Case Study

Diagnosis of Panic Disorder in Prepubertal Children

BENEDETTO VITIELLO, M.D., DAVID BEHAR, M.D., SAUL WOLFSON, M.D., AND

SUSAN V. McLEER, M.D.

Abstract. Few reports on panic disorder in children are available, despite the retrospectively documentedonset 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-IlI-R criteria for adult-type panic disorder. Hyperthyroidism, cardiologic, andrespiratory problems were excluded as well as abuse of caffeine or other drugs. The first panic attack occurredbetween 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. Althoughnot common, panic disorder should be considered in children with school phobia and positive family history. Asit is in adults, mitral valve prolapse may be associated with panic disorder in children. J. Am. Acad. Child Adolesc.Psychiatry, 1990,29,5:782-784. Key Words: panic disorders, children, mitral valve prolapse.

Anxiety disorders in children are usually classified apartfrom the anxiety disorders in adults. DSM-III and DSM-III-R(American Psychiatric Association, 1980, 1987) maintainthis tradition with "Anxiety Disorders in Childhood andAdolescence," namely, separation anxiety, avoidant disor­der, and overanxious disorder. A similar split in classifica­tion existed for depression before the use of adult criteria foraffective disorders became accepted in children. The presentclassification of anxiety disorders in children tantalizes byparalleling adult agoraphobia, social phobia, and generalizedanxiety disorder. There are suggestions of a continuity be­tween childhood and adult anxiety disorders. For instance,adult agoraphobics often reported having suffered from sep­aration anxiety as children (Gittelman and Klein, 1984). Abetter understanding of anxiety disorders in these differentage groups could ultimately lead to a more satisfactory clas­sification of childhood anxiety disorders, given also the factthat the interrater reliability of current childhood anxietydisorders is disappointing (kappa coefficients from 0.25 to0.44 versus 0.63 to 0.72 for adult anxiety disorders) (Ameri­can Psychiatric Association, 1980).

Panic disorder, which has a lifetime prevalence of about1.4% (Robins etal., 1984), often has an early onset. The peakof onset has been found to be between 15 and 19 years, with18% of adult patients indicating onset before 10 years of age(von Korff et al., 1985). This retrospectively documentedpresence of panic disorder in childhood contrasts with the

AcceptedNovember2, i989.Drs. Vitiello, Behar, and McLeer are with the Medical College of

Pennsylvania at the Eastern Pennsylvania Psychiatric institute, Phila­delphia, PA. Dr. Wolfson is with the Eastern State School and Hospital,Trevose,PA.

Presented at the 8th World Congress ofPsychiatry, Athens, Greece,October, i989.

The authors gratefully acknowledge the help ofM. A. Delaney, M.D.Reprint requests toDr. Vitiello, ClinicaiNeuropharmacology, Lab. of

Clinical Sciences, NiMH, NiH ClinicalCenter, iOI3D-4i, Bethesda, MD20892.

0890-8567/90/2905-0782$02.0010© 1990 by the American Acad­emy of Child and Adolescent Psychiatry.

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dearth of reports of panic symptoms in prepubertal children.Clinical descriptions of panic attacks in children are available(van Winter and Stickler, 1984; Biederman, 1987). Vitielloet al. (1987) reported on two cases of DSM-III panic disorderin prepubertal children, followed by Alessi and Magen(1987), who found that 5% of 136 child psychiatric inpatientshad this diagnosis. Last and Strauss (1989) reported a 9.6%prevalence of panic disorder in postpubertal child psychiatricoutpatients. Recently, other clinical reports of this disorderin children and adolescents have been published (Moreau etal. 1989; Hayward et al. 1989).

Mitral valve prolapse has been reported to be more frequentin adult patients with panic disorder (Crowe, 1985a). Single­case reports of association of mitral valve prolapse withseparation anxiety (Casat et al., 1987) and with panic disorderin children (Vitiello et al., 1987) are available.

The purposes of the present clinical report are: (1) toprovide additional evidence of the presence of adult-typepanic disorder in children; (2) to describe the clinical featuresof this disorder in childhood and its relationship with schoolphobia and separation anxiety; (3) to document the presenceof mitral valve prolapse in some of these children.

Cases

The authors report on six children, five boys and one girl,all white, aged 8 to 13 years, suffering from DSM-III-R panicdisorder. Patients were prepubertal (Tanner stage I or II) atthe time of diagnosis. Five were outpatients and one aninpatient. They were among approximately 320 inpatientsand 840 outpatients, aged 5 to 13 years, who were referred tothe authors' academic child psychiatry services during thepast 4 years. All the referred children received a completepsychiatric evaluation by child psychiatry fellows, supervisedby trained child psychiatrists. Children who presented withsymptoms suggestive of discrete episodes of anxiety werereferred to the authors for additional evaluation. Diagnosisof panic disorder (DSM-III-R) was obtained by two indepen­dent child psychiatrists. In addition to an unstructured psy­chiatric interview, the Diagnostic Interview for Children and

