Agoraphobia

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Agoraphobia
ICD-10 F40.00 Without panic disorder, F40.01 With panic disorder
ICD-9 300.22 Without panic disorder, 300.21 With panic disorder

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2], Haleigh Williams, B.S., Irfan Dotani

Overview

Agoraphobia is an anxiety disorder characterized by intense terror and anxiety over any place or situation from which one might not easily be able to escape. This often leads sufferers to avoid leaving their homes, using public transportation or air travel, or being in crowded spaces. The average age of onset of agoraphobia is 20 years. Agoraphobia is closely associated with panic disorder; the two are commonly comorbid. Patients with agoraphobia often exhibit depressive symptoms, as well as social or specific phobias, which can make the disorder difficult to diagnose. Patients with severe agoraphobia may become confined to their homes. The word "agoraphobia" is an English adoption of the Greek words agora (αγορά) and phobos (φόβος), literally translated as "a fear of the marketplace." This etymology is the reason for the common misconception that agoraphobia is a fear of open spaces.

Historical Perspective

  • In 1871, Agoraphobia was first described by Karl Friedrich Otto Westphal, a German psychiatrist.
  • Westphal coined the term after observing three of his patients, who exhibited severe anxiety and dread upon traveling to certain public areas of Berlin, in the city where he worked.

Classification

  • Though some experts have argued that agoraphobia can reasonably be thought of as a severe consequence of panic disorder, a comparison of the multivariate comorbidity patterns of agoraphobia and panic disorder supports the independent classification of these disorders.[3]

Pathophysiology

Relationship to Balance Disorders

  • Agoraphobia may be related to defects in balance. Researchers who noticed a similarity between the situations commonly avoided by sufferers of agoraphobia and the types of environments that trigger disorientation in people with balance disorders administered a battery of audiovestibular tests, coupled with moving platform posturography, to 36 subjects with agoraphobic symptoms and 20 normal, healthy controls.
    • Over 60% of the former group were destabilized by these disorienting conditions, compared to a mere 10% of the control group.
    • Postural instability was found to be highly related to agoraphobic avoidance (r = 0.63, P < 0.01), event after the researchers controlled for symptoms, anxiety, and agoraphobic cognitions.[4]

Attachment Theory

  • Some scholars (e.g., Liotti 1996, Bowlby 1998) have explained agoraphobia as an attachment deficit, i.e., the temporary loss of the ability to tolerate spatial separations from a secure base.[5][6]

Spatial Theory

  • In the social sciences, there is a perceived clinical bias (e.g., Davidson 2003) in agoraphobia research. Branches of the social sciences, especially geography, have increasingly become interested in what may be thought of as a spatial phenomenon.[7]

Associated Conditions

Differential Diagnosis

Epidemiology and Demographics

Prevalence

  • The prevalence of agoraphobia is 1,700 per 100,000 (1.7%) of the overall population.[1]

Age

  • Among children, ages 13 to 18, there is a lifetime prevalence of 2,400 per 100,000 (2.4%) for agoraphobia.[9]
  • Among adults in the United States, agoraphobia has a 12-month prevalence of 800 per 100,000 (0.8%). 40.6% of these cases are classified as "severe."[10]

Gender

  • No gender disparity in the incidence of agoraphobia has been widely established.[10]
  • Some studies have suggested that panic disorder patients with agoraphobia are more likely to be female than patients who have panic disorder but not agoraphobia. Female patients were also found to have a higher prevalence of comorbidities.[11]

Race

  • No racial predilection has been established for agoraphobia.[10]

Risk Factors

  • The exact cause of agoraphobia is unknown. In some instances, someone who has a panic attack may begin to exhibit signs of agoraphobia out of fear that another panic attack will occur.[12]
  • Risk factors for agoraphobia include:[1]
    • Anxiety sensitivity
    • Behavioral inhibition
    • Genetic predisposition
    • Neurotic disposition (neuroticism)
    • Negative events in childhood
      • Separation/divorce of parents
      • Death of parent
      • Bullying
    • Stressful or traumatic events (e.g., being attacked or mugged)

