AGORAPHOBIA

AGORAPHOBIA

The term Agoraphobia is derived from the two Greek words agora and phobos, agora meaning market place and phobos meaning fear. So Agoraphobia is “fear of the marketplace.” The term agoraphobia was coined in 1871 to describe the condition of patients who were afraid to venture alone into public places. So Agoraphobia refers to a fear of or anxiety regarding places from which escape might be difficult. It can be the most disabling of the phobias because it can significantly interfere with a person’s ability to function in work and or social situations i.e. outside the home.

So Agoraphobia is an example of irrational fear of situations. It is the commonest type of phobia encountered in clinical practice. Although earlier it was thought to be a fear of open spaces only, however now it includes not only fear of open spaces but also public places, crowded places, and any other place from where there is no easy escape to a safe place. In fact, the patient is afraid of all such places or situations from where escape may be perceived to be difficult or help may not be available, if he/she suddenly develops these embarrassing or incapacitating symptoms. These embarrassing or incapacitating symptoms are the classical symptoms of panic disorder.

Agoraphobia may occur with full-blown panic attack i.e. agoraphobia with panic disorder or only a few symptoms like dizziness or tachycardia and is referred to as agoraphobia without panic disorder.

EPIDEMIOLOGY

Every year approximately 1.7% of adolescents and adults have a diagnosis of agoraphobia. Females are twice as likely as males to experience agoraphobia. Agoraphobia may occur in childhood, but incidence peaks in late adolescence and early adulthood. Twelve-month prevalence in individuals older than 65 years is 0.4%. Prevalence rates do not appear to vary systematically across cultural/racial groups.

DIAGNOSIS AND CLINICAL FEATURES

According to DSM-5 Diagnostic Criteria for Agoraphobia:

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.

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).

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

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

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

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

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

H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease) is present, the fear, anxiety, or avoidance is clearly excessive.

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 dysmorphic disorder), reminders of traumatic events (as in posttraumatic 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.

DEVELOPMENT AND COURSE

The majority of individuals with panic disorder show signs of anxiety and agoraphobia before the onset of panic disorder. In two-thirds of all cases of agoraphobia, initial onset is before age 35 years. There is a substantial incidence risk in late adolescence and early adulthood, with indications for a second high incidence risk phase after age 40 years. First onset in childhood is rare. The overall mean age at onset for agoraphobia is 17 years, although the age at onset without preceding panic attacks or panic disorder is 25-29 years.

The course of agoraphobia is typically persistent and chronic. Complete remission is rare (10%), unless the agoraphobia is treated. With more severe agoraphobia, rates of full remission decrease, whereas rates of relapse and chronicity increase.

RISK AND PROGNOSTIC FACTORS

1. Temperamental: Behavioural inhibition and neurotic disposition (i.e., negative affectivity [neuroticism] and anxiety sensitivity) are closely associated with agoraphobia but are relevant to most anxiety disorders (phobic disorders, panic disorder, generalized anxiety disorder). Anxiety sensitivity (the disposition to believe that symptoms of anxiety are harmful) is also characteristic of individuals with agoraphobia.

2. Environmental: Negative events in childhood (e.g., separation, death of parent) and other stressful events, such as being attacked or mugged, are associated with the onset of agoraphobia. Furthermore, individuals with agoraphobia describe the family climate and child-rearing behaviour as being characterized by reduced warmth and increased overprotection.

3. Genetic and physiological: Heritability for agoraphobia is 61%. Of the various phobias, agoraphobia has the strongest and most specific association with the genetic factor that represents proneness to phobias.

COMORBIDITY

The majority of individuals with agoraphobia also have other mental disorders. The most frequent additional diagnoses are other anxiety disorders (e.g., specific phobias, panic disorder, and social anxiety disorder), depressive disorders (major depressive disorder), PTSD, and alcohol use disorder. Whereas other anxiety disorders (e.g., separation anxiety disorder, specific phobias, panic disorder) frequently precede onset of agoraphobia, depressive disorders and substance use disorders typically occur secondary to agoraphobia.

