Agoraphobia

Overview

Definition

Agoraphobia is fear or anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder in a situation in which it would be difficult to escape or to readily obtain help in the event that one develops panic-like symptoms, thus leading to avoidance.

• The condition involves a fear of actual or potential exposure to public spaces and active attempts to avoid this situation.
• Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with phobic disorders might have good insight Insight Psychiatric Assessment and know that their fear is excessive, or they might have poor insight Insight Psychiatric Assessment.

Epidemiology

• Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency of agoraphobia: around 1.7%
• Median age at presentation: 20 years
• More common in females than in males
• Most commonly occurs in conjunction with panic disorder Panic disorder Panic disorder is a condition marked by recurrent and episodic panic attacks that occur abruptly and without a trigger. These episodes are time-limited and present with cardiorespiratory (palpitations, shortness of breath, choking), GI (nausea, abdominal distress), and neurologic (paresthesias, lightheadedness) symptoms. Panic Disorder, but may occur independently
• Presence of panic disorder Panic disorder Panic disorder is a condition marked by recurrent and episodic panic attacks that occur abruptly and without a trigger. These episodes are time-limited and present with cardiorespiratory (palpitations, shortness of breath, choking), GI (nausea, abdominal distress), and neurologic (paresthesias, lightheadedness) symptoms. Panic Disorder or other phobias Phobias Neurological Examination increase the risk of having agoraphobia.

Pathophysiology

• Genetic factors: family history Family History Adult Health Maintenance increases the risk of developing any anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder, but not agoraphobia specifically.
• Neurobiologic factors:
  • Studies showed increased activation in the ventral striatum Striatum Striped gray matter and white matter consisting of the neostriatum and paleostriatum (globus pallidus). It is located in front of and lateral to the thalamus in each cerebral hemisphere. The gray substance is made up of the caudate nucleus and the lentiform nucleus (the latter consisting of the globus pallidus and putamen). The white matter is the internal capsule. Basal Ganglia: Anatomy and left insula.
  • More anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder in anticipating the feared situation than from experiencing actual situation
• Personality traits:
  • Introversion: associated with increased risk of agoraphobia and situational avoidance
  • Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder sensitivity:
    • Fear of the sensations or behaviors of anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder due to the belief that the anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder symptoms are harmful
    • ↑ Panic disorder Panic disorder Panic disorder is a condition marked by recurrent and episodic panic attacks that occur abruptly and without a trigger. These episodes are time-limited and present with cardiorespiratory (palpitations, shortness of breath, choking), GI (nausea, abdominal distress), and neurologic (paresthesias, lightheadedness) symptoms. Panic Disorder and agoraphobia without panic attacks
  • Dependent personality: a marker of risk for agoraphobia
• Social or environmental factors:
  • Childhood fears
  • Traumatic events (especially if the previous experience indicates that escaping or removing one’s self from the situation reduces the anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder)

Clinical Presentation and Diagnosis

Clinical features

• Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder and/or avoidance of ≥ 2 situations that commonly include being in:
  • Crowds 
  • Being outside on their own
  • Wide open spaces (parking lots, bridges)
  • Enclosed places (shopping malls, grocery stores, movie theaters)
  • Public transportation
• Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship have a fear that they would not be able to escape or that help is not available when they have panic-like symptoms.
• The fear of the situation is intense and disproportionate to the real situation.
• Avoidance is done actively or the patient requires a companion.
• The symptoms significantly impair daily function.
• The anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder is persistent, occurring for ≥ 6 months.
• These symptoms are not due to substance use disorder or a medical or another mental disorder.

Diagnosis

• Clinical, based on symptoms reported
• Some tools used:
  • Agoraphobia subscale of the Fear Questionnaire
  • Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder and Related Disorders Interview Schedule for DSM-5 (ADIS-5)
    • Comprehensive and time-consuming
    • Not ideal for general practice settings

