Patient Presentation
A 17-year-old male came to clinic for difficulty eating for the past day. He was known to have generalized anxiety and specific panic attacks around food that he was being treated for with psychotherapy and selective serotonin reuptake inhibitors. He had not had a panic attack for many months. The day before he was at a picnic and choked on some potato salad while he had been talking and laughing with friends. He choked, coughed and then had emesis, he had feelings of anxiety and being out of control immediately afterwards. He noted he had tachycardia, tachypnea and sweating at that time. He walked away from the group and did deep breathing which helped but didn’t stop the problem. When he was calmer he drove himself home and since then has continued to have perseverative thoughts about the incident and is afraid to eat solid food. He had been drinking. He slept poorly. He stated that he knows that this is not rational, but he has been unable to calm his mind about it. The review of systems was negative.

The pertinent physical exam revealed a healthy male with slight tachycardia at 106 beats/minute, respiratory rate of 24/minute and normal blood pressure. He seemed anxious overall and seemed most anxious that he felt he should be able to control his feelings better than he was able to. His physical was normal.

The diagnosis of panic attack after a precipitating event was made. The pediatrician discussed options with the teenager. He decided that he was going to call his therapist and see if the therapist could see him or talk by phone or telemedicine the same day. He decided he didn’t want to try a benzodiazepine medication, but said that in the past he had used diphenhydramine for allergies which helped make him sleepy. “I actually already feel better just being checked out. I’m going to call my therapist, and I’m tired now because I didn’t sleep very well. I think I will be better after I get some sleep. My sister and parents are also really helpful, so I know I’ll be better,” he stated. A safety plan and reasons to followup were discussed.

Discussion
Panic disorder is “…one of the anxiety disorders and is characterized by repeated, unexpected panic attacks, involving physical symptoms such as racing heart, dizziness and chest pains, along with a fear of recurring attacks and changing behaviors to avoid further attacks.” It has both physical manifestations and mental ones including extreme fear such as mortal fear, loss of control and fear of alienation.
It is most common in teenagers aged 15-19 and is very common with about 1% of teens experiencing attacks. A study of college students in multiple countries found a lifetime prevalence of 5%.

A review of generalized anxiety disorder and an anxiety differential diagnosis can be found here.

Learning Point
Treatment for patients with panic attack is often multimodal with behavior and medication therapy used singly or in combination. Behavioral therapy to help the patient and family to understand the problem, recognize the triggers and increase coping skills to manage their symptoms are the basics. Cognitive behavioral therapy (CBT) has been used to treat patients with success. Relaxation methods often are very helpful to pediatric aged patients to manage their symptoms. Supportive school and home environments can offer consistency and reassurance can also help. Appropriate physical activity and exercise also can help patients with anxiety.

Selective serotonin reuptake inhibitors (SSRI) are usually the first type of medications used in addition to behavior therapy. SSRIs do carry a “black box warning” for a potential increase in suicidal ideation. Therefore this must be discussed with the patient and family along with a safety plan and close monitoring of the patient. Other medication options include benzodiazepines, selective serotonin and norepinephrine reuptake inhhibitors, and tricyclic antidepressants. Patients are usually treated with medication for at least 6-12 months before slow tapering of the medication.

For patients who are acutely having a panic attack, acknowledging the problem, calming talking with them, trying to decrease the ambient stimulation, and helping them to slow their breathing giving them time and space to help themselves often will be enough to bring some relief. Helping to fulfill other physiological needs such as hunger, thirst, sleep, too cold/too warm, etc also decreases the stress for the patient. For some patients a short-acting benzodiazepine such as lorazepam is sometimes used one time. Acute followup and counseling should be arranged for patients before they leave the emergency room or clinic.

Questions for Further Discussion
1. What is the difference between a fear and phobia? A review can be found here
2. What mental health resources are available in your community?

Related Cases

Disease: Panic Disorder | Anxiety

Symptom/Presentation: Behavior Problems | Mental Status Changes | Sleep Disturbance

Specialty: Psychiatry and Psychology

Age: Teenager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Panic Disorder

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Wang Z, Whiteside SPH, Sim L, et al. Comparative Effectiveness and Safety of Cognitive Behavioral Therapy and Pharmacotherapy for Childhood Anxiety Disorders. JAMA Pediatr. 2017;171(11):1049-1056. doi:10.1001/jamapediatrics.2017.3036

Auerbach RP, Mortier P, Bruffaerts R, et al. The WHO World Mental Health Surveys International College Student Project: Prevalence and Distribution of Mental Disorders. J Abnorm Psychol. 2018;127(7):623-638. doi:10.1037/abn0000362

Strohle A, Gensichen J, Domschke K. The Diagnosis and Treatment of Anxiety Disorders. Dtsch Arztebl Int. 2018;155(37):611-620. doi:10.3238/arztebl.2018.0611

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa