The Treatment of Agoraphobia and panic disorders

To begin, phobias are of three different kinds: Agoraphobia, Social Phobia, and Simple Phobia. Ninety percent of all phobias start with a panic attack: a severe, scary, and self-limited experience that usually starts during a person's late teens or early twenties.

A panic attack generally lasts 20 minutes to an hour and can repeat itself five times a day. Panic disorders eventually lead to phobias, which are really an avoidance behavior, limiting one's personal, social, marital, and occupational life.There are four aspects of treatment. The first is medication. If you have a panic disorder, you need medication. Of course, nobody wants to be on medication, especially phobics who have a tremendous need for control (control of their lives, their bodies, and their relationships.) However, studies show that panic disorder is biologically determined; it is a chemical pro-cess that goes on in the brain. In a way, panic disorder is an alarm system that has gone amuck, out of control, and gives warning to the person of a danger that does not exist.

You can get treated without medication, but it will be much more difficult until you learn how to deal with your condition. This could last weeks or months. The medication that we use most frequently for treatment of panic disorder is Xanax, or on rare occasions, Ativan or Klonopin. Usually we use 0.5 mg to 1 mg of Xanax three times a day. Xanax can cause some sedation in the beginning, but the sedation will disappear after a week and you will be able to carry on with your daily activities far more effectively than when you were having panic attacks. Xanax usually should be taken in the morning when you wake up, about 1:00 p.m. and about 6/7:00 p.m. However, if you have problems with sleep, you might take the medication in the morning, afternoon and before going to bed.

On occasion, I may recommend the medication be taken four times a day, which would be morning, noon, afternoon and before going to bed. If you are pregnant, Xanax should not be taken, especially during the first trimester.A good number of patients with panic disorder (50%) also suffer from depression. Fortunately we have a number of effective anti-depressant medications available today. One anti-depressant medication that not only is an anti-depressant, but is also used as an anti-panic medication. This is called Imipramine, which is also very safely used in conjunction with Xanax. Imipramine is used from 50-150 mg. We usually start at 50 mg at nights and gradually increase it every week to 100 mg and then to 150 mg. We maintain it around 150 mg.

Imipramine can cause dryness of the mouth, sedation, constipation, and on some occasions, palpitations. Very rarely, Imipramine can also cause agitation and restlessness. The best thing to do is to check with me if you have other side effects or if you feel agitated. The sedation of the Imipramine also disappears in about 10 days.A REMINDER: You should not drink on either of these medications. If you have to drink socially, you can have 1-2 oz. of liquor, which is the equivalent of 1-2 beers every 24 hours; but remember, you will feel the effect of alcohol twice as much. The anti-depressant effect of Imipramine will not show itself for 1-2 weeks and sometimes it takes up to 3 weeks. After that you notice a definite change in your mood and the frequency and/or severity of the panic attacks.

The second aspect of treatment is your participation in individual desensitization. If you are having specific phobias, de-sensitization involves going with the thera-pist to the place or doing the behavior that you are fearful of. This is done gradually and you will never be pushed into a situation. However, remember that changes cannot come easily and you have to be ready to face some discomfort while you go through desensitization. The desensitization meeting is also used as a form of individual psychotherapy in which you will be able to discuss the issues of your life that have been related to your phobias and/or your personal concerns.

The third aspect of your treatment is participation in group therapy. Many people are hesitant to go to group therapy. However, in group therapy you will receive support from therapists, other patients, and give support to others, share exper-iences, try to show off some, and learn as well as teach. You will learn that you are not alone. Group therapy also has the advan-tage of allowing you to admit to yourself and to others that you do have a problem with phobias, freeing yourself from all the se-crets that you have been keeping.

The fourth and last aspect of the treatment is education. Education is provided by introducing you to reading material that is given to you or is available in the office upon your request after you finish the program or throughout the life of your program. you can have the benefit of receiving the newsletter, "Phobia Free, Flying High". In this you will read about the latest findings in the treatment of phobias and panic disorder as well as get to know per-sonal stories of others in our clinic like you.Please share this information with your family members. Try to educate them about your condition, and remember that you did not get to this point overnight and you will not get over your condition overnight either.

Panic disorder, if untreated, can affect your potential for earnings, for a happy life, achieving your personal dreams, your marriage, and your physical health. But if treatment is sought, all these things can be restored.It is estimated that approximately 2% of the adult population suffer from agoraphobia with panic attacks. The condition was described originally by Westfall more than 100 years ago and has not changed since. The patient who is in full bloom has fear of going places (agora means market). In

today's terms, it could be translated into fear of going to malls, grocery stores, driving, using elevators, escalators, being in high or closed places, social gatherings or public places. Victims of this condition often refuse to fly or take public transportation and many prefer to stay home or only go places with someone they can truly trust. On occasion, agoraphobics become totally housebound.

