Role of Panic Attacks in the Intractability of Asthma in Children

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108 PEDIATRICS Vol. 94 No. I July 1994

EXPERIENCE

AND

REASON-Briefly

Recorded

“In Medicine one must pay attention not to plausible theorizing but to experience and reason together. ... I agree that theorizing is to be approved, provided that it is based on facts, and systematically makes its

deductions from what is observed. ...But condusions drawn from unaided reason can hardly be serviceable;

only those drawn from observed fact.” Hippocrates: Precepts. (Short communications of factual material are

published here. Comments and criticisms appear as letters to the Editor.)

Role

of Panic

Attacks

in the

Intractability

of Asthma

in Children

Many authors have stressed the impact of anxiety

on asthma. Kinsman has demonstrated how a

“pan-icky’ life-style could interfere with asthma

manage-ment and even result in an increase in use of medi-cations.’ Similar findings were observed in children at our institution.2”

Contrary to the concept of a “panicky” patient as used by Kinsman,’ the American Psychiatric

Associ-ation defines a specific entity called panic state or

panic disorder remarkable by its intensity and

pain-fulness as well as in the intense fear of resurgence it provokes in patients.

The official criteria of panic disorder in DSM3-R4 in the adult classification are:

A) One or more panic attacks (discrete periods of

intense fear or discomfort) that were unexpected,

ie, did not occur immediately on exposure to a

situation that almost always caused anxiety.

B) Either four attacks have occurred within a 4-week

period or one of more attacks have been followed

by a period of at least 1 month of persistent fear of

having another attack.

C) At least four of the symptoms shown in Table 1 developed during at least one of the attacks.

This entity has not been recognized until recently

in children.5 One reason may be that children under 12 years of age are unable to adequately describe these symptoms. In adult asthmatics, Karajgi de-scnbed a prevalence of panic attacks 5.3 times higher

than in the normal population.6 It is therefore a

reasonable hypothesis that a similar phenomena exists in children. Our clinical work conducted in a large pediatric hospital in Montreal indicates such a possibility.

Since many symptoms of panic can be easily

mis-taken for asthma symptoms, we studied the effects of real panic attacks (following the definition of DSMIII-R) on asthma in children. Rapid and noisy

breathing, rapid pulse, sweating, and even chest pain are part of both panic attacks and asthma

Received for publication Jul 27, 1993; accepted Nov 19, 1993.

Reprint requests to (C.B.) D#{233}partement de Psychiatrie, H#{244}pitalSte-justine, 3175 C#{244}teSte-Catherine, Montreal, Quebec H3T 1C5.

PEDIATRKS (ISBN 0031 4005). Copyright C 1994 by the American Acad-emy of Pediatrics.

attacks. For children, intense fear is also present in

both instances.

Our question was whether, when we recognize

and treat this entity in young asthmatics, we only solve the psychiatric problem or we also change the course of asthma. In other words, can this psychiatric condition potentiate an asthma crisis.

The following clinical case demonstrates the chal-lenge in differentiating between two possible condi-tions. This difficulty may be due to a child’s inability

to express body sensations as an adult might, but

rather with images and vague complaints.7

CLINICAL CASE

A 3-year-old male with difficUlty of breathing, in-drawing wheeze, tachypnea, and a significant improvement of symptoms

after bronchodilator inhalation was diagnosed as having asthma.

A few months later, he was admitted to the intensive care unit for

prolonged seizures following an acute attack of asthma. When he

returned to a regular ward, he started complaining about

persis-tent stomach pain for two consecutive days. Since no infectious cause could be detected, aminophyffin toxidty was suspected,

even though blood concentrations never reached toxic levels.

He was subsequently admitted 13 times for asthma attacks in

the next 3 years. By the age of 6 years and 6 months he was on

prednisone constantly, and every attempt to interrupt the use of

this medication resulted in rehospitalization. He was also using

inhaled salbutamol or ipratropium bromide several times a night, bedomethasone aerosol, and prednisone daily (15 mg alternating

with 10 mg). For this entire period of time, his pulmonary function showed constant obstructive airway disorder.

The patient was hospitalized for a complete re-evaluation. The

parents were very concerned about several previous “spells”

when the boy turned blue, was not responsive, and even had sphincter release or convulsions. These attacks provoked a lot of

anxiety for the parents, who were additionally confused about the

nature of their child’s ifiness, because we had not accurately

differentiated his symptoms from those of epilepsy.

On physical examination he had athoracic circumference of 70

cm compared to the norm of 58 ± 2 cm, a hypertrophy of the

respiratory muscles, a diminution of vesicular murmur, and a

prolonged expiration.

The patient presented overwhelming fears of all kinds, such as

the fear of dying or choking and of monsters and darkness. He

presented a strange behavior on the ward: he would bang his chest

with both fists like amonkey and explain that “it hurts there.” In

addition, nurses noticed that he woke up every night, panicking, coughing, and breathing heavily. They also noted perspiring,

choking, and tachycardia.

