Panic Disorder in Children and Adolescents

Panic disorder is characterized by recurrent unexpected panic attacks, along with fear of having additional attacks.  A panic attack is a sudden rush of intense fear or discomfort, accompanied by at least four of the following symptoms:

• Accelerated heart rate or heart palpitations
• Sweating
• Trembling or shaking
• Shortness of breath or smothering sensations
• Feelings of choking
• Chest discomfort or pain
• Nausea or abdominal distress
• Dizziness, light-headedness, or faintness
• Chills or heat flashes
• Numbing or tingling sensations
• Feelings of unreality (derealization) or being detached or “out of body” (depersonalization)
• Fear of “going crazy” or losing control
• Fear of dying

Having panic attacks does not necessarily mean the child or adolescent has panic disorder.  To receive a diagnosis of panic disorder, the child or adolescent must also experience a month or more of at least one of the following:

• Persistent worry about having another panic attack or the possible consequences of another panic attack (such as having a heart attack or losing control)
• Problematic changes in behavior related to the attacks (such as avoiding exercise or certain situations because they might trigger a panic attack)

Panic disorder is only diagnosed when at least some of the panic attacks are not expected (“out of the blue”).  If the child or adolescent only has panic attacks in specific situations, like when giving a class presentation, panic disorder would not be diagnosed.

Panic disorder is characterized by abnormalities of brain function (including abnormal activation in the amygdala and other regions implicated in fear circuitry, such as the anterior cingulate cortex and insula), the nervous system (including the hypothalamic-pituitary-adrenal axis), and the respiratory system (including hyperventilation resulting in low levels of carbon dioxide),which are all thought to contribute to symptoms.  

In addition, misinterpreting bodily sensations as dangerous and avoiding certain bodily sensations are thought to contribute to the onset and persistence of panic disorder.  

Panic disorder is thought to have a genetic component, although having a genetic predisposition to panic disorder does not necessarily mean that someone will develop panic disorder.

Currently, clinical research suggests that the following treatments are effective:

• Cognitive-behavioral therapy consists of gradually exposing the child to feared bodily sensations while simultaneously refraining from avoidance behaviors.  The child also learns to interpret bodily sensations in more accurate and less threatening ways.  CBT also often includes parent interventions, which help parents more effectively manage their child's behavior and help to reduce their child's anxiety symptoms.
• Antidepressant medications, which are thought to help by improving the amount of serotonin in the brain, have not been studied extensively in pediatric panic disorder. However, medications that have been found effective for other types of pediatric anxiety include selective serotonin reuptake inhibitors (SSRIs) including:
• Fluoxetine
• Fluvoxamine
• Sertraline
• Paroxetine

Other Effective Treatments

In the event of non-response to first-line treatments, the following treatments have shown some evidence of efficacy in the treatment of pediatric anxiety:

• Alternative psychotherapeutic strategies such as psychodynamic psychotherapy
• Alternative medications, such as imipramine, clomipramine, or buspirone

Note: benzodiazepine treatment has generally not been found to be effective in pediatric anxiety disorders, despite evidence of short-term efficacy in adults.