Agoraphobia

Agoraphobia is fear or anxiety in a situation that would be difficult to leave or to obtain help in the event that one develops panic-like symptoms. Situations include being in public or open spaces, lines, crowds, or public transport. If severe, the condition results in significant social and occupational disability in which patients actively avoid the situation, and in certain cases, refuse to leave their homes alone. Diagnosis is clinical, based on the presenting symptoms. Agoraphobia occurs frequently 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. Management is best approached with CBT and medications (selective serotonin reuptake inhibitors Serotonin Reuptake Inhibitors Antidepressants encompass several drug classes and are used to treat individuals with depression, anxiety, and psychiatric conditions, as well as those with chronic pain and symptoms of menopause. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and many other drugs in a class of their own. Serotonin Reuptake Inhibitors and Similar Antidepressant Medications (SSRIs)).

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Overview

Definition

Agoraphobia is fear or anxiety 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 with phobic disorders might have good insight and know that their fear is excessive, or they might have poor insight.

Epidemiology

  • Prevalence 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 increase the risk of having agoraphobia.

Pathophysiology

  • Genetic factors: family history increases the risk of developing any anxiety disorder, but not agoraphobia specifically.
  • Neurobiologic factors:
    • Studies showed increased activation in the ventral striatum and left insula.
    • More anxiety in anticipating the feared situation than from experiencing actual situation
  • Personality traits:
    • Introversion: associated with increased risk of agoraphobia and situational avoidance
    • Anxiety sensitivity: 
      • Fear of the sensations or behaviors of anxiety due to the belief that the anxiety symptoms are harmful
      • ↑ 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)

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Clinical Presentation and Diagnosis

Clinical features

  • Anxiety 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, groceries, movie theaters)
    • Public transportation
  • Patients 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 is persistent, occurring for ≥ 6 months.
  • These symptoms are not due to substance abuse or a medical or another mental disorder.

Diagnosis

  • Clinical, based on symptoms reported
  • Some tools used:
    • Agoraphobia subscale of the Fear Questionnaire
    • Anxiety 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 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: 
    • CBT, which includes gradual exposure
    • Psychoeducation with breath training and muscle relaxation is also effective. 
    • Behavioral therapy aims to create systematic desensitization 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, lorazepam, clonazepam 
    • Antidepressants (selective serotonin reuptake inhibitors Serotonin Reuptake Inhibitors Antidepressants encompass several drug classes and are used to treat individuals with depression, anxiety, and psychiatric conditions, as well as those with chronic pain and symptoms of menopause. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and many other drugs in a class of their own. Serotonin Reuptake Inhibitors and Similar Antidepressant Medications (SSRIs)):
      • Have higher safety profile but take longer to achieve therapeutic dose
      • Examples: sertraline, citalopram, paroxetine

Other Anxiety Disorders

The following table summarizes the most important information about anxiety disorders.

