Agoraphobia

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 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 Disability Determination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for social security and workman's compensation benefits. ABCDE Assessment in which patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship 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 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 reuptake inhibitors ( SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants)).

Last updated: Jul 6, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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 Escape With constant immune mechanisms holding unstable tumor cells in equilibrium, tumor-cell variants may emerge. These cancer cells may express fewer antigens on their surfaces or lose their MHC class I expression.Variants may also protect themselves from T-cell attack via expression of IC molecules on their surfaces, like normal cells.Creation of an immunosuppressive state in the microenvironment is another way to grow without immunologic interference. Cancer Immunotherapy or to readily obtain help in the event that one develops panic-like symptoms, thus leading to avoidance.

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 Median After arranging the data from loWest to highest, the median is the middle value, separating the lower half from the upper half of the data set. Measures of Central Tendency and Dispersion age at presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor: 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 Sensitivity Binary classification measures to assess test results. Sensitivity or recall rate is the proportion of true positives. Blotting Techniques
      • 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)

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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, groceries, 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 Escape With constant immune mechanisms holding unstable tumor cells in equilibrium, tumor-cell variants may emerge. These cancer cells may express fewer antigens on their surfaces or lose their MHC class I expression.Variants may also protect themselves from T-cell attack via expression of IC molecules on their surfaces, like normal cells.Creation of an immunosuppressive state in the microenvironment is another way to grow without immunologic interference. Cancer Immunotherapy 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 abuse 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
  • 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 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 reuptake inhibitors ( SSRIs SSRIs 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.

Table: Comparison of anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorders
Condition Most important features Duration Treatment
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 Recurrent and unexpected abrupt surges (within minutes) of intense fear or discomfort ≥ 1 month
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 SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants) and CBT
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 Unreasonable fear of a certain object or situations ≥ 6 months
  • 1st-line: CBT
  • Medication has an insignificant role.
Social 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 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
Agoraphobia Fear of being in situations or places where it is difficult to leave or escape Escape With constant immune mechanisms holding unstable tumor cells in equilibrium, tumor-cell variants may emerge. These cancer cells may express fewer antigens on their surfaces or lose their MHC class I expression.Variants may also protect themselves from T-cell attack via expression of IC molecules on their surfaces, like normal cells.Creation of an immunosuppressive state in the microenvironment is another way to grow without immunologic interference. Cancer Immunotherapy ≥ 6 months 1st-line: SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants or CBT
Separation anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder Fear of being separated from attachment Attachment The binding of virus particles to virus receptors on the host cell surface, facilitating virus entry into the cell. Virology 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 Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder arises from concerns about having or acquiring a certain illness. ≥ 6 months
  • Schedule regular Regular Insulin 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 Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder
  • Intoxication with cocaine Cocaine An alkaloid ester extracted from the leaves of plants including coca. It is a local anesthetic and vasoconstrictor and is clinically used for that purpose, particularly in the eye, ear, nose, and throat. It also has powerful central nervous system effects similar to the amphetamines and is a drug of abuse. Cocaine, like amphetamines, acts by multiple mechanisms on brain catecholaminergic neurons; the mechanism of its reinforcing effects is thought to involve inhibition of dopamine uptake. Local Anesthetics or amphetamine
  • Withdrawal from alcohol or 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
  • Medications such as β2-agonists ( albuterol Albuterol A short-acting beta-2 adrenergic agonist that is primarily used as a bronchodilator agent to treat asthma. Sympathomimetic Drugs) or levothyroxine Levothyroxine Thyroid Replacement Therapy
BDZs: 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
SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants: selective 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 reuptake inhibitors

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 Phobia A phobia can be defined as an irrational fear that results in avoidance of the feared subject, activity, or situation. Social Anxiety Disorder: 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 Phobia A phobia can be defined as an irrational fear that results in avoidance of the feared subject, activity, or situation. 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 Phobia A phobia can be defined as an irrational fear that results in avoidance of the feared subject, activity, or situation. 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 Attachment The binding of virus particles to virus receptors on the host cell surface, facilitating virus entry into the cell. Virology. 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.

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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