Panic Disorder

Panic Disorder is an anxiety disorder where kids have sudden anxiety attacks called “Panic Attacks.” These attacks have specific symptoms like a racing heartbeat, sweating, dizziness, shortness of breath, and nausea. Sometimes a person might even feel like they are dying. These symptoms usually last about 10 minutes and often come from feelings of fear and a strong urge to leave the place or situation that started the attack. Kids who have had Panic Attacks often connect them with certain places or situations and feel anxious about having another attack in the same place. Fear of having another Panic Attack can cause a new one, so kids with Panic Disorder often avoid places where they have had an attack.

What are the symptoms of Panic Disorder?

Panic Disorder involves repeated, unexpected Panic Attacks. Between attacks, the person constantly worries about having another attack and/or changes their behaviors or activities to avoid having an attack. Specific symptoms of a Panic Attack include:

Core Symptoms of a Panic Attack

– Heart palpitations or fast heart rate

– Sweating

– Trembling or shaking

– Shortness of breath or feeling smothered

– Choking feeling

– Chest pain or discomfort

– Nausea or stomach distress

– Dizziness, unsteadiness, light-headedness, or faintness

– Chills or heat sensations

– Numbness or tingling

– Feeling detached from oneself or that things are not real

– Fear of losing control or “going crazy”

– Fear of dying

How is Panic Disorder diagnosed?

A child-adolescent psychiatrist may diagnose a child or teen with Panic Disorder after finding that their worries and/or avoidance behaviors are linked to a specific situation or place; they have trouble controlling their thoughts or feelings related to their symptoms, the situation, or the event; their symptoms have lasted for at least one month; and their symptoms cause significant problems in other parts of everyday life (e.g., social, family, school, etc.).

The psychiatrist may interview and/or assess both the child or teen and a caregiver to figure out the specifics of the child’s or teen’s distress and may use behavior and emotion rating forms to help with the diagnosis. The practitioner will also try to determine that the child’s or teen’s distress is not related to something unexpected.

Panic Disorder facts

Worldwide frequency of the condition:

Panic Disorder is estimated to affect 2% to 3% of the global population. Anxiety disorders, in general, affect approximately 6.5% of the global population.

Impact of the condition in Brazil:

Despite limited data, the estimated prevalence of anxiety disorders in Brazil is 2.9% in children (5-9 years) and 8.6% in adolescents (10-19 years). Panic disorder is a type of anxiety disorder, and there is no nationally representative data on it alone.

Gender ratio:

Data indicate that Panic Disorder is diagnosed more frequently in girls/women than in boys/men, with an estimated ratio of 2:1.

Peak age of onset:

The most common age of onset of Panic Disorder is estimated to be 15.5 years.

Proportion of the condition that emerges before age 18:

According to recent data, 75.0% of people with Panic Disorder will have been diagnosed by the age of 18.

What are the associated factors for Panic Disorder?

Some common factors linked with Panic Disorder are:

– Genetic and familial factors: A tendency toward an anxiety disorder most likely results from a combination of multiple genes interacting with environmental factors.

– History of asthma.

– Environmental factors: These include stressors in the months before a first Panic Attack (e.g., negative experiences with drugs, disease, death), adversity (e.g., exposure to previous trauma), low economic resources, and smoking.

– Temperament: These include anxiety sensitivity, harm avoidance, and behavioral inhibition.

What other disorders co-occur with Panic Disorder?

Even though each child and teen is different, individuals who meet the criteria for Panic Disorder sometimes also struggle with other anxiety disorders, depression, and bipolar disorders.

How is Panic Disorder treated?

Panic Disorder is usually treated with psychotherapy or a combination of psychotherapy and medication. Caregivers and other family members are an important part of treatment since they can help kids and teens practice the skills they learn in therapy.

There are multiple therapies that have been shown to effectively treat symptoms of Panic Disorder, but the one with the most evidence is a type of therapy called cognitive-behavioral therapy (CBT). CBT is a term that refers to a wide range of different cognitive and behavioral techniques. One technique is called interoceptive exposure. Using this technique, a therapist engages the child in exercises that mimic the physical symptoms (e.g., hyperventilation, increased heart rate) that usually trigger anxiety or panic, starting slowly and with small triggers. As the child becomes upset, the therapist teaches them ways to think about and handle their fear related to these symptoms. They repeat this process with bigger and bigger exercises. Other parts of CBT focus on lessening the fear that causes kids to avoid situations that remind them of Panic Attacks. Over time, changing their behaviors can ease their anxiety.

