure: Nothing to disclose.

Nirupama Natarajan, MD Fellow in Child and Adolescent Psychiatry, Carilion Clinic, Virginia Tech Carilion School of Medicine

Nirupama Natarajan, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, American Academy of Child and Adolescent Psychiatry, American Academy of Psychiatry and the Law, American Medical Association, American Psychiatric Association, American Society for Adolescent Psychiatry, Association for Academic Psychiatry, Medical Society of Virginia, Association of Clinical Research Professionals, American Association of Physicians of Indian Origin, American Society of Clinical Psychopharmacology, American Association for Emergency Psychiatry

Disclosure: Nothing to disclose.

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Chet Johnson, MD Medical Director, Child Development Unit, Department of Pediatrics, Professor, University of Kansas Medical Center

Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Lene Holm Larsen, PhD Instructor, Department of Child and Adolescent Psychiatry, Children’s Memorial Hospital of Chicago

Disclosure: Nothing to disclose.

Carrie Sylvester, MD, MPH Senior Child and Adolescent Psychiatrist, Sound Mental Health

Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Pediatric Panic Disorder

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