LETTERS TO THE EDITOR Panic Disorder and Anger Attacks To the Editor: Anxiety disorders of childhood and adolescence are quite common. A number of researchers have suggested a possible genetic link between separation anxiety and shyness in childhood and panic disorderagoraphobia in adults. However, it is only recently that the possibility of the existence of panic disorder in prepubertal children has been raised (Ballenger et aI., 1989; Black and Robbins, 1990). Most of the cases reported begin in adolescence with occasional retrospective reports of prepubertal onset. Despite Klein's caution against the use of retrospective data to diagnose panic attacks in childhood (Klein and Klein, 1990), several cases of patients diagnosed in childhood with panic disorder have appeared. That panic disorder is an important condition to understand for child psychiatrists can be gleaned from recent reports of comorbidity with affective disorders in children hospitalized for somatic complaints, confusing the clinical picture in patients with seizure disorders and neurological conditions, not uncommonly calling forth unnecessary neurological work-ups (Hirsch et aI., 1990). Panic may occur without the subjective feeling of fear and anxiety (Russell et aI., 1991). And Fava et al. (1990) have reported the possibility of anger attacks as a variant of panic disorder in adults in which the symptoms of panic appear with angry "outbursts of anger that [were] perceived to be excessive and grossly out of proportion to any precipitating psychosocial stressors," but without the subjective feelings of anxiety. This report is of a child who exhibited spontaneous panic attacks from age 5, separation anxiety from age 2 1/2, as well as episodes of severe anger outbursts with symptoms not unlike those reported by Fava et aI., all of which responded rapidly and dramatically to a low dose of imipramine. P.G. is a 6-year-old female referred by her psychotherapist after making little progress in psychotherapy. A dramatic increase in her symptoms after a March 1990 earthquake was reported. These could be divided into two types: Clear-cut anxiety reactions, such as being unable to fall asleep without an adult with her, were the first type. She would become tense, stiffen, tremble, perspire, and her heart would pound. These would also occur without a precipitant. The second was more like a tantrum, involving P.G. running through the house, slamming doors and being verbally abusive. On occasion, she would fall to the floor, heart pounding, shaking, moaning, screaming, and crying, her back arched, her eyes rolled up under her lids, and be noticeably very angry. After the March 1990 earthquake, she frequently would have attacks of both types, lasting up to 40 minutes, sometimes more than one per day, and with little or no apparent provocation. She could offer no explanation for what was happening and seemed to be "out of it" during most of these episodes. The family history is positive in that mother had had several panic attacks followed by the development of a driving phobia several years previously and a number of such attacks set off by caffeine. The father's family had a positive history of affective disorders, and his brother was in jail for killing a policeman. After a 48-hour ambulatory EEG, during which two to three episodes occurred, was read as normal, the patient began receiving a small dose of imipramine, 10 mg at night. When she reached 20 mg, she became much less negative, less controlling, and even "empathic to friends." There were no episodes of panic or tantrums over a 10month period. During Month 5, her mother reported some increased tiredness and the dose was lowered to 10 mg. There was a return of J. Am. Acad. Child Adolesc. Psychiatry, 31:2, March 1992

some of the angry outbursts. Both symptoms cleared when the dose was increased to 15 mg/day. We have seen a number of children referred for depression and oppositional behavior that included angry outbursts, suicidal ideation, and dysphoric feelings. On closer scrutiny, symptoms of anxiety emerged that did not dominate the clinical picture. These children responded fairly rapidly to relatively small doses of imipramine, which has been shown to be efficacious in treating anxiety disorders in children. As with Fava et al.'s patients, these children responded to doses of tricyclic antidepressants more rapidly than would be expected if they had major affective disorders and in doses usually thought to be too low for the treatment of these conditions. In the study by Fava et aI., the patients showed a recurrence of their symptoms abruptly after the discontinuation of the tricyclics, which appeared to be the case with P.G. when we lowered her dose of imipramine, and the angry outbursts were not ameliorated by medications usually used to treat these symptoms. This case is reported as a possible example of a prepubertal child with panic disorder, who may also exhibit the occurrence of angry outbursts as a panic variant as described by Fava et al. for adults. Herbert A. Schreier, M.D. Oakland Children's Hospital REFERENCES

Ballenger, J. c., Carek, D. J., Steele, J. J. & Cornish-McTighe, D. (1989), Three cases of panic disorder with agoraphobia in children. Am. J. Psychiatry, 146:922-924. Black, B. & Robbins, D. R. (1990), Panic disorder in children and adolescents. J. Am. Acad. Child Adolesc. Psychiatry, 29:36-44. Fava, M., Anderson, K. & Rosenbaum, J. F. (1990), "Anger attacks": possible variants of panic and major depressive disorders. Am. J. Psychiatry, 147:867-870 Hirsch, E., Peretti, S., Boulay, C., Sllal, F. & Maton, B. (1990), Poster session IV: monitoring, surgery, antiepileptic drugs. Epilepsia, 31:5. Klein, D. F. & Klein, R. G. (1990), Does panic disorder exist in childhood? J. Am. Acad. Child Adolesc. Psychiatry, 29:834 (letter). Russell, J. L., Kushner, M. G., Beitman, B. D. & Bartles, K. M. (1991), Nonfearful panic disorder in neurology patients validated by lactate challenge. Am. J. Psychiatry, 148:361-364.

Suicidality with Clomipramine To the Editor: Regarding the continuing discussion of the possible induction of suicidal ideation or behavior by serotonergic medication, especially fluoxetine (Fuller and Beasley, 1991; King et aI., 1991a, b), the following case describes the appearance of new suicidal ideation in a child taking another serotonin-uptake-blocking agent, clomipramine. An 8- year 9-month-old white Roman Catholic male, taking clomipramine for severely distressing obsessive thoughts (primarily blasphemous), experienced partial relief and no side effects at 50 mg/day (1.3 mglkg/day). After 2 months on this dose, he noted a new symptom, having to read sentences over and over because of the obsessive thought that he had not gotten them right. The patient requested an increase in the dose. Nine days after raising the dose to 75 mg/day (2.1 mg/kg/day), he noted the abrupt onset of the wish to die. This occurred after frustrations in sports and with peers that he and his

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