Many people with agoraphobia learn to avoid situations which might trigger

Diagnosis and Prevalence

Examples of anxiety disorders are panic disorder, agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and other phobias. Each of these disorders is distinct and defined by specific diagnostic criteria according to DSM-5.1 To meet criteria for the diagnosis of an anxiety disorder, the symptoms must cause impairment of functioning. In women, the lifetime prevalence of anxiety disorders is as follows: panic disorder, 5%; generalized anxiety disorder, 5%; obsessive-compulsive disorder, 3%; social phobia, 6%; other specific phobias, 13%; and posttraumatic stress disorder, 10%. The prevalence of anxiety disorders ranges from 13% to 21% in pregnancy and 11% to 17% postpartum,64 and multiple anxiety disorders are often present in a single individual. In addition, the majority of women with anxiety disorders develop comorbid MDD. Although rates of obsessive-compulsive disorder are similar in men and women, all other anxiety disorders are 1.5 to 2 times more common in women. Without treatment, anxiety disorders usually have a chronic course.

Panic attacks are characterized by brief, intense episodes (lasting 5 to 15 minutes) of fear or discomfort. Such attacks occur in many anxiety disorders as well as in healthy individuals exposed to acute stress. Symptoms include palpitations, sweating, shortness of breath, choking, nausea, abdominal discomfort, dizziness, unsteadiness, numbness or tingling, chills, hot flashes, or a fear of dying or losing control. Panic disorder is diagnosed when attacks are recurrent or associated with a fear of future attacks. The most disabling consequence of panic disorder is agoraphobia, which occurs in 30% to 40% of women with untreated panic disorder. Patients with agoraphobia restrict their activities outside the home or insist on being accompanied by a trusted person due to fear of having a panic attack where help is unavailable.

Generalized anxiety disorder is characterized by excessive worrying about multiple problems. The issues of concern to persons with generalized anxiety disorder are realistic, but the level of worry is much more intense than appropriate. For example, a woman might worry for hours about whether a friend received a thank-you note for a gift. Individuals with generalized anxiety disorder have symptoms associated with worry, such as muscle tension, fatigue, headache, nausea, diarrhea, or abdominal pain.

In contrast to generalized anxiety disorder, women with obsessive-compulsive disorder focus on more idiosyncratic and often unrealistic concerns. Obsessive-compulsive disorder is characterized by disturbing intrusive thoughts and the performance of compulsions to temporarily relieve the distress generated by the intrusive thoughts. Obsessional thoughts usually focus on a few key themes: contamination, causing harm, offensive violent or sexual images, religious preoccupations, and urges for symmetry or ordering. Compulsions performed to relieve these intrusive worries include cleaning or washing, checking, repeating, ordering, hoarding, and mental rituals such as counting and praying. During pregnancy and postpartum, contamination concerns and intrusive violent thoughts are particularly common. Differentiating obsessional thoughts and images from delusions and hallucinations can be challenging.65New mothers with obsessive-compulsive disorder may experience disturbing obsessions and mental images of harming their baby. They are highly distressed by these thoughts and are not at increased risk of harming their infant.

Psychological, psychiatric

Rapid and sometimes serious mood swings to mania or depression, and other adverse effects, including enuresis, aggression, impaired memory, sedation, and ataxia, can occur in patients with panic disorder treated with alprazolam [12,13].

Disinhibition has been reported as a major problem with alprazolam, particularly in patients with borderline personality disorder [14]. Several case reports have suggested that alprazolam can cause behavioral disinhibition [15], in common with other benzodiazepines that are occasionally used for recreational or criminal purposes [16]. In one study, covering the period January 1989 to June 1990, the medical records of 323 psychiatric inpatients treated with alprazolam, clonazepam, or no benzodiazepine were reviewed [17]. The frequencies of behavioral disturbances were not significantly different in the different groups, suggesting that alprazolam does not have unique disinhibitory activity and that disinhibition with benzodiazepines may not be an important clinical problem in all psychiatric populations. The study design did not allow the establishment of a relation between the prescription of the benzodiazepine and worsening behaviors, and the findings need to be interpreted conservatively, because it was a retrospective review of a heterogeneous population.

