Neurologic presentations of panic disorder in childhood and adolescence

Panic disorder in children and adolescents with noncardiac chest pain

Adults with panic disorder (PD) often present to medical settings with noncardiac chest pain (NCCP), but less is known about children and adolescents with this complaint. We sought to characterize PD in youth with NCCP and compare features with PD in youth in psychiatric outpatient settings. Using a semi-structured diagnostic interview we evaluated 132 youth (ages 8-17) with NCCP recruited from two medical settings. Twenty-seven (20.5 %) met full DSM-IV criteria for PD, eleven of which were children (<13 years). Most frequent panic symptoms were somatic complaints, although cognitive symptoms were also common. Only 14.8 % had clinically significant agoraphobia. Comorbid anxiety disorders and major depression were common. Overall, clinical features of PD among youth with NCCP are similar to PD in psychiatric settings. Interventions for PD may benefit youth who present initially with NCCP. Systematic psychiatric screening could increase detection of PD and improve care for this population.

Paroxysmal nonepileptic events of childhood

The paroxysmal nonepileptic events of childhood are a group of disorders, syndromes, and phenomena that mimic true epileptic seizures. Clinical experience and a clear description of the event in question will usually lead to a correct categorization. They span in age from neonate to young adult and are apt to be the most common diagnostic challenges clinicians face regularly. The key to diagnosis is a detailed history and careful observation. Despite the large number of discrete entities enumerated herein, common principles in clinical approach are successful and described. Each entity can pose a significant clinical challenge in identification, etiologic pathophysiology, genetics, and management. A simple division is offered here separating those episodes that are associated with an altered mental status or occurring during sleep and those without an altered mental status or occurring while awake.

Pharmacological treatment options for panic disorder in children and adolescents

Although panic disorder usually emerges in early to middle adulthood, adults with panic disorder often retrospectively report that their panic symptoms began in childhood or early adolescence. The majority of these juvenile cases are being misdiagnosed, and/or do not come to clinical attention. Awareness of early-onset panic disorder, as well as a more precise definition of early signs and possible clinical subtypes, can favour timely diagnosis and treatment, reduce clinical impairment and improve the prognosis of these patients. In the context of a multimodal approach, pharmacological treatment can be helpful. This review focuses on the empirical evidence of pharmacotherapy in early-onset panic disorder, including selective serotonin re-uptake inhibitors, benzodiazepines and tricyclics. The data supporting efficacy are still limited, and no controlled studies are available. Practical guidelines for the management of these patients are provided, including treatment of the most frequent psychiatric comorbidities.

Non-rapid eye movement sleep parasomnias

Parasomnias are unpleasant or undesirable behavioral or experiential phenomena that occur during sleep. Once believed unitary phenomena related to psychiatric disorders, it is now clear that parasomnias result from several different phenomena and usually are not related to psychiatric conditions. Parasomnias are categorized as primary (disorders of the sleep states) and secondary (disorders of other organ systems that manifest themselves during sleep). Primary sleep parasomnias can be classified according to the sleep state of origin: rapid eye movement sleep, non-rapid eye movement sleep, and miscellaneous (those not respecting sleep state). Secondary sleep parasomnias are classified by the organ system involved.

[Are eight-year olds already suffering from panic disorder? Investigation of prevalence with focus on panic disorder and agoraphobia]

A representative sample of 826 eight-year-old second-graders in Dresden was examined in a two-stage procedure to ascertain the 6-month prevalence of DSM-IV anxiety disorders. Particular care was taken to assess panic disorder. The eight-year-olds had already been interviewed personally in a screening session and in 230 children an individual diagnostic examination with a structured diagnostic interview was carried out. The total prevalence of anxiety disorder was 9.5%. No case of either panic disorder or agoraphobia was found. For the diagnosis of agoraphobia the DSM-IV diagnostic criterion was lacking in which situations typical to agoraphobia are feared or avoided because escape would be difficult or it would be difficult to reach help. Eight-year-olds do not forge this cognitive link. In agoraphobic situations 2.5% of the children (almost exclusively, girls) suffer from a specific phobia. The prevalence of anxiety disorders is markedly higher among girls than in boys.

