Panic Disorder, Agoraphobia and
Isolated Phobias
Panic attacks
can occur in the context of several psychiatric conditions. A panic attack
is a time-limited intense episode in which the individual experiences
feelings of dread accompanied by physical sensations. Panic attacks
usually average a couple of minutes but can last as long as 10 minutes and
occasionally longer. Some really feel that they are about to die or have a
serious medical problem. Children tend to have less insight than adults.
Children may also be less articulate in describing their symptoms.
Common symptoms
include:
- Chest
pain
- Excessive
perspiration
- Heart
palpitations
- Dizziness
- Flushing
- Tremor
- Nausea
- Numbness
in extremities
- Choking
sensation or shortness of breath
- Feeling
that one is not entirely in reality
- Extreme
anxiety
- Fear
that one is going to die
- Fear
that one will become insane or lose control.
Panic Disorder
is more likely to start in late adolescence or in adulthood. However, it
can occur in children. The incidence of panic disorder with or without
agoraphobia is lower than the incidence of simple phobia in children and
adolescents.
and colleagues diagnosed panic disorder in 6% and agoraphobia in 15%
of children and adolescents referred to a pediatric psychopharmacology
clinic. Many of the children with panic disorder also had agoraphobia. The
children with panic or agoraphobia had a high rate of co-morbid
depression, and other anxiety disorders. However they also had a high
incidence of disruptive behavior disorders such as Conduct Disorder and
ADHD. The course of the panic disorder and agoraphobia appeared to be
chronic.
Studies of
adult panic disorder indicate that there is a high incidence of suicidal
behavior, especially when it is accompanied by depression. Adults with
panic disorder have an increased incidence of substance abuse. Thus one
must look closely for the presence of other psychiatric disorders and make
sure that the child or adolescent gets treatment. One should also screen
for substance abuse.
A child with
panic disorder should have a careful medical screening. It may be
appropriate to screen for thyroid problems, excessive caffeine intake,
diabetes and other conditions. Some sensitive individuals might have a
panic-like reaction to certain asthma medications.
Treatment of
panic disorder: Both medication and therapy have been used effectively. In
children and adolescents with mild or moderate anxiety, it makes sense to
start first with psychotherapy. If this is only partially effective,
medication may be added. In children with severe anxiety or with co-morbid
disorders, one might start therapy and medications simultaneously.
Medications are similar to those used for adults. These would include SSRI
medications (such as fluoxetine, fluvoxamine, sertraline, and paroxetine.)
Individuals with panic disorder often respond to much lower doses of SSRIs,
and may not do as well if started off with higher doses. Other medications
used include ? blockers such as propranolol, the tricyclics (such as
Nortryptiline), and occasionally the benzodiazepines (such as clonazepam.)
Psychotherapy:
Individuals benefit from regular meals, adequate sleep, regular exercise
and a supportive environment. One might teach the individual to use deep
abdominal breathing and other relaxation techniques. Once real medical
causes have been ruled out, the individual should remind himself that the
symptoms are frightening but not dangerous. The person should learn to
label the episode as a panic attack and understand it as an exaggeration
of a normal reaction to stress. The person should not try to fight the
episode, but should simply accept that it is happening and is time
limited. Some learn to go outside themselves and rate the symptoms on a
scale of 1-10. The individual should be encouraged to stay in the present
and notice what is going on in the here and now.
If agoraphobia
is present, the child should make up a hierarchy of fear-inducing
situations. With help from parents and therapists, the child should move
up the hierarchy of feared situations.
Simple Phobias
Simple phobias
are fairly common in children. Phobias often begin in childhood. Many do
not cause significant life impairment and thus would not meet criteria for
a formal psychiatric diagnosis. Milne et al found 2.3% of young
adolescents in a community sample met criteria for a clinical phobic
disorder. However, a much larger number, 22% had milder phobic symptoms.
Girls had a higher rate than boys, and African Americans had a higher rate
than Caucasians. Individuals with more severe phobias were more likely to
have other psychiatric diagnoses than those with milder phobias.
The therapist
should work with a parent or other responsible adult to gradually
desensitize the child to the feared object. Relaxation training is helpful
here too.
References
J et al, Panic Disorder
and Agoraphobia in Consecutively Referred Children and Adolescents,
Journal of the American Academy of Child and Adolescent Psychiatry, Vol.
36, No. 2, 1997.
Clark, D.B. et
al, Identifying Anxiety Disorders in Adolescents Hospitalized for Alcohol
Abuse or Dependence, Psychiatric Services, Vol. 46, No. 6, 1995.
Milne, J.M. et
al, Frequency of Phobic Disorder in a Community Sample of Young
Adolescents, Journal of the American Academy of Child and Adolescent
Psychiatry, 34:9-13. 1995.
See our other articles on anxiety
disorders
in children, adolescents and adults