Case Study: Panic Disorder on a Child Psychiatric Consultation Service

Case Study Panic Disorder on a Child Psychiatric Consultation Service E. JANE GARLAND, M.D., F.R.C.P.(C),

AND

DERRYCK H. SMITH, M.D., F.R.C.P(C)

Abstract. 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-lII-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. J. Am. Acad. Child Adolesc. Psychiatry, 1990,29,5:785-788. Key Words: panic disorder, psychiatric consultation, somatization.

While "panic anxiety" and panic disorder have been recognized in the adult psychiatric literature for 20 years (Klein, 1964), the first cases of childhood panic disorder were reported only recently (Van Winter and Stickler, 1984; Herskowitz, 1986). In these initially reported cases, the diagnosis of panic disorder was made only after nonproductive investigation of somatic symptoms which were suggestive of cardiac, respiratory, or neurological disorders, including temporal lobe epilepsy. Furthermore, these childhood cases were found in pediatric populations and reported in the pediatric literature. Psychiatric comorbidity was not noted. At the same time, no cases of panic disorder were identified by structured interview in a study of 102 consecutive child psychiatry clinic referrals (Hershberg et al., 1982). More recently, panic disorder has been increasingly reported in child psychiatric populations. In the first clinical report, panic disorder was diagnosed by structured interview in two of 11 children referred for child psychiatric evaluation because of separation anxiety and school refusal (Vitiello et aI., 1987). In a subsequent, briefreport, the diagnosis of panic disorder was proposed for three children evaluated for severe separation anxiety or overanxious disorder who had a history of "panic-like" symptoms (Biederman, 1987). A study of 61 consecutive adolescent psychiatric admission, using a structured diagnostic interview, revealed that 10 (16%) cases met the criteria for panic disorder (Alessi et al., 1987). However, all of these adolescents had another primary psychiatric diagnosis, with 90% having a depressive disorder and half diagnosed as borderline personality disorder. Separation Accepted February 13, 1990. Dr. Garland is Consultant Psychiatrist, University Hospital-UBC Site Vancouver, B.C. Dr. Smith is Clinical Associate Professor, Department ofPsychiatry , University ofBritish Columbia, and Head, Department of Psychiatry, British Columbia Children' s Hospital, Vancouver, B .C. Reprint requests to Dr. Garland, Department ofPsychiatry, University Hospital-Ulltl Site, 2255 WesbrookMall, Vancouver, B.C., Canada V6T2A1. 0890-8567/90/2905-0785$02.00/0© 1990 by the American Academy of Child and Adolescent Psychiatry.

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anxiety disorder was diagnosed in four of these patients. In a similar study of prepubertal children on a psychiatric inpatient unit, seven met the criteria for panic disorder based on diagnostic symptom checklist covering the 2 week period since admission (Alessi and Magen, 1988). Four of these children also had a depressive disorder, and six had separation anxiety disorder. It is interesting to note that in a study of 220 children, judged by family history to be at high or low risk for depression, seven cases of panic disorder were identified by structured interview, all from the high-risk group (Moreau et al., 1989). All of these children had a comorbid psychiatric diagnosis; five had major depression, and five separation anxiety disorder. In a recent report of six children and adolescents with panic disorder, all had a history of a depressive disorder (Black and Robbins, 1990). Several features emerge from these reports. First, panic disorder is more likely to be diagnosed in child psychiatric populations if specific diagnostic questions are asked. Also, panic disorder is likely to be diagnosed in psychiatrically ill children and adolescents who have another primary diagnosis, particularly separation anxiety or depressive disorder. Finally, in these reports, family history of panic attacks is common, extensive, and often multigenerational (Moreau et aI., 1989; Biederman, 1987; Vitiello et aI., 1987; Van Winter and Stickler, 1984). In contrast to this relatively small number of panic disorder cases, there is a more extensive pediatric literature, with large case series, documenting the "hyperventilation syndrome" in children (Herman et aI., 1981; Joorabchi, 1977). The clinical features of this well described syndrome clearly meet the diagnostic criteria for panic disorder (American Psychiatric Association, 1980, 1987). Follow-up suggests that over half of these children have continued anxiety symptoms as adults and that over one-third developed depressive symptoms (Herman et al., 1981). This parallels the reported incidence of secondary major depressive episodes in adults with primary panic disorder (Breier et aI., 1984; Lesser et al., 1988). These pediatric reports suggest that just as adults with panic disorder have in the past been found in cardiology