Agoraphobics almost always have a history of panic attacks. Panic attacks are very scary and leave a lasting impression on sufferers. Panic attacks have physiological as well as behavioral symptoms. The most noticed physiological symptoms are tachycardia, palpitations, butterflies, hyperventilation (or short and fast respiration), gastrointestinal symptoms, and dizzy spells. The behavioral symptoms include fear of losing control. going crazy, embarrassing one's self and even dying. Many have fears of urinating or losing control of bowels in public.

Victims often develop anticipation anxiety as a result of the fear of a recurrence of the panic attack. They thus become afraid of being alone in public and can become totally dependent on a relative or trusted other. It is at this point that agoraphobia is born.

Panic attacks usually start during a person's early twenties but could occur as early as the teens or as late as the sixties. A panic attack could be triggered by the use of coffee, cocaine, amphetamines, marijuana or normal physiological changes in pulse rate like a dizzy spell or a palpitation. Very frequently panic attacks occur after traumatic and/or dramatic changes in one's life like divorce, marriage, graduation, death of a loved one or a move.

Unfortunately, the panic attacks continue to recur after the initial episode. With little Information as to the cause, the patient then develops anticipation anxiety which leads to phobias. A phobia is an attempt to relieve anxiety by avoiding situations that supposedly trigger the panlc attack. The patient, afraid he's going to have a panic attack at any moment, will begin to avoid things like driving or going to malls - anywhere an attack might strike, leaving him without access to help. Or he may decide that he's only safe when another person is with him in case he gets “sick." By then full-blown agoraphobia is in force and the sufferer is more and more incapacitated by his condition. Due to the interruptions in one's social, academic, familial and vocational life caused by this condition, patients can become frustrated and severely depressed.

The treatment of agoraphobia with panic disorder has changed dramatically in the past ten years. Many patients who in the past might have to go on receiving psychotherapy for many years, even electroconvulslve therapy, now respond to the combination of medication and desensitization. As a matter of fact, treatment of this condition has been one of the better contributions to psychiatry in this century. More and more panic attacks are seen as a physiologic condition in people who have the predisposition for their development. This is the reason that medications have been so effective.

Medications used in the treatment of agoraphobia are from three different classes. The first are benzodiazapines, the most common used being alprazolam, doses of 1 - 3 mg. per day are used with a great deal of success. The drawbacks can be dependency and/or rebound effect when the medication is decreased. Tricyclic antidepressants have been used very successfully. Imipramine is the classic drug with a dose, on the average, of 100-200 mg. per day. The benefits are that antldepressants or tricyclics are safer in use without fear of dependency or rebounding of symptoms. However, the side effects are intolerable to some patients and the symptom relief does not occur for an average of 2-3 weeks. The third group is MAO Inhibitors which have been used widely. They are basically safe with a good record except for the drawback that the patients have to be on a special diet and should not be treated with sympathomimetic drugs (even nose drops). Patients usually respond to 45 mg. of phenelazine (Nardil).

Even though medications cause a dramatic change in patient's panic attack and in time agoraphobia, the treatment of choice in treating agoraphobia is desensitization. Through this technique, with the help of a therapist, patients are encouraged to go back to driving with the therapist in the car, return to malls, grocery stores and are even taken on special trips flying to other cities.

As many patients with agoraphobia feel that their condition is most unusual and unheard of, getting them in group therapy helps them to support each other. The use of adjunct individual

therapy in the treatment of this condition is also helpful.

Drinking Kava can also help your case of Anxiety.

The primary use for Kava in the South Pacific is as a social tonic. Whether it is in village nakamals or commercial kava bars people gather after work to have a few shells of kava. Kava’s relaxing effect assists in people discussing matters in a free and open manner.

Kava has been known as a form of reducing anxiety in Western countries for a number of decades now. Its ability to sooth nerves and tension and also relax the body in a physical sense was followed up by a number of German studies n the 90’s.

IN CONCLUSION: Treatment of panic disorder and agoraphobia has been revolutionized in the past ten years. Many patients who are regular customers of emergency rooms and have spent years seeing different specialists for treatment of their panic attack are treated successfully with medications, that basically relieve the panlc attack. The use of IN VIVO desensitization and group therapy have been very successful in relieving agoraphobia and eventually weaning the patient from medication. By early detection and treatment of panic attack and agoraphobia, the other medical as well as psychiatric psychosomatic disorders, especially high blood pressure, depression and alcoholism in such patients can be prevented.

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