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Agoraphobia

Agoraphobia with Panic Attacks

What is Agoraphobia?

A panic disorder is the presence of recurrent, unexpected panic attacks followed by constant worry that the panic attacks will return and the implications or consequences of the attacks. There may also be a change in behavior associated with the attacks. Agoraphobia is a fear of being out in public. The fear is generally caused by panic attacks. This fear leads to staying home and persistently avoiding these situations, or enduring the situation with intense dread and with the help of a companion. Examples of feared situations are being in a grocery store, shopping mall, or other crowded situations. Agoraphobia is usually diagnosed in association with panic disorder, in which there are recurrent panic attacks that may be predictable or occur unexpectedly. A panic attack is a sudden onset of multiple symptoms of intense fear, consistent with a sense of an impending disaster.

Panic disorder, with or without agoraphobia, is present in between one to three percent of people at some time in their lives. Agoraphobia tends to begin in a person's 20s. Women are affected more often than men. The distress is not due to a social or specific phobia or another anxiety disorder.

With this diagnosis, the panic attacks are judged not directly due to drug abuse, a medical condition (such as an overactive thyroid gland), or side effects of medication. The panic is not explained by other anxiety disorders such as a specific or social phobia, obsessive-compulsive disorder, posttraumatic stress disorder, or separation anxiety disorder.

How is Agoraphobia diagnosed?

Before diagnosing agoraphobia, a physician should perform a complete physical examination and compile a thorough medical history to rule out any potential physical cause. If a mental disorder is suspected, the patient will be referred to a psychiatrist, psychologist or other mental health professional.

Agoraphobia will be diagnosed if the patient has symptoms consistent with agoraphobia that are not caused by another mental condition. Other mental conditions that may present with symptoms similar to those of agoraphobia include:

  • Obsessive-compulsive disorder
  • Post-traumatic stress disorder
  • Separation anxiety disorder
  • Social phobia
  • Specific phobia
Agoraphobia frequently occurs with another condition called panic disorder. Many patients share at least some of the symptoms of both of these conditions. Patients may be diagnosed as having either panic disorder with agoraphobia or agoraphobia without history of panic disorder.

The criteria used to diagnose these two conditions are virtually identical. However there is one key exception: agoraphobia without history of panic disorder is diagnosed if the patient's fear is focused on the potential for experiencing incapacitating or embarrassing, panic-like symptoms or attacks with limited symptoms. For example, the patient may fear having heart-related symptoms and not being able to get help. This differs from panic disorder with agoraphobia, in which the patient's fear is centered on the possibility of full-blown panic attacks, after experiencing panic attacks. In essence, patients who are diagnosed with agoraphobia without history of panic disorder do not have a history of recurrent panic attacks.

Finally, agoraphobia will not be diagnosed for conditions in which a patient's fears are reasonable given certain medical conditions. For example, a patient who has Crohn's disease (a chronic autoimmune disease) may fear being struck with an episode of diarrhea at an inconvenient time. This fear is normal given the patient's circumstances.

How is Agoraphobia treated?

In the majority of cases, a combination of psychotherapy and anti-anxiety and antidepressant medications is the most effective treatment. Cognitive therapy is done to suggest that panic is a misinterpretation of body sensations and that the danger is not as extreme as is perceived. Relaxation training and progressive muscle relaxation can be done, along with respiratory control training. Exposure therapy, where the person is gradually exposed little by little to the dreaded situation, is a useful treatment. Supportive psychotherapy is done as needed. Drug therapy is usually a serotonin-specific reuptake inhibitor (SSRI) with some use of benzodiazepine. Tricyclic antidepressants are occasionally prescribed.

Medication for Agoraphobia

Information
Brand
Generic
Label
Zoloft Oral
Zoloft
Sertraline
Off-Label
generic Elavil
Elavil
Amitriptyline
Off-Label
Paroxetine online
Paxil
Paroxetine
Off-Label

Klonopin (Clonazepam), Xanax (Alprazolam), Prozac (Fluoxetine), Tofranil (Imipramine), Trileptal (Oxcarbazepine)



What might complicate it?

Staying at home can often result in a loss of most relationships and employment. Some individuals may become convinced that they have an undiagnosed life threatening disease or that they are going crazy and may limit their activities even further.

Predicted outcome

Outcome is variable. The panic attacks come and go over the years. The agoraphobia may subside if the panic attacks subside but may remain chronically present.

Alternatives

Other possibilities are agoraphobia without a history of panic disorder, anxiety disorder due to a medical condition, substance-induced anxiety disorder, social phobia, specific phobia, obsessive-compulsive disorder, hyperventilation syndrome, separation anxiety disorder, and delusional disorder. Medical causes include an underactive or overactive thyroid gland.

Appropriate specialists

Psychiatrist or psychologist.

Questions for your doctor

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions regarding agoraphobia:
  1. Are my symptoms indicative of agoraphobia?
  2. How is agoraphobia typically diagnosed?
  3. What is causing my agoraphobia?
  4. How is agoraphobia related to panic disorder?
  5. Do I have panic disorder?
  6. Is my agoraphobia medically dangerous?
  7. Will my agoraphobia become worse if I don’t treat it?
  8. What are my treatment options? How effective are treatments?
  9. Will I ever be able to overcome my agoraphobia?
  10. Are my children at risk of developing agoraphobia since I have the condition?

Last updated 24 June 2021