Agoraphobia/panic disorder occurred in 31 patients, 15 of whom had originally been treated with alprazolam and 16 with placebo, had been previously followed during an 8-week treatment period, and had alprazolam-induced memory impairment [18]. These patients were reviewed 3.5 years after treatment to determine whether the memory impairment persisted. Those who had used alprazolam performed as well as those who had taken placebo on the memory task and other objective tests. The performances in both groups were similar to pretreatment values. However, there were differences in subjective ratings: those who had used alprazolam rated themselves as less attentive and clear-headed and more incompetent and clumsy. Memory impairment found while patients were taking alprazolam did not persist 3.5 years later.

Abrupt withdrawal of alprazolam after prolonged treatment of panic disorder is associated with panic attacks.

A 77-year-old married woman with panic attacks did not experience them while she took alprazolam 0.5 mg bd for 5 months; however, the attacks recurred after an increase in dose to 0.5 mg qds [19].

The authors suggested that the duration of action of alprazolam is too brief to prevent rebound anxiety with administration four times a day, but this explanation is highly speculative. This case illustrates the potential severity of alprazolam rebound and how its long-term use can exacerbate the symptoms for which it was originally administered.

Agoraphobia

Agoraphobia shares several features with other phobic disorders: social anxiety disorder and specific phobia (Table 2). It refers to a fear of multiple, interrelated situations that can be grouped into three “clusters.” Situations in the first cluster are those of which the person is afraid because it might be difficult or impossible to immediately escape; they include being in crowded or enclosed places (e.g., shopping centers, cinemas, tunnels) and using public transportation (e.g., buses, trains, planes). The second cluster is represented by situations (e.g., traveling far away from home, staying at home alone) in which the person is alone or outside of their safety zone, so immediate medical or other help might not be available. Situations in the third cluster are those from which it might be awkward or embarrassing to escape immediately (e.g., standing in line, sitting in the middle of a row in a theater).

Table 2. General Characteristics of the PhobicDisorders (Agoraphobia, Social Anxiety Disorder, Specific Phobia)

•

The fear pertains to the known objects, situations, activities, or phenomena (“phobic stimuli”)

The fear is out of proportion to the actual threat posed by the phobic stimuli and to the sociocultural context

Insight that the fear is irrational or excessive is usually preserved, but may be absent in children

Exposure to phobic stimuli elicits an immediate fearful response, sometimes in the form of a panic attack

Phobic stimuli are avoided or endured with great distress and/or fear if avoidance is not possible

The fear is persistent and lasts for months and years (minimum 6 months according to the DSM-5)

The fear or fear-related avoidance causes significant distress or impairment in functioning

These situations are often feared because of the anticipation of panic attacks or symptoms, and the purpose of the subsequent avoidance is to prevent them. This is the reason for the frequent co-occurrence of agoraphobia and panic disorder and for the view that agoraphobia is actually a part of panic disorder. However, in many cases of agoraphobia, the fear is unrelated to panic9,10 and sufferers believe that their avoidance is due to fears of falling, being incontinent, getting lost, having an accident, or being mugged. Unlike other phobic disorders, agoraphobia is characterized by reliance on a “phobic companion” (i.e., a person who accompanies the affected individual to a variety of agoraphobic situations so that full-scale avoidance is averted). In the absence of a phobic companion, avoidance is usually extensive and often leads to the person becoming homebound and incapacitated.

Many of the epidemiological findings on agoraphobia (Table 1) are derived from the data on panic disorder with agoraphobia and some may relate more to panic disorder than to agoraphobia. Higher prevalence rates of agoraphobia than those of panic disorder and earlier mean age of onset of agoraphobia than that of panic disorder also suggest the conceptual independence of agoraphobia from panic disorder. It has been consistently reported that agoraphobia is much more likely to occur in women, which gave rise to the hypotheses about gender-related psychological and social factors in the development of agoraphobia. However, the dominant explanatory model is that agoraphobic fear is a consequence of learning (i.e., of associating unpleasant anxiety symptoms or traumatic experiences with certain situations); avoidance, in turn, maintains this fear.

Abstract

Agoraphobia is marked by anxiety about situations from which escape may be difficult if panic-like symptoms arise, and typically entails avoidance of public transportation, open or enclosed areas, crowds, and being alone away from home. Panic attacks are sudden, brief episodes of extreme anxiety. Not uncommon in themselves, the panic attacks of significance in panic disorder arise unexpectedly and are associated with significant distress and impairment. Syndromes that include agoraphobia or panic attacks have been classified formally as distinct anxiety disorders in the United States since 1980. Agoraphobia with panic disorder, recognized as a diagnosis in the ICD-10-CM but not in the DSM-5, is the combined syndrome that is especially familiar in mental health practice settings. Since the 1970s clinical researchers have developed effective pharmacological and psychological treatments for agoraphobia and panic syndromes.

