Case Study 7:

A 35-year-old clothing salesman was showing a particularly fussy customer a suit 2 months ago and suddenly began to sweat profusely. His heart started to pound, he felt dizzy, and became fearful that he was about to die. The customer didn’t notice his condition and continued to question him about the suit in minute detail. The patient, feeling faint, abruptly left the customer and went to lie down in the back of the store. The customer became insulted, complained to the manager, and left. When the manager found the patient he was slumped in a chair in the back room trembling. Approximately 10 minutes later the patient’s symptoms began to subside. He saw his physician the next day who found no evidence of any medical problems. Two weeks later, he had another similar unexpected attack. Since that time he has worried continuously about having another attack. His friends and colleagues have noticed that he is no longer as spontaneous and outgoing as he had been in the past.


Diagnosis
Agoraphobia Without History of Panic Disorder
Treatment

Antidepressants: Some of the antidepressants administrated in patients with agoraphobia include: selective serotonin uptake inhibitors (SSRIs), which is the first choice medication prescribed for agoraphobia patients, due to their few side effects, tricyclic antidepressants (TCAs), or MAO inhibitors (MAOIs). Unfortunately, the desired effects occur only after several weeks of treatment.
Anti-anxiety medication: Benzodiazepine tranquilizers are prescribed because of their immediate effects in reducing the symptoms. Anti-anxiety medication help controlling the anxiety and panic attacks. The main disadvantage of benzodiazepine is increased agoraphobia symptoms when the treatment is stopped. Benzadiazepine also reduces the mental sharpness needed if the patient undergoes psychotherapy.
Psychotherapy. Individuals with agoraphobia seems to benefit mostly from psychotherapy. There are three types of psychotherapies used to treat agoraphobia: (1) behavioral therapy, (2) cognitive therapy, and (3) cognitive-behavioral therapy.
Behavioral therapy. Behavioral therapy is an effective treatment because individuals with agoraphobia learn to modify and gain control over unwanted behaviors, and to cope with challenging situations. During the initial phases of behavioral therapy, the person identifies those situations where the avoidance behavior occurs. The unwanted and unhealthy behaviors are changed through systematic desensitization (also called exposure therapy). The first step is learning relaxation skills that allows the person to cope and control the fear and anxiety. The second step is gradual exposure (first in imagination and than in reality) to feared stimulus.
Cognitive therapy. Cognitive therapy is another therapy that can bring relief in those with agoraphobia. It can serve as an alternative if the behavioral therapy failes. Cognitive therapy focuses on re-training the way the person thinks. The benefit of this type of therapy is that (1) the person gains information regarding their condition and what it causes, (2) learns relaxations techniques that help him control the fear, anxiety, and panic attack symptoms, (3) gains control over the dysfunctional thoughts by realistically evaluating and modifying the thinking patterns that trigger the agoraphobic symptoms, and (4) faces the feared situation by applying the new skills achieved.
Cognitive-behavioral therapy. Cognitive-behavioral therapy is considered the most effective psychotherapy that can treat agoraphobia. This type of therapy considers that our thoughts and not the external situations, people or events, trigger the behavior and feelings. This form of therapy combines methods from behavioral and cognitive therapies for a better outcome. Cognitive-behavioral therapy retrains the way a person thinks and reacts to different stimulus. This is possible if following several steps:
Education, a step where the therapist explains the cognitive, emotional, and behavioral processes involved in anxiety, panic attacks or panic-like-symptoms.
Monitoring, a step where the person monitors the frequency, severity, and length of panic attacks or panic-like symptoms, and identifies the situations when panic attacks or panic-like symptoms occur.
Physical control strategies, a step where the person learns relaxation techniques which decrease the physical symptoms (heavy breathing, fast heart beat, trembling, etc.) that maintains the fear and anxiety.
Psychological control strategies, a step where the person is taught to realistically evaluate and modify thinking patterns that trigger and help maintain the fear and anxiety.
Behavioral strategies, a step where the person is encouraged to face the feared situations that cause anxiety by applying their newly learned skills.
Individuals with agoraphobia seems to mostly benefit from exposure therapy, when the person eliminates the association originally formed between panic symptoms and feared situations, and cognitive restructuring, when the person identifies those thoughts associated with the feared situations, and replace them with realistic, functional thoughts.

Summary

The Patient seems to only experience these attacks during high stress situations and feels extremely helpless during and shortly after the attack. Him living in constant fear of having another attack. So I would recommend him taking a combination of anti-anxiety medication and therapy. the combination of both of these should help him regain his life back and become the the outgoing that he use to be.