LETTERS TO THE EDITOR had" a funny feeling in my throat ," smelled " a funny smell ," and felt that "I might do something I can 't control. " She reported at least three such unexpected episodes per week during the prior month . Susan's parents reported that she was continuously anxious , but that definite episodes of sudden, extreme increases in fearfulness occurred frequently . These occurred predictably on going to school but also occurred unexpectedly, for example , while playing at home. During these episodes, Susan complained of nausea, feeling hot, a funny feeling in her throat, sweating, trembling, fear of losing control, and that her " heart felt funny." Her parents reported at least 10 unexpected episodes in the previous 6 months and at least one per week for the last several weeks . They also described a pattern of persistent avoidance of certain situations, especially going to school, movie theaters, shopping malls, crowds , public places such as museums, traveling long distances, and leaving the house in general. When her parents pushed herto go out with them, she complained, " What if! get sick?" When going into a public place, she would ask constantly how they could escape if they needed to. Susan acknowledged the wish to avoid these situations and explained that this was because ' 'I might get really nervous all of a sudden and I couldn't get out " and " everyone would see that I was nervous and it would be really embarrassing. " She was not otherwise socially anxious or avoidant. She stated that she did not feel safe going out whether her mother was with her or not. Unexpected panic attacks occurred even when the mother was present and separation was not anticipated. In fact , panic attacks were associated with separation only when going to school. She did not otherw ise have unusual difficulties with separation. Age at onset of panic attacks was unclear, but they had become more prominent following a hospitalization for functional megacolon 7 months previously . Phobic avoidance had been present for 4 to 5 months but had become progress ively more severe. Susan had previously been diagnosed as suffering from separation anxiety disorder (SAD) and did meet diagnostic criteria for SAD, though the SAD symptoms developed after the onset of panic attacks and phobic avoidance. Apart from hypochondriacal concerns , she did not have symptoms of overanxious disorder. She also met diagnostic criteria for major depressive episode, mild. The patient's father suffered from PDAG and social phobia, and an older sister had suffered a depressive episode at age 6. Within 4 weeks of starting treatment with desipramine, Susan was free of panic attacks and attending school without difficulty. Case 2. Laurie was a 12-year-old girl referred with a complaint of " panic attacks . " Laurie and her father were interviewed using the Anxiety Disorder s Interview Schedule for Children and Parents (Silverman and Nelles, 1988). Both reported panic attacks occurring since she was 9 years old, characterized by sudden onset of extreme fearfulness , crying, breathlessness, dizziness , flushing, sweating, tachycardia, palpitations, tremulousne ss, feeling that she may lose control, nausea, headache, feeling a lump in the throat, and pleading with her parents to take her away from whatever situation they were in. These episodes lasted 5 to 10 minutes and were occurring I to 2 times daily . The frequency and severity of attacks had increased significantly in recent months and particularly in the last several weeks since Laurie had started back to school after summer vacation . Laurie had difficulty understanding questions regarding the extent to which her attacks were unexpected or situationally predisposed, but she was certain that at least some of her attacks were entirely unexpected. Her parents reported that greater than 50% of her attacks were unexpected, and that others were associated with certain situations, particularly getting ready for school and going to movie theaters or restaurants. There was phobic avoidance of movie theaters, restaurants, elevators, and crowds. There was reluctance to go to school which Laurie specifically related to her fear of not being able to talk with one of her parents in the event of a panic attack at school.

Does Panic Disorder Exist in Childhood? To the Editor: Black and Robbins (1990) report the onset of panic disorder in children. We believe they should be more critical abut the validity of retrospective reports of onset before age 10. It is certainly difficult for many to distinguish early separation or social anxiety from spontaneous panic. Additionally, in Black and Robbins' series, only Case 5 has a really early onset, with an atypical presentation due to very frequent episodes of depersonalization . Also, this subject denied any somatic symptoms at first. A differential diagnosis should consider the possibility of cerebral dysrhythmia. Case 4 had the onset of separation anxiety at age 9 but did not develop frank panic attacks until age 14. Case I sounds like the real thing at age II, but was the subject pubertal? We have been very interested in the matterofage of onset and regularly ask detailed, historical questions of the many patients seen with panic disorder. We cannot recall a prepubertal case of typical panic disorder . By following the children of patients with panic disorder , we may have something more systemati c to say in the future. DonaldF. Klein , M.D . RachelG . Klein , Ph.D. New York State Psychiatric Institute REFERENCE

Black, B. & Robbins , D. R. (1990), Panic disorder in children and adolescents.J. Am. Acad . Chi/dAdolesc. Psychiatry, 29:36-44.

The authors reply: Drs. Klein and Klein question the reliability of our retrospect ive reports of onset of panic disorder before age 10 and go on to question whether or not panic disorder (PD) occurs before puberty. Of the cases we reported, only Case 5 reported onset of panic attacks before age 10. This report is substantiated by the patient's clear recall of the circumstances of her first attack and her report that the attacks had always been characterized by an identical constellation of symptoms . Her mother also corroborated the history. The clinical presentation is typical ofPD, and the diagno sis is additionally supported by the course of illness and family history . Case I reported onset at age II . We do not have information on his pubertal status at that time. In addition to our one retrospective diagnosis of prepubertal onset PD, the case reports we reviewed described 18 cases of PD in children who were specifically described as being either prepubertal or less than 10 years old at the time the child was assessed and diagnosed. Several additional cases were between 10 and 13 years of age at the time of diagnosis but without pubertal status specified. Many additional cases retrospectively reported onsetofPD before puberty . Vitiello et al. (1990) have described six cases of PD in children who were prepubertal at the time they were diagnosed . We have subsequently seen two prepubert al children (both Tanner stage I) with panic disorder with agoraphobia (PDAG). Case 1. Susan , an 8-year-old girl, was referred with a complaint of "panic attacks." The patient and her parent s were interviewed using the Kiddie-SADS diagnostic interview, modified for use with children with anxiety disorders (Last, 1986, unpublished manuscript). Susan reported unexpected episodes of sudden, extreme fearfulness, stating that "one minute I feel fine, then 'poof' I'm real scared and nervous for no reason . " She described specific episodes without apparent precipitant during which she suddenly felt very frightened, sweaty,

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