Panic Disorder in Children and Adolescents

Symptoms of a panic attack 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). Older children and adolescents (who are able to clearly articulate their sentiments) often describe a sensation of impending doom. 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. Avoidance behaviors are considered agoraphobia if they greatly impair functioning, such as going to school, visiting the mall, or participating in other typical activities.

• Evaluation for general medical conditions

• Psychiatric assessment

• Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, Text Revision (DSM-5-TR) criteria

Panic disorder is diagnosed based on a history of recurrent panic attacks, usually after a physical examination is done to exclude medical causes of somatic symptoms (1). Thus, it is primarily a diagnosis of exclusion. 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, obsessive-compulsive disorder [OCD], social anxiety disorder) is needed because any 1 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.

• Selective serotonin reuptake inhibitors (SSRIs) for long-term management

• Benzodiazepines for short-term acute management (until SSRIs become effective)

• Cognitive behavioral therapy

Treatment of panic disorder is usually a combination of pharmacotherapy and cognitive behavioral therapy. In children, it can be difficult to begin behavioral therapy until after the panic attacks have been controlled adequately by medications.

SSRIs are the recommended treatment for long-term management; however, it can take several weeks for patients to experience improvement (1). Benzodiazepines work quickly in managing the acute anxiety that occurs in panic attacks and have been effective in the early phase of treatment until the onset of action of SSRIs (2). While there is limited data on benzodiazepines in panic disorder, lorazepam has been shown to be effective and well-tolerated when used in the short-term in managing procedure-related anxiety (which can present similar to panic episodes) (). While there is limited data on benzodiazepines in panic disorder, lorazepam has been shown to be effective and well-tolerated when used in the short-term in managing procedure-related anxiety (which can present similar to panic episodes) (3). Lorazepam can be preferentially administered as needed at the onset of a panic episode, or if necessary, orally 2 to 3 times/day until concurrently prescribed SSRIs become effective.). Lorazepam can be preferentially administered as needed at the onset of a panic episode, or if necessary, orally 2 to 3 times/day until concurrently prescribed SSRIs become effective.

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 over time. Longitudinal studies indicate that panic disorder is a chronic condition characterized by intermittent remissions and relapses over many years, with factors such as comorbid depression and other anxiety disorders increasing the severity and likelihood of relapse (1). Some patients experience long periods of spontaneous symptom remission, only to experience a relapse years later.