Natural History, Complications, and Prognosis

Natural History

  • People with agoraphobia may experience panic attacks in situations in which they feel trapped, insecure, out of control, or too far from their personal comfort zone. In severe cases, an agoraphobic person may be completely confined to his or her home.[13]
    • Some people with agoraphobia are comfortable seeing visitors, but only in a defined space in which they feel in control.
      • Such people may live for years without leaving their homes, while happily seeing visitors and working, as long as they can stay within their safety zones.
      • If someone suffering from agoraphobia leaves his or her "safety zone," an anxiety attack may occur.
    • Agoraphobia patients can experience sudden panic attacks when traveling to places where they fear, where help would be difficult to obtain. During a panic attack, adrenaline is released in large amounts for several minutes causing the classical "fight or flight" condition.
      • The attack typically has an abrupt onset, building to maximum intensity within 10 to 15 minutes, and rarely lasts longer than 30 minutes. [14]
      • These symptoms include palpitations, sweating, trembling, and shortness of breath. Many patients report a fear of dying, or losing control of emotions or behavior. [14]

Complications

  • Complications associated with agoraphobia may encompass physical, behavioral, or lifestyle changes.
    • The avoidance behaviors associated with agoraphobia are established correlates of treatment discontinuation.[15]
    • Individuals with agoraphobia are more likely to show signs of decreased assertiveness, perhaps because their illness cultivates feelings of helplessness and insecurity.[16]
    • The avoidance of places or structures in which panic attacks have occurred may limit a patient’s job prospects or proximity to desirable facilities or services.[17]

Prognosis

  • The prognosis of agoraphobia depends upon the severity of the disease.
  • The prognosis is generally good with early medical intervention; if left untreated, the disorder may become more difficult for healthcare providers to effectively manage.[12]

Diagnosis

Diagnostic Criteria

DSM-V Diagnostic Criteria for Agoraphobia

The fifth version of the DSM, released in 2013, sets forth the following as diagnostic criteria for agoraphobia:[1]

  • A. Marked fear or anxiety about two (or more) of the following five situations:
  • 1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).
  • 2. Being in open spaces (e.g., parking lots, marketplaces, bridges).
  • 3. Being in enclosed places (e.g., shops, theaters, cinemas).
  • 4. Standing in line or being in a crowd.
  • 5. Being outside of the home alone.

AND

  • B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence).

AND

  • C. The agoraphobic situations almost always provoke fear or anxiety.

AND

  • D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.

AND

  • E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the socio cultural context.

AND

  • F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

AND

  • G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

AND

AND

  • I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder—for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in social anxiety disorder): and are not related exclusively to obsessions (as in obsessive-compulsive disorder),perceived defects or flaws in physical appearance (as in body dysmorhic disorder), reminders of traumatic events (as in post traumatic stress disorder), or fear of separation (as in separation anxiety disorder).

Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned.

History and Symptoms

Symptoms of agoraphobia may include the following:[12]

  • Fear of crowds, bridges, and/or being outside alone
  • Fear of losing control of oneself in a public place
  • Feeling dependent upon others
  • Feeling helpless
  • Feeling that one’s body or surroundings are not real
  • Being easily agitated or angered
  • Staying in one’s house for long periods of time
  • Self-medication with drugs or alcohol
  • Inability to function at work or other inherently social settings
  • Depression or suicidal ideation

If agoraphobic patients find themselves in a situation that triggers their anxiety, symptoms may include the following:[12]

Physical Examination

  • Healthcare providers will examine a patient who is exhibiting signs of agoraphobia for a history of panic disorders.
  • The clinician will also get a description of the relevant symptoms and behaviors of the patient and, if possible, from any family members or friends who might have knowledge of relevant behaviors.[12]

Treatment

Medical Therapy

  • The mainstay of therapy for agoraphobia is a combination of CBT, talk therapy, and medicine. Certain drugs that are regularly used to treat depression, such as SSRIs and SNRIs, may also be helpful in the treatment of agoraphobia.[12]
    • Treatment delivery factors, particularly therapist adherence, are important indicators of the potential for successful CBT.[18]
    • Studies have shown that therapist-directed CBT has a more significant impact on agoraphobic psychopathology in the short-term than do SSRIs/SNRIs.[19]
    • At a physician’s discretion, sedatives or hypnotics may also be prescribed. A physician may advise an agoraphobic patient to take such drugs when the symptoms of agoraphobia are particularly severe or as a preventive measure, when one expects to be exposed to a triggering situation.[12]

Surgery

  • Surgical intervention is not recommended for the management of agoraphobia.

Primary Prevention

  • There is no established method for the primary prevention of agoraphobia.