Auditory hallucinations in nonpsychotic children with affective syndromes and migraines: report of 13 cases

This report describes the discovery of a possible association between auditory hallucinations, migraine, and affective/anxiety disorders in nonpsychotic children. The cases were culled by a review of all consultations in an outpatient practice in an 8-month period. Thirteen cases of nonpsychotic children who experienced hallucinations (auditory in 12) were found. All but one suffered from a variety of major affective or anxiety/panic disorders and migraine headaches. The family histories were strongly positive for affective/anxiety disorders and migraine, and four of the parents also had a history of hearing voices. The age of onset of the auditory hallucinations, where known (8 cases), was between 4 and 8 years. In only two cases did the voices accompany the migraine attacks, and these two children also heard voices at other times. Although a strong association between migraine and anxiety, panic, and affective syndromes in adults has been repeatedly found in epidemiologic study, no such association has been studied in children, and this is the first known report of a possible association between migraine, affective/anxiety disorders, and auditory hallucinations in nonpsychotic children. It suggests the need for epidemiologic study.

A critical review of pharmacotherapy for youth with anxiety disorders: things are not as they seem

Given the increasing trend in clinical child psychology and psychiatry toward cost-effective and pharmacological treatment, a review of key factors that influence treatment outcomes in this area seems warranted. This is especially important for the rapidly changing area of childhood anxiety disorders. In this article, we look at different change producing procedures to illustrate the claim that pharmacological studies are not necessarily what they seem. Specifically, pharmacological outcome studies are classified and reviewed on the basis of varying "secondary" treatments described in method sections. Three groups and efficacy rates were determined: (a) pharmacotherapy only (42.83%), (b) pharmacotherapy plus general/supportive psychotherapy (27.74%), and (c) pharmacotherapy plus a behavior therapy component (65.28%). We also discuss the implications of these findings for research as well as other methodological and theoretical concerns regarding the reviewed articles. These concerns include (a) methods used to diagnose participants, (b) methods used to assess improvement, (c) emphasis on diagnostic categories, (d) exclusionary criteria and comorbidity, (e) participant attrition and follow-up, and (f) key developmental and social contextual variables.

Children's cognitive responses to the somatic symptoms of panic

The purpose of this study was to test Nelles and Barlow's (1988) hypothesis that spontaneous panic attacks are rare or nonexistent prior to adolescence as children lack the ability to make the internal, catastrophic attributions (i.e., thoughts of losing control, going crazy, or dying) characteristic of panic according to the cognitive model (Clark, 1986). Conceptions of panic attacks, including the understanding of symptoms and causes, and cognitive interpretations of the somatic symptoms of panic were examined in children from Grades 3, 6, and 9. A significant main effect for grade was found for conceptions of panic attacks, with third graders receiving significantly lower scores than sixth and ninth graders. However, the majority of all children, regardless of age, tended to employ internal (e.g., "I'd think I was scared or nervous") rather than external (e.g., "I'd think I was feeling that way because of the temperature or the weather") explanations of panic attacks. No significant grade differences were found for the tendency to make internal versus external and catastrophic versus noncatastrophic attributions in response to the somatic symptoms of panic. When presented with panic imagery in a panic induction phase, children, regardless of age, made more internal and noncatastrophic attributions. Finally, internal attributional style in response to negative outcomes and anxiety sensitivity were found to be significant predictors of internal, catastrophic attributions. The challenge that these findings pose to Nelles and Barlow's hypothesis, and their relevance for understanding children's cognitive interpretations of panic symptomatology are discussed.

Assessment and phenomenology of nonclinical panic attacks in adolescent girls

Recent reviews of studies concerning panic attacks in adolescents have emphasized research limitations, noting problems of validity, reliability, and lack of normative data. To address some of these limitations we evaluated two methods of panic ascertainment (questionnaire versus interview), reliability of interview-determined panic, and clinical correlates of panic symptoms in a large sample (N = 1013) of early adolescent girls. The 5.4% of the sample who, when interviewed, reported ever experiencing a panic attack scored significantly higher on measures of depression, anxiety sensitivity, and alcohol use, but were not more avoidant than others. Using the interview as the standard, the questionnaire had a specificity of 81% and a sensitivity of 72%. Adolescents do experience panic attacks-whether identified by questionnaire or interview-although for many the attacks may not be salient. Longitudinal studies are required to determine those qualities of nonclinical panic (severity, context, interpretation/attribution), which render some episodes as clinically meaningful.

