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Panic Disorder in Children and Adolescents

by Josephine Elia, MD

Panic disorder is characterized by recurrent, frequent (at least once/wk) panic attacks. Panic attacks are discrete spells lasting about 20 min; during attacks, children experience somatic symptoms, cognitive symptoms, or both. Diagnosis is by history. Treatment is with benzodiazepines or SSRIs and behavioral therapy.

Panic disorder is much less common among prepubertal children than among adolescents. Panic attacks can occur alone or in other anxiety disorders (eg, agoraphobia, separation anxiety), other mental disorders (eg, OCD), or certain medical disorders (eg, asthma). Panic attacks can trigger an asthma attack and vice versa.

Symptoms involve a sudden surge of intense fear, accompanied by somatic symptoms (eg, palpitations, sweating, trembling, shortness of breath or choking, chest pain, nausea, dizziness). Compared with those in adults, panic attacks in children and adolescents are often more dramatic in presentation (eg, with screaming, weeping, and hyperventilation). This display can be alarming to parents and others.

Panic attacks usually develop spontaneously, but over time, children begin to attribute them to certain situations and environments. Affected children then attempt to avoid those situations, which can lead to agoraphobia (see Agoraphobia in Children and Adolescents). Avoidance behaviors are considered agoraphobia if they greatly impair normal functioning, such as going to school, visiting the mall, or doing other typical activities.

Diagnosis

  • Clinical evaluation

  • Evaluation for other causes

Panic disorder is diagnosed based on history, usually after a physical examination is done to rule out physical causes of somatic symptoms. Many children undergo considerable diagnostic testing before panic disorder is suspected. The presence of other disorders, especially asthma, can also complicate the diagnosis. Thorough screening for other disorders (eg, OCD, social anxiety disorder) is needed because any one of these disorders may be the primary problem causing panic attacks as a symptom.

In adults, important diagnostic criteria for panic disorder include concerns about future attacks, the implications of the attacks, and changes in behavior. However, children and younger adolescents usually lack the insight and forethought needed to develop these features, except they may change behavior to avoid situations they believe are related to the panic attack.

Prognosis

Prognosis is good with treatment. Without treatment, adolescents may drop out of school, withdraw from society, and become reclusive and suicidal.

Panic disorder often waxes and wanes in severity without any discernible reason. Some patients experience long periods of spontaneous symptom remission, only to experience a relapse years later.

Treatment

  • Usually benzodiazepines or SSRIs plus behavioral therapy

Treatment is usually a combination of drug therapy and behavioral therapy. In children, it is difficult to even begin behavioral therapy until after the panic attacks have been controlled by drugs. Benzodiazepines are the most effective drugs, but SSRIs are often preferred because benzodiazepines are sedating and may greatly impair learning and memory. However, SSRIs do not work quickly, and a short course of a benzodiazepine (eg, lorazepam 0.5 to 2.0 mg po tid) may be helpful until the SSRI is effective.

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