GARLAND AND SMITH TABLE

Case

Age/Sex (Onset Age)

I. Cases ofPanic Disorder on Consultation Servi ce 1984-88

Severity (Frequency; No. DSM-lll-R Symptoms)

Family History

81M (8)

1-4/day; 9 symptoms

Alcohol abuse in father

2

151M (13)

2-3/day; 7 symptoms

3

15/F (12)

1-2/week; 6 symptoms

4

15.5/F (13)

1-5/day; 9 symptoms

PTSD in father; MDE and BMD in 2nd-degree relatives PD in mother; MDE in sib; Alcohol abuse in father None noted

Note : PD

=

panic disorder; MDE

=

major depressive episode; BMD

clinics with "irritable heart ," children with panic disorder without associated serious psychopathology may be more likely to present to pediatric rather than child psychiatric professionals. Indeed, children of preadolescent age may poorly describe the cognitive and emotional aspects of anxiety while presenting the somatic symptoms of distress . Furthermore, unless the syndrome is recognized, various labels such as "pseudoseizures" or conversion disorder may be applied for want of a clear diagnosis (Black and Robbins, 1990). Based on this literature, one would predict that, unless serious behavioral disturbance, such as school refusal or aggression (Alessi et al., 1988), had supervened to precipitate psychiatric assessment, uncomplicated childhood panic disorder may be more likely found in pediatric clinics. With the increased awareness of panic disorder by pediatricians, child psychiatric consultation may be requested. The authors observed, for example, on their Consultation Service an increased referral of cases from the neurology clinic for evaluation of potential panic disorder after an educational rounds on this topic . A review was undertaken of cases of panic disorder seen on the Child Psychiatry Consultation Service of a tertiary referral children's hospital in order to compare the presentation of Consultation Service panic disorder cases with those previously reported in child psychiatric inpatient and outpatient populations.

Panic Disorder Cases The record of diagnoses made on the Child Psychiatry Consultation Service at the British Columbia Children's Hospital was reviewed for the years 1984 to 1988 inclusive. All cases were identified in which panic disorder or panic attacks were mentioned in the initial, differential, or final diagnoses as well as cases with anxiety disorders and somatic symp toms. These charts were reviewed for documentation of panic disorder symptoms as well as other medical and psychiatric diagnoses. DSM-IIl-R criteria were used in evaluating the documented symptoms. All available information on 786

Diagnoses

Treatment

Panic disorder; Specific developmental disorder not otherwise specified Panic disorder; Agoraphobia (school refusal); Tricuspid and mitral valve prolapse Panic disorder; Family problem

Panic disorder; Ventricular septal defect

=

bipolar mood disorder; PTSD

Education; Imipramine

Propranolol; Alprazolam (recommended) Education; Stress reduction (improved) Education; Clonazepam

=

post-traumatic stress disorder.

