Agoraphobia

Definition

The term agoraphobia is translated from Greek as "fear of the marketplace." Agoraphobia today describes severe and pervasive anxiety about being in situations from which escape might be difficult or embarrassing and/or from which help may not be available should a panic attack occur. This anxiety leads to the following behavior: 1) avoidance of these types of situations, i.e., being alone outside of the home, traveling in a car, bus, or airplane, being in a crowded area, or being on a bridge; 2) endurance of such situations under great stress, i.e., a panic attack may occur; or 3) requiring another person's company when in said situations. Agoraphobia typically accompanies a panic disorder although on rare occasions, it may also occur when criteria of a panic disorder are not fully met (Morrison, 1995). In panic disorder, panic attacks recur and the person develops an intense apprehension of having another attack. This fear - called anticipatory anxiety or fear of fear - can be present most of the time and seriously interfere with the person's life even when a panic attack is not in progress. In addition, the person may develop irrational fears called phobias, such as agoraphobia, about situations where a panic attack has occurred. If agoraphobia occurs with panic disorder, the onset is usually during the 20s, and women are affected more often than men.

Agoraphobia affects about a third of all people with panic disorder. Typically, people with agoraphobia restrict themselves to a "zone of safety" that may include only the home or the immediate neighborhood. Any movement beyond the edges of this zone creates mounting anxiety. As noted earlier, sometimes a person with agoraphobia is unable to leave home alone, but can travel if accompanied by a particular family member or friend. Even when they restrict themselves to "safe" situations, most people with agoraphobia continue to have panic attacks at least a few times a month.

People with agoraphobia can be seriously disabled by their condition. Some are unable to work, and they may need to rely heavily on other family members, who must do the shopping and run all the household errands, as well as accompany the affected person on rare excursions outside the "safety zone." People with this disorder may become house bound for years, with resulting impairment of social and interpersonal relationships. Thus the person with agoraphobia typically leads a life of extreme dependency as well as great discomfort.

Symptoms

• Fear of being alone

• Fear of losing control in a public place

• Fear of being in places where escape might be difficult

• Becoming house bound for prolonged periods

• Feelings of detachment or estrangement from others

• Feelings of helplessness

• Dependence upon others

• Feeling that the body is unreal

• Feeling that the environment is unreal

• Anxiety or panic attack (acute severe anxiety)

• Unusual temper or agitation with trembling or twitching

Additional symptoms that may occur:

• Lightheadedness, near Fainting

• Dizziness

• Excessive sweating

• Skin flushing

• Breathing difficulty

• Chest pain

• Heartbeat sensations

• Nausea and vomiting

• Numbness and tingling

• Abdominal distress that occurs when upset

• Confused or disordered thoughts

• Intense fear of going crazy

• Intense fear of dying

There may be a history of phobias, or the health care provider may receive a description of typical behaviors from family, friends, or the affected person. The pulse (heart rate) is often rapid, sweating is present, and the patient may have high blood pressure. A person may be described as having Agoraphobia if other mental disorders or medical conditions do not provide better explanation for the person's symptoms.

Causes

The etiology of most anxiety disorders, although not fully understood, has come into sharper focus in the last decade. In broad terms, the likelihood of developing anxiety involves a combination of life experiences, psychological traits, and/or genetic factors. The anxiety disorders are so heterogeneous that the relative roles of these factors are likely to differ. It is not clear why females have higher rates than males of most anxiety disorders, although some theories have suggested a role for the gonadal steroids. Other research on women's responses to stress also suggests that women experience a wider range of life events (e.g., those happening to friends) as stressful as compared with men who react to a more limited range of stressful events, specifically those affecting themselves or close family members.

The National Institute of Mental Health supports a sizable and multifaceted research program on panic disorder - its causes, diagnosis, treatment, and prevention. This research involves studies of panic disorder in human subjects and investigations of the biological basis for anxiety and related phenomena in animals. It is part of a massive effort to overcome the major mental disorders, an effort that started during the 1990s - the Decade of the Brain. Here is a description of some of the most important new research on panic disorder and its causes.

Genetics. Panic disorder runs in families. One study has shown that if one twin in a genetically identical pair has panic disorder, it is likely that the other twin will also. Fraternal, or non-identical twin pairs do not show this high degree of "concordance" with respect to panic disorder. Thus, it appears that some genetic factor, in combination with environment, may be responsible for vulnerability to this condition.

NIMH-supported scientists are studying families in which several individuals have panic disorder. The aim of these studies is to identify the specific gene or genes involved in the condition. Identification of these genes may lead to new approaches for diagnosing and treating panic disorder.