Table: Comparison of anxiety disorders
Condition Most important features Duration Treatment
Panic disorder Recurrent and unexpected abrupt surges (within minutes) of intense fear or discomfort ≥ 1 month
  • Acute attack: BDZs
  • Maintenance: SSRIs, CBT
Generalized anxiety disorder Generalized anxiety disorder Generalized anxiety disorder (GAD) is a common mental condition defined by excessive, uncontrollable worrying causing distress and occurring frequently for at least 6 months. Generalized anxiety disorder is more common in women. Clinical presentation includes fatigue, low concentration, restlessness, irritability, and sleep disturbance. Generalized Anxiety Disorder Chronic multiple worries usually about issues, events, activities ≥ 6 months Combination of antidepressants (SSRIs) and CBT
Specific phobia Unreasonable fear of a certain object or situations ≥ 6 months
  • 1st-line: CBT
  • Medication has an insignificant role.
Social phobia ( social anxiety disorder Social anxiety disorder Social anxiety disorder, or social phobia, is a psychiatric illness marked by fear and avoidance of social interactions due to concerns about embarrassment. The disorder usually occurs in more than one social situation for more than 6 months and leads to a significant decline in function. Social Anxiety Disorder) Fear or avoidance of social interactions due to concerns about being embarrassed ≥ 6 months
  • 1st-line: SSRIs or CBT
  • Performance-only subtype: β-blockers or BDZs
Agoraphobia Fear of being in situations or places where it is difficult to leave or escape ≥ 6 months 1st-line: SSRIs or CBT
Separation anxiety disorder Fear of being separated from attachment figures ≥ 1 month
  • 1st-line: CBT
  • Medications might be used if CBT alone fails.
Illness anxiety disorder Illness Anxiety Disorder Illness anxiety disorder, formerly known as hypochondriasis, is a chronic condition characterized by a prolonged and exaggerated concern about one's health and possible illness. Patients fear or are convinced that they have a disease and interpret minor or normal bodily symptoms as signs of a serious medical condition. Illness Anxiety Disorder Anxiety arises from concerns about having or acquiring a certain illness. ≥ 6 months
  • Schedule regular follow-up visits.
  • Avoid doing unnecessary diagnostic tests Diagnostic tests Diagnostic tests are important aspects in making a diagnosis. Some of the most important epidemiological values of diagnostic tests include sensitivity and specificity, false positives and false negatives, positive and negative predictive values, likelihood ratios, and pre-test and post-test probabilities. Epidemiological Values of Diagnostic Tests.
  • Avoid referrals.
  • CBT and antidepressants if these measures fail
Substance- or drug-induced anxiety disorder
  • Intoxication with cocaine or amphetamine
  • Withdrawal from alcohol or benzodiazepines
  • Medications such as β2-agonists (albuterol) or levothyroxine
BDZs: benzodiazepines
SSRIs: selective serotonin reuptake inhibitors Serotonin Reuptake Inhibitors Antidepressants encompass several drug classes and are used to treat individuals with depression, anxiety, and psychiatric conditions, as well as those with chronic pain and symptoms of menopause. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and many other drugs in a class of their own. Serotonin Reuptake Inhibitors and Similar Antidepressant Medications

Differential Diagnosis

  • Panic disorder: chronic mental disorder marked by recurrent and episodic panic attacks that occur abruptly without a trigger. Panic disorder is associated with anxiety or fear of having another attack or its complications and some behavioral changes. If the panic attack is triggered by a known, identified trigger, then the correct diagnosis would be specific phobia. 
  • Social phobia: also called social anxiety disorder Social anxiety disorder Social anxiety disorder, or social phobia, is a psychiatric illness marked by fear and avoidance of social interactions due to concerns about embarrassment. The disorder usually occurs in more than one social situation for more than 6 months and leads to a significant decline in function. Social Anxiety Disorder (SAD). Social phobia 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, serotonin–norepinephrine reuptake inhibitor (SNRIs)), and β-blockers for performance-only subtypes. People with social phobia are afraid of being negatively judged by others.  
  • Separation anxiety disorder: pathologic exaggeration of anxiety that is a universal human developmental milestone in early childhood. This anxiety disorder is marked by real or anticipated separation from someone to whom the patient has made an attachment. Separation anxiety 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.

References

  1. Dave, P. (2017). Clinical management of anxiety disorders. Retrieved June 22, 2021. https://www.researchgate.net/publication/348489972_Clinical_Management_of_Anxiety_Disorders
  2. Grant, J. (2021). Overview of anxiety disorders. Retrieved June 22, 2021. https://www.researchgate.net/publication/348495093_Overview_of_Anxiety_Disorders
  3. Palkar, P. (2020). Neurobiology of anxiety disorders. Retrieved June 22, 2021, from https://www.researchgate.net/publication/341407589_Neurobiology_of_Anxiety_Disorders
  4. Roy-Byrne, P. (2018). Agoraphobia in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis. UpToDate. Retrieved June 26, 2021, from https://www.uptodate.com/contents/agoraphobia-in-adults-epidemiology-pathogenesis-clinical-manifestations-course-and-diagnosis 
  5. Roy-Byrne, P. (2020). Pharmacotherapy for panic disorder with or without agoraphobia in adults. UpToDate. Retrieved June 26, 2021, from https://www.uptodate.com/contents/pharmacotherapy-for-panic-disorder-with-or-without-agoraphobia-in-adults 
  6. Sadock, B. J., Sadock, V. A., Ruiz, P. (2014). Anxiety disorders. Chapter 9 of Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th ed. Philadelphia: Lippincott Williams and Wilkins, pp. 387–417.

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