investigations, treatment, and outcome was obtained from the chart. Symptoms meeting the diagnostic criteria for panic disorder were documented in four patients over this time period. These cases are summarized in Table I. Three of these had been referred from pediatric clinics after a thorough investigation had failed to yield a diagnosis. The referral to psychiatry followed many months of somatic investigation and treatmenttrials leading to frustration for the child, family, and clinicians. Psychiatric consultation appeared to be viewed by the family as invalidating the severity and reality of the symptoms, and parents had difficulty accepting the diagnosis of panic disorder. The first case illustrates the typical course of these patients through the health care system. This previously well developing 8-year-old boy , the youngest of three children in an intact family living in a small northern village, experienced his first spontaneous panic attack in the context of several stressors . He had recently reentered school with a new, strict teacher in Grade 3, and a reading disability had been recognized . He had some realistic worries about his father's physical health . Five minutes before the first panic attack, he had seen a grizzly bear in the wild very close to his small boat. This first attack was a typical episode of panic anxiety accompanied by fear , feelings of unreality, a sense that sounds were louder than usual while his vision was blurring, feeling that his hands were "fat" and numb, palpitations, nausea, and chest tightness. When subsequent episodes occurred at increasing frequency up to several times a day, the family physician was consulted. Within a month of onset, the family doctor referred the child several hundred miles to the B.C. Children's Hospital outpatient clinic to the first of several consultants, a cardiologist. This led to thorough cardiac evaluation, including ECG and echocardiogram. When the results ofthese investigations were normal, referral was made to a neurologist. Neurological evaluation, including a normal physical exam, CT scan and EEG, was followed by a tentative diagnosis of temporal lobe epilepsy. He was given a trial of carbamazepine which worsened the symptoms. The parents J. Am .Acad. Child Adolesc. Psychiatry, 29:5. September 1990

PANIC DISORDER ON CONSULTATION SERVICE

were very concerned and read several books in an effort to become educated on epilepsy and its treatment. By this time, the boy was frequently refusing to attend school and was developing mild agoraphobic symptoms. He was also experiencing anticipatory anxiety, initial insomnia due to fear of nighttime attacks, an irritable mood, and decreased concentration. He began to exhibit some oppositional behavior. His parents frequently had him in to the family doctor and he was identified as being "sick" in his family and small community. After 3 months of unexplained symptoms, a diagnostic hospital admission was arranged. Based on detailed clinical and EEG evaluation, temporal lobe epilepsy was ruled out and a tentative diagnosis of "complicated migraines" was considered. Finally, due to failure to substantiate other diagnoses, psychiatric consultation was requested with a referral diagnosis of "conversion reaction. " The diagnosis of panic disorder was made by the consultant psychiatrist based on symptoms meeting DSM-IlI -R diagnostic criteria. The parents had difficulty accepting this "psychiatric" diagnosis initially and wanted additional somatic investigations. There were given literature on panic disorder and gradually accepted this as a medical diagnosis. Imipramine and a behavioral approach emphasizing school attendance were recommended, to be supervised by a pediatrician and mental health center in their local area. At telephone followup 3 months later, the panic attacks had decreased greatly in frequency but school attendance was inconsistent. In the second case, a 15-year-old boy had 2 years of symptoms which were investigated by primary care physicians and a naturopath. The child had been place on homeopathic and dietary treatments before referral to the Children's Hospital. Inpatient cardiac and metabolic investigations including catecholamine levels preceded psychiatric referral. Echocardiography showed tricuspid and mitral valve prolapse. A trial of propranolol was unsuccessful in resolving his symptoms. Despite the psychiatric consultant's diagnosis of panic disorder, the parents were very reluctant to accept this opinion and sought additional consultation elsewhere rather than proceeding with a recommended trial of alprazolam. The outcome is not known. There was a family history of affective and anxiety disorders. Symptoms of agoraphobia with school refusal were prominent in the child, but were tolerated by the parents who saw him as physically "sick. " The third case was exceptional in this series in that this 15-year-old girl was referred directly to psychiatry for evaluation of anxiety attacks, which she identified as attacks similar to her mother's panic attacks. The family appeared to have made the diagnosis themselves and were seeking confirmation and advice. In this case, the attacks were less frequent, with fewer documented symptoms than in the other three cases. The patient felt she could manage without pharmacotherapy. The final patient, a 15-year-old girl, presented to her family physician and pediatrician complaining of "spells" characterized primarily by shortness of breath and chest tightness accompanied by anxiety. She had a small ventricular septal J. Am. Acad. Child Adolesc.Psychiatry. 29:5. September J 990

