Assessment of Panic Disorder Across the Life Span

Although panic disorder is believed to emerge in late adolescence or early adulthood, adults with panic disorder often report having had panic symptoms starting in childhood or early adolescence (9). In most such individuals panic disorder may have either been misdiagnosed or not come to clinical attention. Epidemiological studies have reported that panic attacks may not be rare in the community samples of adolescents, although panic disorder may not be commonly reported. For instance, Goodwin and Gotlib (10) reported a prevalence of 3.3% of panic attacks from among 1,285 youth, aged 9–17 years, whereas Whitaker et al. (11) reported lifetime prevalence of panic disorder to be 0.6% using a structured interview with 5,000 students aged 14–17 years. A much higher prevalence of panic disorder has, however, been reported in the clinical samples. Biederman et al. (12) reported that 6% of the children and adolescents consecutively referred to their pediatric psychopharmacology clinic met the criteria for panic disorder. Similarly, Masi et al. (13) found that 10.4% of their consecutive outpatients referred to a mood and anxiety service had panic disorder.

Clinical presentation of panic symptoms in younger children compared with that in adolescents can be intriguing (14). Such a presentation can be manifested by the presence of atypical symptoms including “hyperventilation syndrome,” nocturnal occurrences, and fewer somatic and cognitive symptoms (15). Still, some of the common symptoms in younger children include palpitations, shortness of breath, sweating, faintness, and weakness (16). Among adolescents, symptoms such as chest pain, trembling, headache, and vertigo are reported (17). Another interesting developmental difference between the two age groups is that children and younger adolescents may attribute their symptoms to the external environment compared with older adolescents. Older adolescents are more competent of internal attributions that are more typically seen with panic disorder. Furthermore, cognitive symptoms appear only among adolescents (18). Interestingly, the fear of dying has been reported to be the earliest cognitive symptom whereas feelings of losing control and symptoms of depersonalization and derealization appear later (15, 17). Given the complexity of establishing a diagnosis of panic disorder in this population, the clinician may benefit by using brief self-reports and rating scales for anxiety disorders, some of which are even available for the preschool child. Table 2 lists some of the freely available assessment tools that include self-report, parent, and clinician versions.

Another interesting aspect in this age group is the association of panic symptoms with comorbid anxiety disorders including separation anxiety disorder and generalized anxiety disorder (27, 28). Separation anxiety disorder has been reported to be associated with early-onset panic disorder but not necessarily with adult onset panic disorder (29). Similarly, agoraphobia has been reported more frequently in younger-onset panic disorder (30). Furthermore, mitral valve prolapse has also been associated with a higher incidence of panic disorder in the adolescent population (31). The clinician should also rule out any medical causes (such as pheochromocytoma and thyroid disease) and substance use disorders, both of which are well known to imitate panic disorder. More details are considered in the next section. Along with these comorbidities, a strong family history of panic disorder should cue the clinician to perform a detailed assessment for panic disorder in the child. Awareness of early-onset panic disorder and a detailed assessment can potentially improve diagnosis and treatment and thus decrease impairment and improve quality of life for these patients.

The American Academy of Child and Adolescent Psychiatry practice parameter for anxiety disorders also provides recommendations for assessment of various anxiety disorders. Although not specifically discussing panic disorder, the practice parameter recommends that clinicians routinely include screening questions about anxiety symptoms and that the questions should use developmentally appropriate language based on DSM-IV-TR criteria. If the screening indicates significant anxiety, the clinician should thoroughly evaluate the patient to determine the type, nature, frequency, and severity of the anxiety disorder and assess the functional impairment caused by it. Clinicians may also find it beneficial to use sections of the available diagnostic interviews such as the Anxiety Disorders Interview Schedule for DSM-IV-Child Version (ADIS). The ADIS has a Feelings Thermometer (ratings from 0 to 8) that may help children quantify and self-monitor ratings of fear and interference with functioning. Younger children may use more developmentally appropriate visual analogs such as smiley faces and upset faces to rate severity and interference (32).