Management

• Agoraphobia is associated with panic disorder Panic disorder Panic disorder is a condition marked by recurrent and episodic panic attacks that occur abruptly and without a trigger. These episodes are time-limited and present with cardiorespiratory (palpitations, shortness of breath, choking), GI (nausea, abdominal distress), and neurologic (paresthesias, lightheadedness) symptoms. Panic Disorder, and treatment studies have often involved patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with both agoraphobia and panic disorders.
• Both pharmacotherapy and psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy showed similar efficacy.
  • Choice is based on availability and patient preference.
  • If monotherapy shows no improvement, the next step is to add the other therapy. 
• Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy:
  • CBT, which includes gradual exposure
  • Psychoeducation Psychoeducation Psychotherapy with breath training and muscle relaxation is also effective. 
  • Behavioral therapy aims to create systematic desensitization Systematic desensitization A behavior therapy technique in which deep muscle relaxation is used to inhibit the effects of graded anxiety-evoking stimuli. Psychotherapy and to change maladaptive behaviors. 
• Medications:
  • Benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines:
    • Most rapid onset of action against panic symptoms
    • Higher potential for misuse 
    • Examples: alprazolam Alprazolam A triazolobenzodiazepine compound with antianxiety and sedative-hypnotic actions, that is efficacious in the treatment of panic disorders, with or without agoraphobia, and in generalized anxiety disorders. Benzodiazepines, lorazepam Lorazepam A benzodiazepine used as an anti-anxiety agent with few side effects. It also has hypnotic, anticonvulsant, and considerable sedative properties and has been proposed as a preanesthetic agent. Benzodiazepines, clonazepam Clonazepam An anticonvulsant used for several types of seizures, including myotonic or atonic seizures, photosensitive epilepsy, and absence seizures, although tolerance may develop. It is seldom effective in generalized tonic-clonic or partial seizures. The mechanism of action appears to involve the enhancement of gamma-aminobutyric acid receptor responses. Benzodiazepines 
  • Antidepressants ( selective serotonin reuptake inhibitors Selective Serotonin Reuptake Inhibitors Serotonin Reuptake Inhibitors and Similar Antidepressants ( SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants)):
    • Have superior safety profile but take longer to achieve therapeutic dose
    • Examples: sertraline Sertraline A selective serotonin uptake inhibitor that is used in the treatment of depression. Serotonin Reuptake Inhibitors and Similar Antidepressants, citalopram Citalopram A furancarbonitrile that is one of the serotonin uptake inhibitors used as an antidepressant. The drug is also effective in reducing ethanol uptake in alcoholics and is used in depressed patients who also suffer from tardive dyskinesia in preference to tricyclic antidepressants, which aggravate dyskinesia. Serotonin Reuptake Inhibitors and Similar Antidepressants, paroxetine Paroxetine A serotonin uptake inhibitor that is effective in the treatment of depression. Serotonin Reuptake Inhibitors and Similar Antidepressants

Other Anxiety Disorders

The following table summarizes the most important information about anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorders.

Differential Diagnosis

• Panic disorder Panic disorder Panic disorder is a condition marked by recurrent and episodic panic attacks that occur abruptly and without a trigger. These episodes are time-limited and present with cardiorespiratory (palpitations, shortness of breath, choking), GI (nausea, abdominal distress), and neurologic (paresthesias, lightheadedness) symptoms. Panic Disorder: chronic mental disorder marked by recurrent and episodic panic attacks that occur abruptly without a trigger Trigger The type of signal that initiates the inspiratory phase by the ventilator Invasive Mechanical Ventilation. Panic disorder Panic disorder Panic disorder is a condition marked by recurrent and episodic panic attacks that occur abruptly and without a trigger. These episodes are time-limited and present with cardiorespiratory (palpitations, shortness of breath, choking), GI (nausea, abdominal distress), and neurologic (paresthesias, lightheadedness) symptoms. Panic Disorder is associated with anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder or fear of having another attack or its complications and some behavioral changes. If the panic attack Panic attack A panic attack is not a mental disorder. Rather, this disorder is a sudden, spontaneous, time-limited period (minutes to an hour) of heightened anxiety or intense fear, often with physical symptoms. Panic Disorder is triggered by a known, identified trigger Trigger The type of signal that initiates the inspiratory phase by the ventilator Invasive Mechanical Ventilation, then the correct diagnosis would be specific phobia Phobia A phobia can be defined as an irrational fear that results in avoidance of the feared subject, activity, or situation. Social Anxiety Disorder. 
• Social phobia Social phobia Anxiety disorder characterized by the persistent and irrational fear, anxiety, or avoidance of social or performance situations. Social Anxiety Disorder: also called social anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder (SAD). Social phobia Social phobia Anxiety disorder characterized by the persistent and irrational fear, anxiety, or avoidance of social or performance situations. Social Anxiety Disorder is the fear or avoidance of social interactions because of concerns about being embarrassed, occurring in > 1 social situation for > 6 months. Treatment includes CBT, antidepressants ( SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants, serotonin Serotonin A biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity. Receptors and Neurotransmitters of the CNS– norepinephrine Norepinephrine Precursor of epinephrine that is secreted by the adrenal medulla and is a widespread central and autonomic neurotransmitter. Norepinephrine is the principal transmitter of most postganglionic sympathetic fibers, and of the diffuse projection system in the brain that arises from the locus ceruleus. Receptors and Neurotransmitters of the CNS reuptake inhibitor ( SNRIs SNRIs Serotonin Reuptake Inhibitors and Similar Antidepressants)), and β-blockers for performance-only subtypes. People with social phobia Social phobia Anxiety disorder characterized by the persistent and irrational fear, anxiety, or avoidance of social or performance situations. Social Anxiety Disorder are afraid of being negatively judged by others.  
• Separation anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder: pathologic exaggeration of anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder that is a universal human developmental milestone in early childhood. This anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder is marked by real or anticipated separation from someone to whom the patient has made an attachment. Separation anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder is seen during the clinical exam, as the patient will be anxious about being detached from their loved ones, whereas in agoraphobia, the patient is focused on panic symptoms triggered from being in public.