defect which was not considered contributory to her symptoms. She was investigated for a respiratory disorder, and a tentative diagnosis of intermittent bronchospasm was made. However, treatment with salbutamol worsened her symptoms. An anxiety disorder was suspected and referral to the psychiatric consultation service was made. Her symptoms clearly met the criteria for panic disorder, and clonazepam was recommended. In each of these cases of panic disorder, chart documentation indicated that these children had clearly and spontaneously described the detailed symptoms of their typical attacks. However, the three teenagers, all aged 15, had 2 to 3 years of symptoms before the diagnosis was made. In those cases that were extensively investigated over a prolonged period, the children had assumed a sick role in their families and social network by the time they presented for psychiatric assessment. Hence, the failure to make this diagnosis earlier was not benign in terms of the effects on the emotional and social development of these children.

Discussion While isolated' 'panic attacks" are seen in acute separation of children from primary attachment figures and on exposure to phobia stimuli, panic disorder usually does not present until adolescence or early adulthood. However, over one-quarter of adults with panic disorder report the onset of panic attacks in adolescence or earlier (Sheehan et al., 1981). The absence of reported cases of childhood panic disorder until very recently may be explained by four factors. The first is that only recently have physicians considered the diagnosis and asked appropriate diagnostic questions. The second factor is that children may have difficulty describing panic attack symptoms. The third factor is that, at onset, there may be variable or incomplete presentation of the panic attack syndrome. Finally, many cases may have been seen by pediatricians with diagnoses of "hyperventilation" or "irritable heart. " Based on these cases and the evidence in the literature, the authors propose that children with panic disorder will present to either a medical or a psychiatric setting depending upon whether their predominant symptoms are somatic or behavioral. Those coming to psychiatric clinics will usually have symptoms of other serious psychiatric illnesses, such as a depressive disorder or behavioral complications (agoraphobia, school refusal, aggression, or attentional disturbances), which may reflect anticipatory anxiety. Those with primarily somatic complaints will be seen in pediatric clinics including subspeciality clinics in cardiology, neurology, and possibly gastroenterology. It is notable that two of these cases had a minor cardiac anomaly. While mitral valve prolapse does not appear to increase the incidence of panic disorder, the coexistence of both disorders may increase the referral rate for evaluation (Hartman et al., 1982). The Consultation Service panic disorder cases, referred by medical specialists, were relatively uncomplicated by serious psychopathology compared to previously reported cases in psychiatric settings. However, the failure of early diagnosis in these cases produced complications of a different nature. These children not only did not receive definitive, specific

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treatment, but also suffered impairment in their socialization and school functioning while investigations continued and diagnostic uncertainty persisted. Once the diagnosis of panic disorder was made, these children could be offered specific treatment for their somatic complaints. While there are no controlled treatment studies in children, nevertheless, as in the cases in the present study, adult panic disorder treatments are being applied, including imipramine (Van Winter and Stickler, 1984), clonazepam (Biederman, 1987), alprazolam (Ballenger et aI., 1989), and phenelzine (Casat et aI., 1987). It has been demonstrated in a placebo-controlled study that imipramine is efficacious in the treatment of school refusal (Gittelman-Klein, 1971), and this effectiveness may be due to the fact that these children were suffering from panic disorder with agoraphobia. As in adults, pharmacological agents are used to control the panic attacks, and behavioral interventions are instituted to treat the secondary symptoms. The complication of school refusal, in particular, requires a behavioral approach because, as in one ofthese cases, this often will not be resolved with medication alone. In the present cases, education of caregivers played a major role in treatment. This was particularly important for parents who had for some time endured the worry that their child was seriously ill, and who had excused their child from expectations and responsibilities due to this sick role. The authors found that for some of these parents, a psychiatric diagnosis was somehow less acceptable than a medical one and there was reluctance to accept it. Provision of literature about panic disorder appeared to be helpful in making this diagnosis more concrete and "medical" for the parents. In summary, the authors' review of panic disorder on a child psychiatric consultation service suggests that psychiatric consultants and pediatricians must suspect panic disorder in children presenting with unexplained somatic symptoms. The authors predict that additional cases of uncomplicated panic disorder would be detected in systematic surveys of pediatric specialty clinics. Early recognition of panic disorder in children would allow definitive treatment, avoid unnecessary invasive investigations of somatic symptoms, and prevent psychiatric complications such as agoraphobia. References Alessi, N. E. & Magen, 1. (1988), Panic disorder in psychiatrically

