eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics
Anxiety Disorder: Panic Disorder: Treatment & Medication
Updated: May 24, 2006
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
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
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.
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.
Fluoxetine (Prozac)
Longest use in children and adolescents. Now available in generic preparations. Long half-life is an advantage and drawback. If it works well, an occasional missed dose is not a problem. If problems occur, eliminating all active metabolites takes a long time (ie, several weeks). Adverse effects of SSRIs appear to be quite idiosyncratic; thus, relatively little reason exists to prefer one to another if dosing is started at a conservative level and advanced as tolerated.
Adult
15-30 mg/d PO is usually sufficient
Even for adults with panic disorder, starting dose and advance rate should be similar to those used in children because of the potential for initially worsening panic symptoms
Patients with social anxiety or another comorbid disorder may need the dose increased to the maximum for that disorder
Pediatric
<18 years: Not approved
2 mg/d PO initially
Children and adolescents benefit from as little as 5-10 mg/d; thus, rate of advance should be conservative
Potent inhibitor of CYP450 3A4 (important to check with a pharmacist for this or any new SSRI if the patient is receiving several medications); increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAOIs and highly protein-bound drugs; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan); discontinue other serotonergic agents at least 2 wk prior to beginning SSRIs
Documented hypersensitivity; MAOIs concurrently or within last 2 wk
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
May cause agitation in children and adolescents; may cause bipolar switch in vulnerable individuals (as with all antidepressants); use with caution in individuals with compromised hepatic function or history of seizures; can cause movement problems, gastrointestinal upset, weight change, and insomnia
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.
Diazepam (Valium)
Individualize dosage and increase cautiously to avoid adverse effects. Note need to use for shortest time possible in patients when abrupt discontinuation is not a risk. Furthermore, should not be continued if patient is not also being monitored by a therapist on a regular basis.
Adult
2-10 mg PO q3-4h, repeat q2-4h prn; not to exceed 30 mg in 8 h
Pediatric
Infants and young children: 0.1-0.3 mg/kg/d PO
Older children and adolescents: 1-2.5 mg PO
Phenothiazines, barbiturates, alcohol, and MAOIs increase CNS toxicity when administered concurrently
Documented hypersensitivity; narrow-angle glaucoma; risk of pregnancy
Pregnancy
D - Unsafe in pregnancy
Precautions
Caution with other CNS depressants, SSRIs, low albumin levels, and hepatic disease
More on Anxiety Disorder: Panic Disorder |
| Overview: Anxiety Disorder: Panic Disorder |
| Differential Diagnoses & Workup: Anxiety Disorder: Panic Disorder |
 Treatment & Medication: Anxiety Disorder: Panic Disorder |
| Follow-up: Anxiety Disorder: Panic Disorder |
| References |
| « Previous Page | Next Page » |
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].
Further Reading
Keywords
panic disorder, hyperventilation syndrome, agoraphobia, panic attacks, unexpected panic attacks, situationally bound panic attacks, situationally predisposed panic attacks, recurrent panic attacks
