eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Anxiety Disorder: Panic Disorder

Author: David S Reitman, MD, MBA, Director of Pediatric and Adolescent Health, John L Gildner Regional Institute for Children and Adolescents; Chairman of Pediatrics, Department of Pediatrics, Suburban Hospital; University Physician, George Washington University; Clinical Assistant Professor of Pediatrics, George Washington University; Attending Staff, Children's National Medical Center
Coauthor(s): Lene Holm Larsen, PhD, Instructor, Department of Child and Adolescent Psychiatry, Children's Memorial Hospital of Chicago; Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Contributor Information and Disclosures

Updated: May 24, 2006

Introduction

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

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).

• Search for CME/CE on This Topic »

• Anxiety Disorders (Psychiatry)

• Anxiety Center
• Anxiety Overview
• Anxiety Causes
• Anxiety Symptoms
• Anxiety Treatment
• Hyperventilation Overview
• Panic Attacks Overview

• School-Based Screening to Identify At-Risk Students Not Already Known to School Professionals: The Columbia Suicide Screen