Children and teens with Panic Disorder tend to respond well to certain antidepressant medications called selective serotonin reuptake inhibitors (SSRIs). These include fluoxetine, sertraline, citalopram, escitalopram, and paroxetine. Other medications called serotonin norepinephrine reuptake inhibitors (SNRIs), such as duloxetine and venlafaxine, are also effective for reducing anxiety in children and teens. Benzodiazepines (e.g., clonazepam, diazepam) and tricyclic antidepressants (e.g., amitriptyline, clomipramine) are not effective in children and teens and should not be used. Medications can have side effects, but they are safe for kids to use with proper monitoring by their doctor and close supervision from their caregivers. A child or teen who is taking one of these medications should see their doctor regularly, especially if their dosage has recently changed.

The combination of CBT and SSRIs/SNRIs can also be considered, given some studies show evidence that the combination is better than either treatment alone in children and teens.

References

Clinical description, symptoms, and diagnostic information

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Child Mind Institute. (2021, September 7). Quick guide to panic disorder. _https://childmind.org/guide/quick-guide-to-panic-disorder/_

– World Health Organization. (2022, February). ICD-11 for mortality and morbidity statistics. 6B01 Panic Disorder. _https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/56162827_

Facts

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Eaton, W. W., Bienvenu, O. J., & Miloyan, B. (2018). Specific phobias. The Lancet Psychiatry, 5(8), 678–686. _https://doi.org/10.1016/S2215-0366(18)30169-X30169-X)_

– Institute for Health Metrics and Evaluation (IHME). (2019). GBD Compare Data Visualization. Seattle, WA: IHME, University of Washington. Available from _http://vizhub.healthdata.org/gbd-compare_. (Accessed 11/15/2022)

– Polanczyk, G. V., Salum, G. A., Sugaya, L. S., Caye, A., & Rohde, L. A. (2015). Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. Journal of Child Psychology and Psychiatry, 56(3), 345–365. _https://doi.org/10.1111/jcpp.12381_

– Sacco, R., Camilleri, N., Eberhardt, J., Umla-Runge, K., & Newbury-Birch, D. (2022). A systematic review and meta-analysis on the prevalence of mental disorders among children and adolescents in Europe. European Child & Adolescent Psychiatry. _https://doi.org/10.1007/s00787-022-02131-2_

– Solmi, M., Radua, J., Olivola, M., Croce, E., Soardo, L., Salazar de Pablo, G., Il Shin, J., Kirkbride, J. B., Jones, P., Kim, J. H., Kim, J. Y., Carvalho, A. F., Seeman, M. V., Correll, C. U., & Fusar-Poli, P. (2022). Age at onset of mental disorders worldwide: Large-scale meta-analysis of 192 epidemiological studies. Molecular Psychiatry, 27(1), 281–295. _https://doi.org/10.1038/s41380-021-01161-7_

Associated factors

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Ayano, G., Betts, K., Maravilla, J. C., & Alati, R. (2021). The risk of anxiety disorders in children of parents with severe psychiatric disorders: A systematic review and meta-analysis. Journal of Affective Disorders, 282, 472–487. _https://doi.org/10.1016/j.jad.2020.12.134_

– Gottschalk, M. G., & Domschke, K. (2017). Genetics of generalized anxiety disorder and related traits. Dialogues in Clinical Neuroscience, 19(2), 159–168. _https://doi.org/10.31887/DCNS.2017.19.2/kdomschke_

– Kendler, K. S. (2013). What psychiatric genetics has taught us about the nature of psychiatric illness and what is left to learn. Molecular Psychiatry, 18(10), 1058–1066. _https://doi.org/10.1038/mp.2013.50_

– Lawrence, P. J., Murayama, K., & Creswell, C. (2019). Systematic Review and Meta-Analysis: Anxiety and Depressive Disorders in Offspring of Parents With Anxiety Disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 58(1), 46–60. _https://doi.org/10.1016/j.jaac.2018.07.898_

– Ye, G., Baldwin, D. S., & Hou, R. (2021). Anxiety in asthma: A systematic review and meta-analysis. Psychological Medicine, 51(1), 11–20. _https://doi.org/10.1017/S0033291720005097_