PANIC DISORDER IN PREPUBERTAL CHILDREN

TABLE I. Children with DSM-IIl-R Panic Disorder

Age at Age at 1st School Mitral Valve Family History ofCase Sex Tanner Diagnosis (yrs) Attack (yrs) Phobia Other Diagnoses Prolapse Panic Disorder

I M 8 5 + Separation anxiety + Paternal grandmother2 M 10 5 + Separation anxiety Brother, father3 M 9 6 Separation anxiety Mother, maternal aunt, and

grandmother4 M II 13 7 + Separation anxiety Mother, maternal grandmother5 M I 11 11 Overanxious Father, paternal grandfather6 F II 12 11 Oppositional + Maternal aunt

TABLE 2. Symptoms Presented during Panic Attacks in SixPrepubertal Children

medical disorders were found. He had an innocent heartmurmur and his echocardiogram was normal. His father andolder brother had suffered from panic disorder since earlyadolescence, and his brother had been school phobic. Apaternal cousin had had panic disorder with agoraphobia as achild and had committed suicide at 19 years.

Demographics, clinical, and echocardiographic findings ofthe six cases are summarized in Table 1. The age of onsetranged from 5 to 11 years. The two patients whose onsetoccurred at 5 years were the most severely disabled of thegroup. The occurrence of the first panic attack was alwaysremembered in detail by the patients and their families, whowere usually able to provide exact date and circumstancesunder which the disorder started. The onset of the disorderwas characterized by anxiety attacks which were unexpectedand nonsituationally related. The symptoms presented dur­ing the panic attacks are summarized in Table 2. Despite thefact that school was never the place of the first attack, threechildren displayed school avoidance a few months after theonset of the panic attacks . In addition to the panic disorder,four patients met criteria for separation anxiety, two foroppositional disorder, and one for overanxious disorder.Reasons for referral to the authors' clinic were the symptomsof panic attacks for three children and the school avoidancefor the remaining three. Mitral valve prolapse was docu­mented in two cases.

Family history was invariably positive for panic disorderand was often reported in several generations. As shown in

Adolescents (DlCA), child and parent versions (Herjanic andCampbell, 1977), and the panic disorder section of the adultDiagnostic Interview Schedule (DIS) (Robins et al., 1981),were administered by one of the two child psychiatrists . TheDIS was used because the DICA lacked a specific section onadult-type panic disorder. The diagnosis of panic disorderwas accepted when both the unstructured and structuredinterviews were consistent with the disorder. None of thesechildren had a history of significant medical problems. Inparticular, none suffered from asthma, hyperthyroidism, neu­rological, or heart diseases. They were not on medications.Caffeine abuse was excluded. Cardiologic examination andbidimensional echocardiogram were obtained in these sixchildren. Cardiologists were blind to the psychiatric diagno­sis. The parents were interviewed on the DIS. Family historywas obtained from the patients' parents. Family members,who were reported to suffer from psychiatric disturbances,were interviewed over the telephone using the DIS. How­ever, for some of them, direct interview was not possible andthe information had to be collected from the closest familymember.

Clinical vignettes of cases 1 and 2 are provided.

Casel

An 8-year-old white boy was referred to the inpatient unitfor severe separation anxiety with school avoidance since firstgrade. At 5 years of age, while at home with his parents, hesuffered a sudden anxiety attack lasting about 15 minutes,with palpitations, dyspnea, trembling, and sweating. Threeyears later, child and parents were still able to remember theexact day and time of this first episode. The attack did notoccur in the context of separation from family members , andthere was no evident trigger. He later presented with similarepisodes, both at home and in school, and refused to attendschool. At cardiologic examination, he had a midsystolicclick . The echocardiogram was positive for mitral valveprolapse. His father reported that his paternal grandmotherhad suffered from panic attacks.

Case 2

A lO-year-old white boy was referred to outpatient servicesfor separation anxiety with school avoidance. At 5.5 years ofage, he developed panic attacks while at home. He presentedwith more than five attacks per month. He later becameschool phobic, requiring a private tutor at home. No relevant

Symptom

Heart poundingWeaknessTrembling or shakingFeeling of dying or going crazyShortness of breathFeeling light-headed, dizzyChest tightness or painTingling of fingers or faceChoking or smotheringSweatingHot or cold flashesBlurred vision

No . of Patients Reporting

6666555444oo

J. Am .Acad. Child Adolesc. Psychiatry ,29:5, September 1990 783

VITIELLO ET AL .

Table I, only one side of the family, maternal (in four cases)or paternal (in the other two) , was affected .

Discussion

DSM-IIl-R criteria for adult-like panic disorder can be usedin prepubertal children. This disorder is not common in theauthors' experience, having been identified in six childrenover 4 years in a clinic that received more than 1,000 referralsduring the same period. However, the prevalence might havebeen underestimated, given that only the patients with severeseparation anxiety/school phobia were referred for structuredinterviewing. No systematic screening of a population wascarried out. Epidemiological data in adults showed a higherprevalence of panic disorder in females and an equal racialdistribution in whites and blacks (Robins et al., 1984) . Bycontrast, the cases in this study were white and predominantlymale. The small sample size, referral biases, or a combinationof these , may account for the discrepancy.