Brain and Biochemical Abnormalities. One line of evidence suggests that panic disorder may be associated with increased activity in the hippocampus and locus coeruleus, portions of the brain that monitor external and internal stimuli and control the brain's responses to them. Also, it has been shown that panic disorder patients have increased activity in a portion of the nervous system called the adrenergic system, which regulates such physiological functions as heart rate and body temperature. However, it is not clear whether these increases reflect the anxiety symptoms or whether they cause them.

Another group of studies suggests that people with panic disorder may have abnormalities in their benzodiazepine receptors, brain components that react with anxiety-reducing substances within the brain.

In conducting their research, scientists can use several different techniques to provoke panic attacks in people who have panic disorder. The best known method is intravenous administration of sodium lactate, the same chemical that normally builds up in the muscles during heavy exercise. Other substances that can trigger panic attacks in susceptible people include caffeine (generally 5 or more cups of coffee are required). Hyperventilation and breathing air with a higher-than-usual level of carbon dioxide can also trigger panic attacks in people with panic disorder.

Because these provocations generally do not trigger panic attacks in people who do not have panic disorder, scientists have inferred that individuals who have panic disorder are biologically different in some way from people who do not. However, it is also true that when the people prone to panic attacks are told in advance about the sensations these provocations will cause, they are much less likely to panic. This suggests that there is a strong psychological component, as well as a biological one, to panic disorder.

NIMH-supported investigators are examining specific parts of the brain and central nervous system to learn which ones play a role in panic disorder, and how they may interact to give rise to this condition. Other studies funded by the Institute are under way to determine what happens during "provoked" panic attacks, and to investigate the role of breathing irregularities in anxiety and panic attacks.

Animal Studies. Studies of anxiety in animals are providing NIMH-sponsored researchers with clues to the underlying causes of this phenomenon. One series of studies involves an inbred line of pointer dogs that exhibit extreme, abnormal fearfulness when approached by humans or startled by loud noises. In contrast with normal pointers, these nervous dogs have been found to react more strongly to caffeine and to have brain tissue that is richer in receptors for adenosine, a naturally occurring sedative that normally exerts a calming effect within the brain. Further study of these animals is expected to reveal how a genetic predisposition toward anxiety is expressed in the brain.

Other animal studies involve macaque monkeys. Some of these animals exhibit anxiety when challenged with an infusion of lactate, much like people with panic disorder. Other macaques do not exhibit this response. NIMH-supported scientists are attempting to determine how the brains of the responsive and non-responsive monkeys differ. This research should provide additional information on the causes of panic disorder.

In addition, research with rats is exploring the effect of various medications on the parts of the brain involved in anxiety. The aim is to develop a clearer picture of which components of the brain are responsible for anxiety, and to learn how their actions can be brought under better control.

Cognitive Factors. Scientists funded by NIMH are investigating the basic thought processes and emotions that come into play during a panic attack and those that contribute to the development and persistence of agoraphobia. The Institute also supports research evaluating the impact of various versions of cognitive-behavioral therapy to determine which variants of the procedure are effective for which people. The NIMH panic disorder research program will also explore the effects of interpersonal stress such as marital conflict on panic disorder with agoraphobia and determine if including spouses in the cognitive-behavioral treatment of the condition improves outcome.

Treatment

The goal of treatment is to help the phobic person function effectively. The success of treatment usually depends upon the severity of the phobia. Systematic desensitization or graded real-life exposure, called "exposure therapy," is a behavioral technique used to treat phobias. It is based upon having the person relax, then imagine the components of the phobia, working from the least fearful to the most fearful. The individual will work with a therapist to develop coping strategies such as relaxation and breathing techniques et al. While "in vivo" or real-life exposure is ideal, imagined exposure is also an acceptable alternative in desensitization exercises. Treating agoraphobia with Exposure Therapy reduced anxiety and improved morale and quality of life with in 75% of cases.

Other types of therapy, such as cognitive therapy, assertiveness training, biofeedback, hypnosis, meditation, relaxation or couples therapy were found to be helpful for some patients. Cognitive-Behavioral Therapy is a combination of cognitive therapy, which can modify or eliminate thought patterns contributing to the patient's symptoms, and behavioral therapy, i.e., "in vivo" or real-life exposure therapy, which aims to help the patient change his or her behavior.

Treatment is complicated by the fact that often patients have difficulty getting to appointments because of their fears. To address this issue, some therapists will go to an agoraphobic patient's home to conduct the initial sessions. Often therapists take their patients on excursions to shopping malls and other places the patients have been avoiding. Or they may accompany their patients who are trying to overcome fear of driving a car.

The patient approaches a feared situation gradually, attempting to stay in spite of rising levels of anxiety. In this way the patient sees that as frightening as the feelings are, they are not dangerous, and they do pass. On each attempt, the patient faces as much fear as he or she can stand. Patients find that with this step-by-step approach, aided by encouragement and skilled advice from the therapist, they can gradually master their fears and enter situations that had seemed unapproachable.