The duster of symptoms fit the requirements for a diagnosis of

panic disorder. This diagnosis was confirmed by a doctor’s

obser-vation on the ward who had just examined the patient and found that his lungs were dear, when he suddenly started breathing heavily and turned blue. Reassuring the child and calming him down sufficed to stop the attack. Subsequently, the child repeti-tively spoke about the “big giant” he was afraid of during his

attacks.

Once the diagnosis of a panic disorder was confirmed, we

started Xanax (alprazolam, 0.125 mg, three times a day). As a

result the child immediately stopped having panic asthma attacks

during a prolonged hospitalization of 50 days, while prednisone

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EXPERIENCE AND REASON 109

TABLE 1. Symptoms of Panic

1) Shortness of breath (dyspnea) 2) Dizziness-faintness

3) Palpitations-tachycardia

4) Trembling-shaking 5) Sweating

6) Choking

7) Nausea-abdominal distress

8) Depersonalization-derealization 9) Numbness-tingling sensation 10) Rushes-chills

11) Chest pain-discomfort 12) Fear of dying

13) Fear of going crazy or doing something uncontrolled

was progressively decreased from 20 mg per day to 10 mg every

other day. When released from the hospital, his pulmonary func-tion was normal compared to the severe obstruction shown by test results on the day of admission (Table 2).

Follow-up after the hospitalization showed that the pulmonary tests remained normal while inhaled steroids (beclomethasone,

200 pg. twice a day) were substituted for prednisone. Xanax has

been continued at the same dosage for 1 year and no respiratory

attack has been noted. Currently, primarily with exercise, attacks

with few symptoms such as chest pain or pseudoepileptic seizures occur occasionally (five consecutive EEGs were conducted and

showed no anomalies).

Subsequently over 20 patients have been treated with anxiolyt-ics and cognitive therapy on our service. All showed significant improvement of their asthma and reduction of medication intake.

INTERPRETATION

In the case presented the respiratory symptoms of

the panic attack were interfering with the diagnosis and treatment of asthma. It resulted in overestima-tion of asthma and resistance to treatment.

Two interpretations are possible, the first one

be-ing that hyperventilation (which is part of a panic attack) may trigger a real asthma attack. The second

interpretation would be that some asthma

symp-toms, like shortness of breath, can trigger a panic

attack. Consequently, it is most important to detect

panic disorders in asthmatic children, particularly when they seem rather refractory to treatment. The most difficult part in this diagnosis is the recognition

and interpretation of the symptoms because of the

awkward description generally given by children.

In our example, the young patient spoke of the

oncoming giant before attacks. Only after

hospital-ization did we understand that it was the child’s equivalent for the sensation of impending doom,

TABLE 2. Pulmonary Functi

Case I

on Before and After Treatment in

Day of Admission, Day of Discharge,

January, 1990 April, 1990

FVC=81% FVC=152%

FEy1 = 52% FEy1 = 142%

FEF = 21% FEF = 115%

FEV1/FVC = 57% FEV1/FVC = 83%

Follow-up, Follow-up,

June, 1991 February, 1993

FVC = 135% FVC = 136%

FEV1=115% FEV1=121%

FEF = 80% FEF =90%

FEV1/FVC = 75% FEV1/FVC = 78%

as the chest banging was the expression of chest

pain and choking.

As it was demonstrated by Woods et al8 and Gorman et al,9 a 5% concentration of CO2 is a

pow-erful trigger of panic attack in adult patients with

panic disorder. It has been observed that, if the CO2

concentration increases, ventromedullar chemore-ceptors are stimulated and will increase the respira-tory rate. In these aforementioned studies, 5% CO2

concentration caused a two- to threefold increase in

minute ventilation. Because patients presenting

panic attacks seem to have an abnormal CO2

chemo-receptor sensitivity, these receptors would respond

by triggering hyperventilation and a subjective feel-ing of asphyxia. In turn, this hyperventilation would

bring with it hypocapnia and alkalosis, which

pro-duce light-headedness, dizziness, and unsteady feel-ings, and can increase smothering sensations.

In an adaptive way, these patients would present chronic hyperventilation in order to maintain low

levels of CO2 and to prevent stimulation of their CO2 receptors. For Gorman et al,9 that corresponds to the observation that patients with a panic disorder have

chronic hyperventilation. Similarly, in children, we can predict that any asthmatic child having CO2

re-ceptors genetically more sensitive,’#{176} or being

sensi-tized by traumatic experiences (like an admission in

intensive care unit), may feel a smothering sensation as when he or she runs, causing hyperventilation,

and subsequently initiating a panic attack. Quoting

Papp, “Symptoms reminiscent of a natural panic at-tack may have the patient misinterpret them as life

threatening, incontrollable events.” At this time, we

should also point out that physical exercise produces lactic acid, which is a stimulator of panic attacks as well.’2

Another possible mechanism explaining these symptoms may be that beginning an asthma attack can increase CO2 and trigger a panic attack, initiating

a vicious circle where panic will increase asthma via hyperventilation and make it untractable. This was

the case for the patient, whose coughing spells at

night were followed by panic attacks and more asthma. Panic attacks and hyperventilation get

entangled with asthma attacks.

