This is Paula. Paula is 7 years old and has agoraphobia.

Heather Perlow, November 14, 2011

Activities Paula used to call her favorite

A few months ago on the school bus..

• She felt sick, thought she was going to vomit and wanted to get off the bus but the driver said she had to wait until they got to school.

• Paula began experiencing symptoms of a panic attack which included an accelerated heart rate, sweating, feeling dizzy and chills which lasted for about 10 minutes.

• By the time Paula got to school and saw the school nurse, the panic attack was over.

After a few similar incidences on the school bus, Paula’s parents have noticed:

• Paula experiences anxiety that she will have a panic attack in situations where escaping is not possible or is difficult or embarrassing.

• She doesn’t like to do the activities she used to enjoy doing (going to the mall, to friends houses, out for ice cream).

• She makes up excuses for not wanting to go outside of her house.

• She experiences an inability to leave her house for long periods of time.

• She has a fear of being alone in any situation or being in crowded places.

• She makes up her own rules for where she can and can not go.

Paula’s own “treatment”• I don't ride in other people's cars• I don't go to birthday parties• I don’t go on trips without my mother or father• I don't go to the mall• I am driven to school• I avoid big crowds• I don't wait in lines

Agoraphobia and School• When Paula’s parents wake her for school, she often experiences abdominal pain,

diarrhea, nausea, headache, or other signs of physical illness.• If her parents allow her to stay home from school, these symptoms disappear.• Paula became afraid that something horrible or embarrassing would happen on the bus

on the way to school such as diarrhea, vomiting, going crazy, and getting sick with no one to help. Because of this, her parents have started driving her to school.

• In the car, Paula complains that she can not enter the school and the idea of going and sitting in her classroom leads to anxiety about what could go wrong.

• Sometimes Paula stays in her classroom for most of the day but can not stay the whole day.

• On bad days, Paula refuses to go to school. • Substitute teachers trigger Paula to go to the nurse and go home from school. • She needs her mother or father to go on class trips.• She can not participate in school performances. • Her parents and teachers are worried about how this is affecting her learning in school.

DSM IV Criteria for AgoraphobiaAccording to the DSM IV, Agoraphobia is defined as:

• A) anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed Panic Attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd, or standing in a line; being on a bridge; and traveling in a bus, train, or automobile.

• B) The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion.

• C) The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as Social Phobia (e.g., avoidance limited to social situations because of fear of embarrassment), Specific Phobia (e.g., avoidance limited to a single situation like elevators), Obsessive-Compulsive Disorder (e.g., avoidance of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., avoidance of leaving home or relatives).

Agoraphobia and other disorders

• Having a history of panic attacks is a risk factor for developing agoraphobia and agoraphobic individuals are at increased risk for developing panic attacks as well.

• Other anxiety disorders that tend to co-occur with agoraphobia include social anxiety disorder and generalized anxiety disorder.

• If a child has panic attacks at age 14 they are much more likely than other children to develop other disorders– 2-3 times more likely to develop Social anxiety disorder– 10 times more likely to develop Generalized Anxiety Disorder– 2-3 times more likely to develop substance abuse– 2-3 times more likely to develop some type of depression

Treatments• Psychotherapy• Medication• Alternative Medicine

Psychotherapy– Cognitive behavioral therapy: focuses on decreasing negative,

anxiety-provoking thoughts and behavior. Has been found to be highly effective in treating agoraphobia.

– Involves learning more about agoraphobia and panic attacks and how to control them. Paula is learning what factors may trigger a panic attack or panic-like symptoms and what makes them worse. She is also learning how to cope with these symptoms, such as using breathing and relaxation techniques.

– She has also been working on changing unwanted or unhealthy behaviors through desensitization or exposure therapy. This technique helps Paula safely face the places and situations that cause fear and anxiety. A therapist sometimes takes her to the mall or on field trips to help her.

Medication• Serotonin Selective Reuptake Inhibitor (SSRI)

– Sertraline (Zoloft), Paroxetine (Paxil), Fluoxetine (Prozac). – Side effects: dry mouth, nausea, tremors, trouble sleeping, blurred

vision, dizziness. Children and teens could also become more anxious or depressed and contemplate suicide or homicide.

• Minor tranquilizers (benzodiazepine)– Cause relaxation but isn’t used as often to treat anxiety because of

problems with addiction, increasing need for higher doses and overdose– Diazepam (Valium), Alprazolam (Xanax), Lorazepam (Ativan) and

Clonazepam (Klonopin).• Beta-blocker medications

– Block the affects of adrenaline on the body– Proprnolol

Alternative Medicine

• Dietary and herbal supplements claim to have calming and anti-anxiety benefits.

• Kava• Bach Rescue Remedy

References

• http://allpsych.com/disorders/anxiety/agoraphobia.html

• http://www.medicinenet.com/agoraphobia/article.htm

• http://jamesdauntchandler.tripod.com/anxiety/panicpamphlet.htm

• http://www.mayoclinic.com/health/agoraphobia/DS00894

• http://www.biologicalunhappiness.com/DSMpanic.htm

• I would use this slide show to teach colleagues about agoraphobia.