Panic attack syndrome

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.

Panikanfälle und Angstsensitivität im Jugendalter

Zusammenfassung. Theoretischer Hintergrund: Das Jugendalter ist mit einem substantiellen Anstieg in der Häufigkeit von Panikanfällen verbunden. Erscheinungsbild und klinische Merkmale von Panikanfällen in dieser Altersgruppe sind noch kaum erforscht. Fragestellung: Neben der Häufigkeit von Panikanfällen wurde v.a. untersucht, ob sich plötzliche Panikanfälle von situationsgebundenen Panikanfällen im Erscheinungsbild sowie in Massen zur Angstsensitivität unterscheiden. Methode: Es wurden 1268 Schüler (12-16 Jahre alt) anhand eines Fragebogens befragt. Ergebnisse: 55% der Jugendlichen hatten bereits einen Panikanfall erlebt. Jugendliche mit plötzlichen Panikanfällen berichteten im Unterschied zu Jugendlichen mit situationsgebundenen Panikanfällen signifikant häufiger kognitive Symptome, die die Bedrohung der körperlichen Unversehrtheit beinhalteten. Jugendliche mit plötzlichen Panikanfällen bzw. Panikstörung zeigten die höchsten Mittelwerte in Massen zur Angstsensitivität und Depressivität. Schlussfolgerungen: Die Befunde sprechen für eine zentrale Rolle kognitiver Symptome und stehen damit im Einklang mit psychologischen Modellvorstellungen zur Panikstörung wie sie für Erwachsene formuliert wurden.

Role of local anesthetics on both cholinergic and serotonergic ionotropic receptors

A great body of experimental evidence indicates that the main target for the pharmacological action of local anesthetics (LAs) is the voltage-gated Na+ channel. However, the epidural and spinal anesthesia as well as the behavioral effects of LAs cannot be explained exclusively by its inhibitory effect on the voltage-gated Na+ channel. Thus, the involvement of other ion channel receptors has been suggested. Particularly, two members of the neurotransmitter-gated ion channel receptor superfamily, the nicotinic acetylcholine receptor (AChR) and the 5-hydroxytryptamine receptor (5-HT3R type). In this regard, the aim of this review is to explain and delineate the mechanism by which LAs inhibit both ionotropic receptors from peripheral and central nervous systems. Local anesthetics inhibit the ion channel activity of both muscle- and neuronal-type AChRs in a noncompetitive fashion. Additionally, LAs inhibit the 5-HT3R by competing with the serotonergic agonist binding sites. The noncompetitive inhibitory action of LAs on the AChR is ascribed to two possible blocking mechanisms. An open-channel-blocking mechanism where the drug binds to the open channel and/or an allosteric mechanism where LAs bind to closed channels. The open-channel-blocking mechanism is in accord with the existence of high-affinity LA binding sites located in the ion channel. The allosteric mechanism seems to be physiologically more relevant than the open-channel-blocking mechanism. The inhibitory property of LAs is also elicited by binding to several low-affinity sites positioned at the lipid-AChR interface. However, there is no clearcut evidence indicating whether these sites are located at either the annular or the nonannular lipid domain. Both tertiary (protonated) and quaternary LAs gain the interior of the channel through the hydrophilic pathway formed by the extracellular ion channel's mouth with the concomitant ion flux blockade. Nevertheless, an alternative mode of action is proposed for both deprotonated tertiary and permanently-uncharged LAs: they may pass from the lipid membrane core to the lumen of the ion channel through a hydrophobic pathway. Perhaps this hydrophobic pathway is structurally related to the nonannular lipid domain. Regarding the LA binding site location on the 5-HT3R, at least two amino acids have been involved. Glutamic acid at position 106 which is located in a residue sequence homologous to loop A from the principal component of the binding site for cholinergic agonists and competitive antagonists, and Trp67 which is positioned in a stretch of amino acids homologous to loop F from the complementary component of the cholinergic ligand binding site.

