Although panic disorder is very rare in childhood, first occurrence of "fearful spells" is often dated retrospectively back to childhood. As in adults, panic disorder in adolescents tends to have a chronic course and is frequently comorbid with other anxiety, depressive, and bipolar disorders. To date, no differences in the clinical presentation between adoles- cents and adults have been found. However, adolescents may be less worried about addi- tional panic attacks than are young adults. Lower prevalence of panic disorder in older adults appears to be attributable to age-related ”dampening” of the autonomic nervous system response. Many older individuals with "panicky feelings" are observed to have a ”hybrid” of limited-symptom panic attacks and generalized anxiety. Also, older adults tend to attribute their panic attacks to certain stressful situations, such as a medical pro- cedure or social setting. Older individuals may retrospectively endorse explanations for the panic attack\(which would preclude the diagnosis of panic disorder), even if an attack might actually have been unexpected in the moment (and thus qualify as the basis for a panic disorder diagnosis). This may result in under-endorsement of unexpected panic at- tacks in older individuals. Thus, careful questioning of older adults is required to assess whether panic attacks were expected before entering the situation, so that unexpected panic attacks and the diagnosis of panic disorder are not overlooked.
While the low rate of panic disorder in children could relate to difficulties in symptom reporting, this seems unlikely given that children are capable of reporting intense fear or panic in relation to separation and to phobic objects or phobic situations. Adolescents might be less willing than adults to openly discuss panic attacks. Therefore, clinicians should be aware that unexpected panic attacks do occur in adolescents, much as they do in adults, and be attuned to this possibility when encountering adolescents presenting with episodes of intense fear or distress.
Temperamental. Negative affectivity (neuroticism) (i.e., proneness to experiencing neg- ative emotions) and anxiety sensitivity (i.e., the disposition to believe that symptoms of anxiety are harmful) are risk factors for the onset of panic attacks and, separately, for worry about panic, although their risk status for the diagnosis of panic disorder is un- known. History of "fearful spells" (i.e., limited-symptom attacks that do not meet full cri- teria for a panic attack) may be a risk factor for later panic attacks and panic disorder.
Although separation anxiety in childhood, especially when severe, may precede the later development of panic disorder, it is not a consistent risk factor.
Environmental. Reports of childhood experiences of sexual and physical abuse are more common in panic disorder than in certain other anxiety disorders. Smoking is a risk factor for panic attacks and panic disorder. Most individuals report identifiable stressors in the months before their first panic attack (e.g., interpersonal stressors and stressors related to physical well-being, such as negative experiences with illicit or prescription drugs, dis- ease, or death in the family).
Genetic and physiological. It is believed that multiple genes confer vulnerability to panic disorder. However, the exact genes, gene products, or functions related to the genetic re- gions implicated remain unknown. Current neural systems models for panic disorder em— phasize the amygdala and related structures, much as in other anxiety disorders. There is an increased risk for panic disorder among offspring of parents with anxiety, depressive, and bipolar disorders. Respiratory disturbance, such as asthma, is associated with panic disorder, in terms of past history, comorbidity, and family history.