As discussed initially, the DSM-IV-TR defines panic disorder as comprising discrete episodes of marked autonomic arousal that are accompanied by catastrophic thinking and are not directly caused by substance use or a medical condition. The DSM-IV-TR requires recurrent unexpected panic attacks plus at least 1 month of persistent concern about experiencing additional attacks, worry about the implications or consequences of attacks, or a significant change in behavior related to attacks to establish the diagnosis of panic disorder. The DSM-IV-TR criteria require that at least 4 of 13 criteria must be present to diagnose a “full” panic attack. When fewer than 4 of the 13 symptoms of a panic attack are present, this is referred to as “limited symptom attack.” Agoraphobia is a fear of places or situations from which escape might be difficult or in which help may be unavailable in the event of a panic attack or panic symptoms. The ICD-10 criteria for panic disorder are similar to the DSM criteria but do not specify a threshold beyond recurrent attacks (33). This section addresses three important areas for the clinician when assessing panic disorder: screening and assessment tools, comorbid psychiatric disorders, and associated medical conditions.

There is very limited literature on the subject of panic disorder in the geriatric population. As a result, most recommendations regarding assessment of panic disorder are derived and extrapolated from the adult literature. Flint et al. (47) have reported a decline in panic attacks in elderly individuals; however, it is important not to dismiss the significance of such anxiety symptoms in this population. Although the diagnostic criteria of panic disorder are similar to those in the general adult population, its presentation may vary in elderly individuals. Panic attacks in this population may be more reactive to transient situations or life changes (48). Many times elderly individuals may not complain of anxiety symptoms but focus on physical symptoms (49). They may not elaborate on their subjective apprehensive states but rather discuss bodily dysfunction. These complaints can force the clinician to delve into extensive medical investigations when the etiology may be more functional. On the contrary, because elderly individuals are more predisposed to having a medical comorbidity, it is imperative not to dismiss their physical complaints either. As a result, panic disorder has not been very well studied and more research on the subject is needed.

Apart from the variability in quality of symptoms for panic disorder in this population, the frequency and severity of reporting of symptoms may vary as well. Sheikh et al. (50) reported that elderly individuals with panic disorder report less severe and fewer panic symptoms, less anxiety and arousal, and higher levels of functioning compared to middle-aged patients with panic disorder. Furthermore, elderly patients with late-onset panic disorder may report less distress with panic symptoms compared with older patients with early-onset panic disorder (50). It may take quite a few panic attacks along with insignificant laboratory results in elderly patients to lead to a diagnosis of panic disorder. The medical comorbidities that may present with panic-like symptoms are similar to those mentioned in the adult population as listed in Table 3 and should be thoroughly assessed, especially in this older population.

To the best of the author's knowledge, there are no specific rating scales available for assessment of severity and diagnosis of panic disorder in the geriatric population, especially because panic disorder has not been very well studied in this age group and possibly also owing to a decline in panic attacks in the population. One of the newly developed scales, the Geriatric Anxiety Inventory (GAI) has recently been shown to measure common symptoms of anxiety in older adults. It consists of 20 items that can be answered in a dichotomous manner, which is “agree/disagree.” The GAI can be self-rated or administered by a trained health professional. The GAI, however, was not designed to diagnose specific anxiety disorders but rather to assess the severity of anxiety symptoms across a range of presentations in older adults (51). Clinicians also use some other assessment tools such as the Hamilton Anxiety Scale and Beck Anxiety Inventory for monitoring the anxiety symptoms that are often comorbid with both psychiatric and medical conditions. It is important to recognize and treat such comorbid anxiety disorders as they can have a significant impact on the quality of life in this population. In fact, it has been reported that such patients may also have a much increased risk of both suicidal attempts and completed suicides (52). In addition, there is also some evidence to suggest that late-onset panic attacks may be due to preexisting depression (48). Furthermore, anxiety may also be a predictor of decline in cognitive functions, which should be simultaneously evaluated (53).

The diagnosis of panic disorder is based on a thorough history (from both the patient and the patient's family or caregivers), mental state examination, physical examination, and investigations selected to screen for medical etiology that could be contributing to symptoms. Initial screening investigations may include a complete blood count, fasting serum glucose level, serum calcium level, thyroid function tests, and an ECG. Physicians should have a high index of suspicion for panic attacks in older patients with multiple episodic physical symptoms that are not explained by physical examination and investigations. In addition, symptoms such as derealization, depersonalization, and fear of losing control should also alert the clinician to the possibility of panic disorder.

Panic disorder is a common, often impairing, anxiety disorder that usually presents in late adolescence or early adulthood. However, an onset in childhood or in the geriatric age group should not be discounted without an adequate and thorough assessment. Clinicians should always screen their patients in all age groups for panic disorder, using some of the DSM-IV-TR-based screening aids. Patients with panic disorder should always be assessed for comorbid psychiatric disorders and causative medical illnesses that may present as panic attacks. Clinicians should also be aware of the variability in clinical presentations that may be associated with both the pediatric and geriatric age groups.