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hospitalized children. Am. J. Psychiatry, 145:1450-1452. - - Robbins, D. R. & Dilsaver, S. C. (1987), Panic and depressive disorders among psychiatrically hospitalized adolescents. Psychiatry Res. 20:275-283. American Psychiatric Association (1987), Diagnostic and Statistical Manual of Mental Disorders, Revised. Washington, DC: American Psychiatric Association. American Psychiatric Association (1980), Diagnostic and Statistical Manual of Mental Disorders, ed. 3. Washington, DC: American Psychiatric Association. Ballenger, J. C.; Carek, D. 1., Steele, J. J. & Cornish-McTighe, D. (1989), Three cases of panic disorder with agoraphobia in children. Am.J.Psychiatry, 146:922-924. Biederman, J. (1987), Clonazepam in the treatment of prepubertal children with panic-like symptoms. J. Clin. Psychiatry,48:(Suppl):38-41. Black, B. & Robbins, D. R. (1990), Panic disorder in children and adolescents.J. Am. Acad. ChildAdolesc. Psychiatry, 29:36-44. Breier, A., Charney,D. S. & Heninger, G. R. (1984), Major depression in patients with agoraphobia and panic disorder. Arch. Gen. Psychiatry, 41:1129-1135. Casat, C. D., Ross, B. A., Scardina, R., Sarno, C. & Smith, K. E. (1987), Separation anxiety and mitral valve prolapse ina 12-yearold girl. J. Am. Acad. Child Adolesc. Psychiatry, 26:444-446. Gittelman-Klein, R. (1971), Controlled imipramine treatment of school phobia. Arch. Gen. Psychiatry,25:204-207. Hartman, N., Kramer, R., Brown, W. T. & Devereux, R. B. (1982), Panic disorder in patients with mitral valve prolapse. Am. J. Psychiatry, 139:669-670. Herman, S. P., Stickler, G. B. & Lucas, A. R. (1981), Hyperventilation syndrome in children and adolescents: long term follow-up. Pediatrics, 67:183-187. Hershberg, S. G., Carlson, G. A., Cantwell, D. P. &Strober,M. (1982), Anxiety and depressive disorders in psychiatrically disturbed children. J. Clin. Psychiatry,43:358-361. Herskowitz, J. (1986), Neurologic presentations of panic disorder in childhood and adolescence. Dev.Med. ChildNeurol., 28:617-623. Joorabchi, B. (1977), Expressions of the hyperventilation syndrome in childhood. Clin.Pediatr., 16:1110-1115. Klein, D. (1964), Delineation of two drug-responsive anxiety syndromes. Psychopharmacologia, 5:397-408. Lesser, I. M., Rubin, R. T., Pecknold, J. C. et al. (1988), Secondary depression in panic disorder and agoraphobia. Arch. Gen. Psychiatry, 45:437-443. Moreau, D. L, Weissman, M. & Warner, V. (1989), Panic disorder in children at high risk for depression. Am. J. Psychiatry, 146:10591060. Sheehan, D. V., Sheehan, K. E. & Minichiello, W. E. (1981), Age of onset of phobic disorders: a reevaluation. Compr. Psychiatry ,22:544553. Van Winter, 1. T. & Stickler, G. B. (1984), Panic attack syndrome. J. Pediatr. 105:661-665. Vitiello, B., Behar, D., Wolfson, S. & Delaney, M. A. (1987), Panic disorder in prepubertal children (letter). Am.J. Psychiatry, 144:525526.

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