Panic, Phobias, and Agoraphobia

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. 

Biederman

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 

Biederman,

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

 

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