Co-occurring disorders

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Preti, A., Vrublevska, J., Veroniki, A. A., Huedo-Medina, T. B., Kyriazis, O., & Fountoulakis, K. N. (2018). Prevalence and treatment of panic disorder in bipolar disorder: Systematic review and meta-analysis. Evidence Based Mental Health, 21(2), 53–60. _https://doi.org/10.1136/eb-2017-102858_

– Saha, S., Lim, C. C. W., Cannon, D. L., Burton, L., Bremner, M., Cosgrove, P., Huo, Y., & McGrath, J. (2021). Co‐morbidity between mood and anxiety disorders: A systematic review and meta‐analysis. Depression and Anxiety, 38(3), 286–306. _https://doi.org/10.1002/da.23113_

Interventions

– Allen, L. B., White, K. S., Barlow, D. H., Shear, M. K., Gorman, J. M., & Woods, S. W. (2010). Cognitive-Behavior Therapy (CBT) for Panic Disorder: Relationship of Anxiety and Depression Comorbidity with Treatment Outcome. Journal of Psychopathology and Behavioral Assessment, 32(2), 185–192. _https://doi.org/10.1007/s10862-009-9151-3_

– Carl, E., Witcraft, S. M., Kauffman, B. Y., Gillespie, E. M., Becker, E. S., Cuijpers, P., Van Ameringen, M., Smits, J. A. J., & Powers, M. B. (2020). Psychological and pharmacological treatments for generalized anxiety disorder (GAD): A meta-analysis of randomized controlled trials. Cognitive Behaviour Therapy, 49(1), 1–21. _https://doi.org/10.1080/16506073.2018.1560358_

– Correll, C. U., Cortese, S., Croatto, G., et al. (2021). Efficacy and acceptability of pharmacological, psychosocial, and brain stimulation interventions in children and adolescents with mental disorders: An umbrella review. World Psychiatry, 20(2), 244–275. _https://doi.org/10.1002/wps.20881_

– Cuijpers, P., Cristea, I. A., Karyotaki, E., Reijnders, M., & Huibers, M. J. H. (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry, 15(3), 245–258. _https://doi.org/10.1002/wps.20346_

– Gosmann, N. P., Costa, M. de A., Jaeger, M. de B., et al. (2021). Selective serotonin reuptake inhibitors, and serotonin and norepinephrine reuptake inhibitors for anxiety, obsessive-compulsive, and stress disorders: A 3-level network meta-analysis. PLoS Med, 18(6), e1003664. _https://doi.org/10.1371/journal.pmed.1003664_

– Mahdi, M., Jhawar, S., Bennett, S. D., & Shafran, R. (2019). Cognitive behavioral therapy for childhood anxiety disorders: What happens to comorbid mood and behavioral disorders? A systematic review. Journal of Affective Disorders, 251, 141–148. _https://doi.org/10.1016/j.jad.2019.03.041_

– Preti, A., Vrublevska, J., Veroniki, A. A., Huedo-Medina, T. B., Kyriazis, O., & Fountoulakis, K. N. (2018). Prevalence and treatment of panic disorder in bipolar disorder: Systematic review and meta-analysis. Evidence Based Mental Health, 21(2), 53–60. _https://doi.org/10.1136/eb-2017-102858_

– Rabasco, A., McKay, D., Smits, J. A., Powers, M. B., Meuret, A. E., & McGrath, P. B. (2022). Psychosocial treatment for panic disorder: An umbrella review of systematic reviews and meta-analyses. Journal of Anxiety Disorders, 86, 102528. _https://doi.org/10.1016/j.janxdis.2022.102528_

– Schwartz, C., Barican, J. L., Yung, D., Zheng, Y., & Waddell, C. (2019). Six decades of preventing and treating childhood anxiety disorders: A systematic review and meta-analysis to inform policy and practice. Evid Based Mental Health, 22(3), 103-110. _https://doi.org/10.1136/ebmental-2019-300096_

– Zhou, X., Zhang, Y., Furukawa, T. A., et al. (2019). Different Types and Acceptability of Psychotherapies for Acute Anxiety Disorders in Children and Adolescents: A Network Meta-analysis. JAMA Psychiatry, 76(1), 41. _https://doi.org/10.1001/jamapsychiatry.2018.3070_