In any case of panic disorder, a fast relief of

symp-toms is important because of the intense pain gener-ated by this syndrome. For asthmatic children, fast

relief is even more important because prolonged

panic attack with hyperventilation can trigger an

asthma attack and aggravate this condition. Many

parents are unaware of the coexistence of two kinds

of crisis. They react by giving salbutamol to a child

who is not in need of such medication, and, because

there is no visible response to the medication,

par-ents give a second treatment. Tachycardia and

tremor caused by salbutamol can, in turn, aggravate a panic attack.

More than in other anxiety disorders,

pharmaceu-tical treatment is reliable in panic disorders, and the

response in children is faster and more conclusive than in adults.’’5 High potency benzodiazepines

(clonazepam and aiprazolam) and tricycics

(imipra-mine) seem equally effective. Medication brings fast

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110 EXPERIENCE AND REASON

relief of symptoms of panic and makes asthma at-tacks easily controlled by the usual treatment.

Nev-ertheless, at the beginning of the treatment of panic, nothing is changed in the treatment of asthma. Only once we achieve a good control over anxiety do we

acknowledge a better control of asthma and decrease

asthma medication.

Among benzodiazepines, alprazolam has been

proven to be a safe medication for children, and very

effective on anxiety.5 Since alprazolam has an

in-termediate half-life, it is easy to control its efficacy

and adjust dosage. For adults, among the worst side

effects of aiprazolam is its potential for tolerance and

dependency. This, however, has not been observed

in children. It coujd be explained by the fact that parents, being in charge of the medication, an in-crease in intake, as observed in adult patients, is impossible. Clonazepam, another high-potency

ben-zodiazepine, is very effective with adults; however,

with children it may cause disinhibition, agitation,

confusion, and depression.’6

Tricycics are also very safe, as long as certain precautions have been taken. Usually a daily dose of

3 mg/kg is enough to control panic. In addition, the effect is sometimes obtained more quickly than for

the treatment of depressive states for which 3 weeks of latency are necessary before the reduction of

cm-ical manifestations. The threat of cardiac arrest due

to tricycics is a more controversial subject. In fact, it has been reported that three boys aged 8 to 10 years have died due to the use of tricycic.17 With regards to the extensive use of imipramine with children in

the past, these accidents should be put into

perspec-tive. Nevertheless, on electrocardiographic

measure-ments, prolongation of PR interval, QT lengthening, and PRS widening have been reported in children

and adolescents treated with imipramine.’8

Conse-quently, the FDA proposes the following guides for this age group: 1) An EKG should be obtained prior treatment and at each dose increase; 2) The PR inter-val should not exceed 0.21 second; 3) The resting heart rate should be less than 1.30 beats per mm; 4) the QRS interval should not exceed 0.02 second more

than the baseline interval.

Anxiolytic medication is the fastest treatment for

blocking extreme anxiety, but it must be

accompa-nied by other methods to deal with the symptom, in order to help the child independently face this prob-lem. Cognitive therapy, discussion of the events

sur-rounding the attacks, reinterpretation of physical signs,’9 and diminution of the sense of loss of con-trol,” expression of emotions and worries, and strict observance of the parents not reinforcing the

symp-toms are very important ways of coping with this

condition and preventing psychomaintenance of

asthma following the term of Kinsman.’ These

ther-apies are the most important between attacks,”2#{176} but

at the moment of an attack, when anxiety is at its

peak, the best treatment for panic is alprazolam. This benzodiazepine seems to be specifically efficient for panic, with no depressive effect on breathing at the

usual therapeutic dosage. It is effective enough to

stop the vicious circle panic -p hyperventilation

asthma -a’ panic. Physicians should be aware of the

possibifity of panic attack complicating asthma in

part of a patient that does not improve after two or

three treatments of albuterol. A family history of

cardiac symptoms, alcohol abuse, drug abuse, or de-pression is also evocative of panic.1#{176}Making the right

diagnosis at the right moment is essential because fo the specificity of treatment and the reversibility of

respiratory problems associated with panic disorder.

ACKNOWLEDGMENTS

We would like to express our gratitude to Caroline De Bie and Sylvie Tass#{233}for their assistance in the preparation of this manu-script.

CHANTAL BARON, MD

JACQUES-EDOUARD MARCO’lTE, MD Departments of Psychiatry and Pediatrics

Section of Pneumology H#{244}pitalSainte-Justine

Umversit#{233} de Montr#{233}al

Montreal, Quebec, Canada H3T 1C5

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1994;94;108

Pediatrics

Chantal Baron and Jacques-Édouard Marcotte