Day # 71: Agoraphobia

Today we will discuss agoraphobia. We will cover the clinical features, epidemiology, clinical pearls, and treatment options for agoraphobia.

Today's Content Level: Beginner, Intermediate

CLINICAL FEATURES

•Agoraphobia is a specific type of anxiety disorder that is centered around situations that would be difficult to leave. The term was coined in 1871 and is derived from the Greek words agor and phobos, meaning "fear of the marketplace".

•It is intense fear and avoidance of being in public places or in a situation that would be difficult to escape or obtain help. Avoidance behavior may become very extreme such as compete confinement to their home.

•Agoraphobia was previously a specificer of panic disorder, but now is a separate diagnosis in DSM-V. Many researchers believe that agoraphobia almost always develops as a complication in patients with panic disorder although there is some disagreement.

The diagnostic criteria for agoraphobia are as follows 1:

• Significant fear/anxiety about ≥2 of the following situations:

  • Using public transportation (cars, buses, trains, planes, etc.)

  • Open spaces (bridges, parking lots, etc.)

  • Enclosed spaces (stores, theaters, etc.)

  • Crowds or standing in lines.

  • Being outside of the home alone.

    • Fear involves worry that they will develop panic-like symptoms or other embarrassing symptoms in these situations and will be unable to receive help or escape.

    • These situations are actively avoided or tolerated with distress and leads to social/occupational dysfunction.

    • Symptoms last ≥ 6 months.

EPIDEMIOLOGY AND PATHOGENESIS

Epidemiology 2

• 12-month prevalence ~ 1.5%

• Lifetime prevalence is controversial (varies between 2-6% across studies)

• Onset is usually before age 35 years old (prevalence is 0.4% in those ≥ 65 yo)

• More common in woman with a ratio of 2:1.

Risk Factors 3

• Childhood adversity including trauma or abuse. Also other stressful events.

• Anxious temperament during childhood as measured by neuroticism and anxiety sensitivity.

• Family climate during childhood years described with reduced warmth and increased overprotection.

• Presence of panic disorder (some studies reports that at least ~75% have panic disorder).

• Presence of other phobias.

• Female gender.

• Does not appear to vary across cultural/racial groups.

Pathogenesis 4

• Strong genetic factor with heritability ~60%.

• Onset frequently follows a traumatic event and experience of panic attacks.

• MRI evidence of stronger activation in the bilateral ventral striatum and left insula compared to controls.

CLINICAL PEARLS

Evaluation

• Examples of screening questions include -> Do you avoid certain situations because you feared having a panic attack or a feeling of discomfort? Can provide examples such as transportation, crowds, enclosed places, etc...

• Agoraphobia often creates significant strain on relationships and this may be the initial reason for presentation.

• Screen for other anxiety disorders, especially panic, social anxiety disorder, GAD, and other phobias. Also screen for depression.

• Optional Questionnaires: Panic and Agoraphobia Scale (PAS).

• Other important features of the clinical interview include:

• Screen for recent stressful events or trauma.

• Substance history (including alcohol, nicotine, and caffeine).

• Family history of anxiety or depressive disorders.

• Rule out anxiety/panic due to another medical condition (see day 64). Particularly in those with atypical, late-onset or new physical symptoms.

Course/Prognosis 5

• Course is typically persistent and chronic.

• Rare full remission of symptoms (~10%) without treatment.

• >50% of patients experience a panic attack prior to developing agoraphobia (some estimate >75%).

• Comorbid diagnoses include other anxiety disorders, depressive disorders, and substance use disorders (particularly alcohol) and often complicate its course.

TREATMENT

•The treatment of agoraphobia employs nearly the same approach used to treat panic disorder that we discussed here. For your convenience, this discussion will be repeated below with few exceptions.

•Treatment options for panic disorder and agoraphobia include psychotherapy, pharmacotherapy, and other alternative treatments. Therapy and medications are both effective separately and together and the most effective treatment is probably a combination of these approaches. Discuss patient’s preference for psychotherapy and/or pharmacotherapy

Psychotherapy

• Cognitive Behavioral Therapy (CBT): Considered first-line with strong evidence for effectiveness. May have more lasting benefit than pharmacotherapy. If poor response after a course of CBT then recommend addition of pharmacotherapy.

• Psychodynamic Psychotherapy (PDP): Mixed results with less overall support compared to CBT.

• Acceptance-Based Approaches: Challenges avoidance of experiences and encourages awareness and acceptance. Evidence is limited but promising.

• Virtual Therapy: Computer programs have been developed that allow patients to see themselves as avatars that are placed in feared situations (public transit, supermarket, etc...). Over time they learn to overcome their anxiety through deconditioning.

• See this post for more details on each of these forms of therapy.

Pharmacotherapy

• SSRIs and SNRIs: Considered first-line medical treatment of panic disorder and agoraphobia. No specific drug has been shown to have significantly higher efficacy than any other. Effective but takes weeks to see treatment effect. Start at half the normal starting dose and titrate up slowly. Often requires a higher dose than treating depression. If good response, continue at least 8-12 months before discontinuing. If poor response after 6 weeks at therapeutic dose, switch to different SSRI. If partial response consider augmentation with low-dose benzodiazepine.

• Benzodiazepines: Risk of tolerance/dependence/addiction and rebound anxiety. Ideally for short-term use only (3-4 weeks) while initiating SSRI/SNRI, but may be considered as augmentation in severe panic disorder / agoraphobia. Favor longer half lives (such as clonazepam) unless slow metabolizers (increased age or liver disease). Used as PRN backup (such as lorazepam) to abort panic, however this engenders dependency on the medication as a safety cue and interferes with exposure to and mastery of avoided situations.

• Buspirone: Partial agonist of serotonin receptors. Sometimes effective. Used to augment SSRI/SNRI, but takes weeks for full effectiveness.

• Pregabalin/Gabapentin: Often used off-label for treatment or augmentation of anxiety disorders. Studies demonstrate mixed results. Relatively quick onset of action and response may be seen in the first week of treatment.

• Treatment-Refractory cases: In these cases other medications can be tried, but are not first line due to adverse effects and no evidence of greater efficacy. Examples include: TCAs (clomipramine in particular), MAOIs, mirtazapine, antipsychotics, antiepileptics, hydroxyzine, beta-blockers, and alpha 2 agonists.

CONCLUSION

Thanks for reading. I hope this series has been helpful. During our next lesson we will discuss separation anxiety as well as selective mutism.

Resources for today's post include: Kaplan and Sadock's Synopsis of Psychiatry, The Maudsley Prescriber's Guide, DSMV, Pocket Psychiatry, and First Aid for the Psychiatry Clerkship. If you want more learning resources then check out our recommended resources page.

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