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. Management is best approached with CBT and medications (selective serotonin reuptake inhibitors (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, but may occur independently
  • Presence of 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, and treatment studies have often involved patients with both agoraphobia and panic disorders.
  • Both pharmacotherapy and 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: 
      • Most rapid onset of action against panic symptoms
      • Higher potential for misuse 
      • Examples: alprazolam, lorazepam, clonazepam 
    • Antidepressants (selective serotonin reuptake inhibitors (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
ConditionMost important featuresDurationTreatment
Panic disorderRecurrent and unexpected abrupt surges (within minutes) of intense fear or discomfort≥ 1 month
  • Acute attack: BDZs
  • Maintenance: SSRIs, CBT
Generalized anxiety disorderChronic multiple worries usually about issues, events, activities≥ 6 monthsCombination of antidepressants (SSRIs) and CBT
Specific phobiaUnreasonable fear of a certain object or situations≥ 6 months
  • 1st-line: CBT
  • Medication has an insignificant role.
Social phobia (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
AgoraphobiaFear of being in situations or places where it is difficult to leave or escape≥ 6 months1st-line: SSRIs or CBT
Separation anxiety disorderFear of being separated from attachment figures≥ 1 month
  • 1st-line: CBT
  • Medications might be used if CBT alone fails.
Illness anxiety disorderAnxiety arises from concerns about having or acquiring a certain illness.≥ 6 months
  • Schedule regular follow-up visits.
  • Avoid doing unnecessary 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

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 (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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