Agoraphobia

Agoraphobia is characterized by anxiety and avoidance of situations in which it would be difficult to escape, difficult to get help if a panic attack occurred, or embarrassing to leave. Common examples include using public transportation, being in crowds, or being in movie theaters. As is clear in the definition, agoraphobia has been thought in recent decades as being closely linked to panic disorder. Clinical samples have borne this out, with very few agoraphobics having no history of panic attacks. Thus, panic attacks have been thought to play a central role in the development of agoraphobia as a behavioral response to prevent the unpleasant experience of a panic attack. However, agoraphobia is currently being proposed as a separate psychiatric disorder in the upcoming DSM-5. This proposal is supported by community population studies that have found most of those with agoraphobia lack associated panic. Instead of fearing a panic attack, these people typically have excessive fear of external threats (e.g., being attacked, being in a collapsing structure).

As with social anxiety disorder, selective serotonin reuptake inhibitors are first-line pharmacotherapeutic agents for agoraphobia with panic disorder, as opposed to benzodiazepines that, despite rapid anxiolytic benefits, are prone to development of dependence. Likewise, cognitive behavior therapy has the strongest evidence basis among psychotherapeutic treatments.

5.12.2.2.7 Agoraphobia

Agoraphobia in children and adolescents is characterized by a persistent fear of being trapped with no way to escape from a place or situation (APA, 2013). For instance, the use of public transport, standing in a line, being in a crowded classroom, being in open or enclosed spaces, may present challenges for young people with agoraphobia who may experience a panic attack or feel intense discomfort and unease (Hudson et al., 2019a,b). Another important criterion is active avoidance behavior which prevents or minimizes contact with the feared place or situation (APA, 2013).

First onset of agoraphobia in childhood is rare, with the mean age of onset around 17 years (Beesdo et al., 2009). Incidence peaks in late adolescence, and if left untreated, agoraphobia follows a prolonged and persistent course which is associated with significant impairment in adult life (APA, 2013). Research shows agoraphobia is diagnosed in 2.4% of adolescents and is twice as likely to be diagnosed in females than males (Merikangas et al., 2010; Wittchen et al., 2011).

Introduction

Agoraphobia consists of a group of fears of public places – especially when the patient is alone – such as going outside, using public transport and being in public places (supermarkets, cinemas, churches, football stadia, etc.), which cause serious interference in daily life. Other external fears may spring from this core phobia, such as using lifts, going through tunnels, crossing bridges, etc., as well as other internal fears, such as excessive worry about physical sensations (palpitations, vertigo, dizziness, etc.) or an intense fear of panic attacks, including fear of social interaction (Echeburúa & Corral, 1995). However, the patognomonic symptom of agoraphobia – and predictor of the appearance of the conditions described – is fear of public places, which is not manifest in specific phobias. The diagnostic criteria of this behavioural disorder according to the DSM-IV (APA, 1994) appear in Table 3.1.

Table 3.1. Diagnostic Criteria for Agoraphobia Without History of Panic Disorder According to the DSM-IV (APA, 1994)

A.

A The presence of agoraphobia – that is, 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 travelling in a bus, train or automobile

B The situations are avoided (e.g., travel is restricted) or else 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 patient does not meet any of the diagnostic criteria for Panic Disorder

D If an associated general medical condition is present, the fear described in Criterion A is clearly in excess of that usually associated with the condition

E The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g. occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobia situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), Separation Anxiety Disorder (e.g., in response to being away from home or close relatives)

F The agoraphobia is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition

The first panic attack can occur unexpectedly in any kind of agoraphobic situation (bus, shop, church, etc.) when the subject finds him/herself in a heightened state of unspecified stress (disgust, sickness, persistent worry). Once this crisis has occurred, the patient tends to avoid the situation and, from then on, this avoidance carries over into other situations. Indeed, avoidance of public places in order to reduce fear or panic becomes the main cause of incapacity in patients, who, in more serious cases, end up confined to their homes. As such, psychopathological symptoms associated with depression, general anxiety and hypochondria are not infrequent, neither are obsessive thoughts.

What triggers agoraphobia?

In which situation would someone with agoraphobia try to avoid?

How does a person with agoraphobia behave?

What are agoraphobics afraid of?