TREATMENT

There are two different types of therapies available for agoraphobia treatment.

1. Pharmacotherapy: Pharmacotherapy includes treatment using benzodiazepines, SSRIs and tri- and tetra cyclic drugs.

i) Benzodiazepines: Benzodiazepines have the most rapid onset of action against panic. Some patients use them as needed when faced with a phobic stimulus. Alprazolam (Xanax) and lorazepam (Ativan) are the most commonly prescribed benzodiazepines. Clonazepam (Klonopin) has also been shown to be effective. The major reservations among clinicians regarding the use of benzodiazepines are the potential for dependence, cognitive impairment, and abuse, particularly with long-term use. However, when used appropriately under medical supervision, benzodiazepines are efficacious and generally well tolerated. The most common side effects are mild dizziness and sedation, both of which are generally attenuated by time or change of dose. Caution must be exercised when using heavy or dangerous machinery or when driving, especially when first starting the medication or when the dose is changed.

ii) Selective Serotonin Reuptake Inhibitors: SSRIs have been shown to help reduce or prevent relapse from various forms of anxiety, including agoraphobia. The main advantages of SSRIs antidepressants include their improved safety profile in overdose and more tolerable side-effect burden. Common side effects of most SSRIs are sleep disturbance, drowsiness, lightheadedness, nausea, and diarrohea; many of these adverse effects improve with continued use. Another commonly reported side effect of SSRIs is sexual dysfunction (i.e., decreased libido, delayed ejaculation in men, delayed orgasm in women. Another issue to be considered when prescribing an SSRI is the possibility of a discontinuation syndrome if these medications are stopped abruptly. Commonly reported symptoms of this condition, which tend to occur 2 to 4 days after medication cessation, include increased anxiety, irritability, tearfulness, dizziness or lightheadedness, malaise, sleep disturbance, and concentration difficulties. This discontinuation syndrome is most common among SSRIs with shorter half-lives.

iii) Tricyclic and Tetracyclic Drugs: Although SSRIs are considered the first-line agents for treatment of panic disorders with or without agoraphobia, the tricyclic drugs clomipramine and imipramine are the most effective in the treatment of these disorders. Dosages must be titrated slowly upward to avoid overstimulation (e.g., “jitteriness” syndrome), and the full clinical benefit requires full dosages and may not be achieved for 8 to 12 weeks. The other adverse effects to these antidepressants are related to their effects on seizure threshold, as well as anticholinergic and potentially harmful cardiac effects, particularly in overdose.

2. Psychotherapy: Psychotherapies include therapies like:- supportive, insight oriented, behaviour, cognitive and virtual psychotherapy.

a) Supportive Psychotherapy: Supportive psychotherapy involves the use of psychodynamic concepts and a therapeutic alliance to promote adaptive coping skills. Adaptive defenses are encouraged and strengthened, and maladaptive ones are discouraged. The therapist assists in reality testing and may offer advice regarding behaviour change.

b) Insight-Oriented Psychotherapy: In insight-oriented psychotherapy, the goal is to increase the development patient’s insight into psychological conflicts that, if unresolved, can manifest as symptomatic behaviour.

c) Behaviour Therapy: In behaviour therapy, the basic assumption is that change can occur without the development of psychological insight into underlying causes. Techniques include: positive and negative reinforcement, systematic desensitization, flooding, graded exposure, response prevention, relaxation techniques, panic control therapy, self-monitoring, and hypnosis.

d) Cognitive Therapy: This is based on the premise that maladaptive behaviour is secondary to distortions in how people perceive themselves and in how other perceives them. Treatment is short term and interactive, with assigned homework and tasks to be performed between sessions that focus on correcting distorted assumptions and cognitions. The emphasis is on confronting and examining situations that elicit interpersonal anxiety and associated mild depression.

e) Virtual Therapy: More recent of all the psychotherapies is the virtual therapy. Computer programs have been developed that allow patients to see themselves as avatars who are then placed in open or crowded spaces (e.g., a supermarket). As they identify with the avatars in repeated computer sessions, they are able to master their anxiety through deconditioning.

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