The genetics of anxiety disorders

The common denominator of anxiety disorders is that they share inappropriate levels of emotions and cognitions that affect rather than enable adaptive behaviours. The variety of symptoms include 'spontaneous' panic attacks with mental and physical symptoms, stimulus bound anxiety associated with avoidance behaviour, and almost constant 'generalized' anxious feelings. According to the DSM-IV criteria the anxiety disorders are classified as shown in Table I.

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.

Chest pain in teenagers. When is it significant?

Chest pain in teenagers often has no obvious organic cause. Onset of symptoms with an emotionally stressful situation may indicate psychogenic chest pain. The differential diagnosis also includes cardiac, musculoskeletal, gastrointestinal, and respiratory disorders. Routine testing generally does not help to establish a diagnosis and may even do harm by reinforcing a patient's unspoken fear of serious illness. Most teenagers with chest pain have no such illness, and symptoms usually resolve without therapy. An important role for primary care physicians is to provide support during evaluation and follow-up.

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.

Diagnosis of panic disorder in prepubertal children

Few reports on panic disorder in children are available, despite the retrospectively documented onset in childhood of about 20% of the cases of adult panic disorder. The authors report on six prepubertal children, aged 8 to 13 years, who met DSM-III-R criteria for adult-type panic disorder. Hyperthyroidism, cardiologic, and respiratory problems were excluded as well as abuse of caffeine or other drugs. The first panic attack occurred between 5 to 11 years of age, with an average interval of 3 years between onset of the disorder and diagnosis. Mitral valve prolapse was documented in two cases. Family history was always positive for panic disorder. Although not common, panic disorder should be considered in children with school phobia and positive family history. As it is in adults, mitral valve prolapse may be associated with panic disorder in children.

Psychosomatic symptoms in adolescence

This article provides the physician with an efficient and comprehensive method for the evaluation and management of adolescent psychosomatic symptoms in the medical care setting. The physician should make a firm statement of the nonorganic nature of the psychosomatic symptom, identify significant stressors, and provide strong recommendations for immediate action. Appropriate referrals should be arranged, and a follow-up visit to assess progress several weeks after the evaluation should be scheduled.

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.

Panic disorder: evidence for genetic vulnerability

Many studies have suggested that a genetic predisposition to the development of panic disorder exists. These studies are examined and their limitations discussed. It is suggested that only by the analysis of comprehensive family and twin data, coupled with other measures such as the search for possible single gene association or linkage and study of the children of panic disorder patients, will the mechanism for the 'familiarity' noted in panic disorder patients be elucidated. Delineation of the mode of transmission of panic disorder may allow preventative intervention with those at risk before they develop panic.

Neurologic presentations of panic disorder in childhood and adolescence

Four children with panic disorder, two boys and two girls between the ages of nine and 16 years, are discussed. They presented with complaints suggesting neurological disorder: 'dizziness', headache, episodic anxiety and 'blackout spells'. Neurological examinations and investigations were normal. Depression and/or anxiety were prominent in all cases. Drug treatment and psychotherapy were of some benefit. Four other children with attention deficit disorders are presented, whose mothers have panic disorder. This association points towards common biochemical influences and suggests that tricyclic drugs may be preferable to CNS stimulants as a form of treatment.

Evaluation and management of psychosomatic symptoms in adolescence

Adolescent patients commonly experience symptoms such as headache, chest pain, abdominal pain, or dizziness that are psychophysiologic responses to stress, anxiety, and depression. Because most symptomatic adolescents initially visit medical providers, and not mental health professionals, the clinician is faced with the challenge of providing a comprehensive evaluation that is not merely focused on the symptom. In addition to a careful medical assessment, this evaluation must include a review of psychosocial functioning in the family, school, peer group, and community. Appropriate management may include supportive counseling, instruction in relaxation techniques, anti-depressant medication, and referral for psychotherapy.