Secondary Prevention

  • Maintenance of a healthy lifestyle may be helpful in the secondary prevention of agoraphobia. This includes:[12]
    • Eating a balanced diet
    • Exercising regularly
    • Getting a sufficient amount of sleep

References

  1. 1.0 1.1 1.2 1.3 1.4 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  2. 2.0 2.1 World Heart Organization (WHO). International Statistical Classification of Diseases and Related Health Problems 10 (ICD-10). Geneva, Switzerland. Retrieved 29 September 2016.
  3. Greene AL, Eaton NR (2016). "Panic disorder and agoraphobia: A direct comparison of their multivariate comorbidity patterns". J Affect Disord. 190: 75–83. doi:10.1016/j.jad.2015.09.060. PMID 26480214.
  4. Yardley L, Britton J, Lear S, Bird J, Luxon LM (1995). "Relationship between balance system function and agoraphobic avoidance". Behav Res Ther. 33 (4): 435–9. PMID 7755529.
  5. G. Liotti, (1996). Insecure attachment and agoraphobia, in: C. Murray-Parkes, J. Stevenson-Hinde, & P. Marris (Eds.). Attachment Across the Life Cycle.
  6. J. Bowlby, (1998). Attachment and Loss (Vol. 2: Separation).
  7. J. Davidson, (2003). Phobic Geographies
  8. Bandelow B, Michaelis S (2015). "Epidemiology of anxiety disorders in the 21st century". Dialogues Clin Neurosci. 17 (3): 327–35. PMC 4610617. PMID 26487813.
  9. Merikangas KR, He JP, Burstein M, Swanson SA, Avenevoli S, Cui L; et al. (2010). "Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication--Adolescent Supplement (NCS-A)". J Am Acad Child Adolesc Psychiatry. 49 (10): 980–9. doi:10.1016/j.jaac.2010.05.017. PMC 2946114. PMID 20855043.
  10. 10.0 10.1 10.2 Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE (2005). "Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication". Arch Gen Psychiatry. 62 (6): 593–602. doi:10.1001/archpsyc.62.6.593. PMID 15939837.
  11. Inoue K, Kaiya H, Hara N, Okazaki Y (2016). "A discussion of various aspects of panic disorder depending on presence or absence of agoraphobia". Compr Psychiatry. 69: 132–5. doi:10.1016/j.comppsych.2016.05.014. PMID 27423353.
  12. 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 NIH: U.S. National Library of Medicine. (2016). Agoraphobia. https://medlineplus.gov/ency/article/000923.htm Retrieved 29 September 2016.
  13. "Treatment of Panic Disorder", NIH Consens Statement, 9 (2): 1–24, Sep 25–27, 1991
  14. 14.0 14.1 David Satcher; et al. (1999). "Chapter 4.2". Mental Health: A Report of the Surgeon General.
  15. Bélanger C, Courchesne C, Leduc AG, Dugal C, El-Baalbaki G, Marchand A; et al. (2016). "Predictors of Dropout From Cognitive-Behavioral Group Treatment for Panic Disorder With Agoraphobia: An Exploratory Study". Behav Modif. doi:10.1177/0145445516656614. PMID 27385412.
  16. Levitan MN, Simoes P, Sardinha AG, Nardi AE (2016). "Agoraphobia Related to Unassertiveness in Panic Disorder". J Nerv Ment Dis. 204 (5): 396–9. doi:10.1097/NMD.0000000000000486. PMID 26915016.
  17. NIH: U.S. National Library of Medicine. (2016). About Panic and Agoraphobia. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0024921/ Retrieved 29 September 2016.
  18. Weck F, Grikscheit F, Höfling V, Kordt A, Hamm AO, Gerlach AL; et al. (2016). "The role of treatment delivery factors in exposure-based cognitive behavioral therapy for panic disorder with agoraphobia". J Anxiety Disord. 42: 10–8. doi:10.1016/j.janxdis.2016.05.007. PMID 27235836.
  19. Liebscher C, Wittmann A, Gechter J, Schlagenhauf F, Lueken U, Plag J; et al. (2016). "Facing the fear--clinical and neural effects of cognitive behavioural and pharmacotherapy in panic disorder with agoraphobia". Eur Neuropsychopharmacol. 26 (3): 431–44. doi:10.1016/j.euroneuro.2016.01.004. PMID 26837851.

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