Panic in children and adolescents: a review

Based on our review of the available data, we conclude that panic attacks are common among adolescents, while both panic attacks and Panic Disorder appear to be present, but less frequent, in children. Furthermore, it is evident that both adolescents and children who report panic attacks describe the occurrence of cognitive symptoms, although with less frequency than physiological ones. Consistent with the cognitive model of panic, it seems that at least some youngsters are capable of experiencing the physiological symptoms of panic accompanied by the requisite catastrophic cognitions. However, a more complete understanding of the cognitive manifestation of panic attacks/disorder among children awaits further investigation. Future research should aim to explore the developmental progression in children's cognitive responses to specific panic symptomatology. Risk factors (e.g. anxiety sensitivity, depression) which may contribute to the likelihood of misinterpreting physiological sensations in a catastrophic manner throughout the course of development should also be assessed: Finally, we are in general agreement with Abelson and Alessi (1992) who argue that we must begin to ask ourselves how panic disorder may be manifested in children. That is, rather than assessing the frequency with which children experience symptoms of adult panic, we should explore what panic would look like in children. They propose that the study of panic in children would be facilitated by a reformulation of separation anxiety as a childhood expression of panic disorder. Although this reformulation makes intuitive sense and is appealing from a developmental perspective, we would insert a strong caveat. Although the research is yet to be conducted, it is probable that childhood separation anxiety is only one of many routes to panic disorder outcome. It is improbable that such direct and continuous pathways are present for the majority of children, adolescents and adults who experience panic disorder. More probably, the pathways are multiple, complex, and discontinuous (Robbins & Rutter, 1990). Much work remains to be done before we are able to ferret out the linkages between developmental processes and clinical outcomes for panic disorder in children and adolescents.

[Panic attacks and panic disorders in the child]

Panic disorders in adults have been the object of many studies. They are better known in adolescents but have been noticed insufficiently in children although panic disorder is potentially dangerous at that age. After demographic considerations, the clinical aspects are examined and illustrated using two detailed observations.

Simultaneous prepubertal onset of panic disorder, night terrors, and somnambulism

Concurrent acute onset of night terrors, somnambulism, and spontaneous daytime panic attacks meeting the criteria for panic disorder is reported in a 10-year-old boy with a family history of panic disorder. Both the parasomnias and the panic disorder were fully responsive to therapeutic doses of imipramine. A second case of night terrors and infrequent full symptom panic attacks is noted in another 10-year-old boy whose mother has panic disorder with agoraphobia. The clinical resemblance and reported differences between night terrors and panic attacks are described. The absence of previous reports of this comorbidity is notable. It is hypothesized that night terror disorder and panic disorder involve a similar constitutional vulnerability to dysregulation of brainstem altering systems.

Panic disorder on a child psychiatric consultation service

In a review of all cases seen from 1984 to 1988 by the psychiatric consultation-liaison service of a tertiary referral pediatric hospital, four cases of definite panic disorder meeting DSM-III-R criteria were identified. Three of these children were referred to the consultation service after intensive investigation of physical complaints had failed to yield a diagnosis. These cases of panic disorder differed from those previously reported in child psychiatric populations by their relative absence of psychiatric comorbidity. This suggests that uncomplicated panic disorder may present with primarily somatic symptoms in pediatric subspecialty clinics, while panic disorder, complicated by behavioral or emotional disturbance, is more likely to present directly to child psychiatric services. Children presenting with somatic symptoms are at risk for receiving nonproductive investigations while having delayed diagnosis and treatment of the panic disorder.

A pilot study of panic attacks in a child and adolescent psychiatric population

This preliminary study examines the prevalence of panic attacks in a child and adolescent psychiatric population through a questionnaire survey of child psychiatrists. Panic attacks were reported in 26% of the sample. The rates varied with patient diagnosis, age, and sex.

Panic disorder in children and adolescents

Panic disorder is a common and well-known psychiatric disorder which commonly has its onset during adolescence. However, the disorder has only recently been described in children and adolescents. The clinical literature describing panic disorder in children and adolescents is reviewed, and six cases are presented. Future directions for research are suggested.