There are clear links between panic disorder and separationanxiety (Gittelman and Klein , 1984), with 24% of the childrenof depressed agoraphobic and panic patients presenting withseparation anxiety (Weissman et al., 1984). In this sample,separation anxiety accompanied the panic disorder in fourcases and school avoidance was present in three. Separationanxiety and school phobia were , however, independent ofpanic disorder, since two children did not have a history ofseparation anxiety or school phobia.

It is worth noting that the average interval between firstpanic attack and diagnosis ofpanic disorder was 3 years . Thismeans that these children remained without appropriate diag­nosis and specific treatment for several years.

Mitral valve prolapse is reported to be more common inpanic disorder patients (prevalence 38% to 50%) than in thegeneral population (Crowe, 1985a). Two of the six cases hadechocardiographically documented mitral valve prolapse.

The family history of these patients (Table 1) shows thepresence of panic disorder on one side of their families . Thisis consistent with an autosomal dominant transmission, assuggested elsewhere (Crowe, 1985b) .

Panic disorder, even if not common in childhood, shouldbe suspected when there is a family history of this disorder.The benefits of this approach are: (1) a nosographically"stronger" diagnosis , with better reliability and higher prog­nostic value than separation anxiety or overanxious disorder;(2) indications for more specific, validated treatments , in­cluding the use of tricyclic antidepressants and benzodiaze-

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pines. In addition, children with panic disorder, as adults ,may have a higher rate of mitral valve prolapse. A higherprevalence of diagnosed panic disorder in children may en­courage attempts to additionally unify (Le. , to see as acontinuum) the adult and child anxiety disorders , as hasbeen done with the affective and schizophrenic disorders .

References

Alessi, N. & Magen , J . (1987), Panic disorder in psychiatrically hospi­talized children. Am.J. Psychiatry, 145:1450-1452.

American Psychiatric Association (1987), Diagnostic and StatisticalManual of Mental Disorders, Third Edition, Revised, Washington,DC:APA,pp.58-64.

--American Psychiatric Association (1980), Diagnostic and Statis­tical Manual ofMental Disorders, Third Edition. Washington , DC:APA.

Biederman, J. (1987), Clonazepam in the treatment of prepubertal chil­dren with panic-like symptoms. J .Clin. Psychiatry, 48 (Suppl):38­41.

Casat, C. , Ross, B. A. , Scardina , R. , Sarno , C. & Smith, K. E. (1987) ,Separation anxiety and mitral valve prolapse in a 12-year-old girl. J .Am.Acad .Child Adolesc. Psychiatry, 26:444-446.

Crowe, R. R. (l985a), Mitral valve prolapse and panic disorder . Psy­chiatr. Clin.NorthAm., 8:63-71.

-- (l985b), The genetics of panic disorder and agoraphobia. Psy­chiatr.Dev.2:171-185.

Gittelman, R. & Klein, D. F. (1984), Relationship between separationanxiety and panic and agoraphobic disorders . Psychopathology,17(Suppl. 1): 56-65.

Hayward, C., Killen, J. D. &Taylor,C. B. (1989), Panic attacks in youngadolescents.Am .J.Psychiatry, 146:1061-1062.

Herjanic , B. & Campbell , W. (1977) , Differentiating psychiatricallydisturbed children on the basis of a structured interview . J .Abnorm .ChildPsychol., 5:127-134.

Last, C. G. & Strauss , C. C. (1989) , Panic disorder in children andadolescents. Journal of Anxiety Disorders, 3:87-95.

Moreau, D. L., Weissman, M. & Warner, V. (1989), Panic disorder inchildren at high risk for depression . Am. J. Psychiatry , 146:1059­1060.

Robins, L. N. ,Helzer, J .E. ,Weissman M. M. , Orvaschel H. , GruenbergE., Burke J. D., Regier D. ( 1984) , Lifetime prevalence of sp ecificpsychiatric disorders in three sites . Arch. Gen. Psychiatry, 41:949­958.

----Croughan,J., Williams,J. B. W. &Spitzer,R. L. (1981),TheNIMH Diagnostic Interview Schedule: Version //1 . (PublicationADM-T-42-3) Washington , DC: Public Health Service .

Van Winter , J. T. & Stickler, G. B. (1984), Panic attack syndrome. J.Pediatr. , 105:661-665.

Vitiello, B. , Behar, D. , Wolfson , S . & Delaney , M. A. (1987), Panicdisorder in prepubertal children . Am.J.Psychiatry, 144:525-526 .

VonKorff,M. R. ,Eaton ,W.W.&Keyl,P. M. (1985),The epidemiologyof panic attacks and panic disorder. Am .J. Epidemiol, 122:970-981.

Weissman , M. M. , Leckrnan, J. F. , Merikangas, K. R. Gammon , G. B.& Prusoff, B. A. (1984) , Depression and anxiety disorders in parentsand children . Arch .Gen .Psychiatry,41:845-852.

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