Many therapists assign the patient "homework" to do between sessions. Sometimes patients spend only a few sessions in one-on-one contact with a therapist and continue to work on their own with the aid of a printed manual.

Often the patient will join a therapy group with others striving to overcome panic disorder or phobias, meeting with them weekly to discuss progress, exchange encouragement, and receive guidance from the therapist.

Cognitive-behavioral therapy generally requires at least 8 to 12 weeks. Some people may need a longer time in treatment to learn and implement the skills. This kind of therapy, which is reported to have a low relapse rate, is effective in eliminating panic attacks or reducing their frequency. It also reduces anticipatory anxiety and the avoidance of feared situations.

Treatment with Medications

In this treatment approach, which is also called pharmacotherapy, a prescription medication is used both to prevent panic attacks or reduce their frequency and severity, and to decrease the associated anticipatory anxiety. When patients find that their panic attacks are less frequent and severe, they are increasingly able to venture into situations that had been off-limits to them. In this way, they benefit from exposure to previously feared situations as well as from the medication.

The three groups of medications most commonly used are the tricyclic antidepressants, the high-potency benzodiazepines, and the monoamine oxidase inhibitors (MAOIs). Determination of which drug to use is based on considerations of safety, efficacy, and the personal needs and p Referencesof the patient. Some information about each of the classes of drugs follows.

The tricyclic antidepressants were the first medications shown to have a beneficial effect against panic disorder. Imipramine is the tricyclic most commonly used for this condition. When imipramine is prescribed, the patient usually starts with small daily doses that are increased every few days until an effective dosage is reached. The slow introduction of imipramine helps minimize side effects such as dry mouth, constipation, and blurred vision. People with panic disorder, who are inclined to be hypervigilant about physical sensations, often find these side effects disturbing at the outset. Side effects usually fade after the patient has been on the medication a few weeks.

It usually takes several weeks for imipramine to have a beneficial effect on panic disorder. Most patients treated with imipramine will be panic-free within a few weeks or months. Treatment generally lasts from 6 to 12 months. Treatment for a shorter period of time is possible, but there is substantial risk that when imipramine is stopped, panic attacks will recur. Extending the period of treatment to 6 months to a year may reduce this risk of a relapse. When the treatment period is complete, the dosage of imipramine is tapered over a period of several weeks.

The high-potency benzodiazepines are a class of medications that effectively reduce anxiety. Alprazolam, clonazepam, and lorazepam are medications that belong to this class. They take effect rapidly, have few bothersome side effects, and are well tolerated by the majority of patients. However, some patients, especially those who have had problems with alcohol or drug dependency, may become dependent on benzodiazepines.

Generally, the physician prescribing one of these drugs starts the patient on a low dose and gradually increases it until panic attacks cease. This procedure minimizes side effects.

Treatment with high-potency benzodiazepines is usually continued for 6 months to a year. One drawback of these medications is that patients may experience withdrawal symptoms - malaise, weakness, and other unpleasant effects - when the treatment is discontinued. Reducing the dose gradually generally minimizes these problems. There may also be a recurrence of panic attacks after the medication is withdrawn.

Of the MAOIs, a class of antidepressants which have been shown to be effective against panic disorder, phenelzine is the most commonly used. Treatment with phenelzine usually starts with a relatively low daily dosage that is increased gradually until panic attacks cease or the patient reaches a maximum dosage of about 100 milligrams a day.

Use of phenelzine or any other MAOI requires the patient to observe exacting dietary restrictions, because there are foods and prescription drugs and certain substances of abuse that can interact with the MAOI to cause a sudden, dangerous rise in blood pressure. All patients who are taking MAOIs should obtain their physician's guidance concerning dietary restrictions and should consult with their physician before using any over-the-counter or prescription medications.

As in the case of the high-potency benzodiazepines and imipramine, treatment with phenelzine or another MAOI generally lasts 6 months to a year. At the conclusion of the treatment period, the medication is gradually tapered.

Newly available antidepressants such as fluoxetine (one of a class of new agents called serotonin reuptake inhibitors) appear to be effective in selected cases of panic disorder. As with other anti-panic medications, it is important to start with very small doses and gradually increase the dosage.

Scientists supported by NIMH are seeking ways to improve drug treatment for panic disorder. Studies are underway to determine the optimal duration of treatment with medications, who they are most likely to help, and how to moderate problems associated with withdrawal.

Combination Treatments

Some patients with anxiety disorders may benefit from both psychotherapy and pharmacotherapy treatment modalities, either combined or used in sequence. The combined approach is said to offer rapid relief, high effectiveness, and a low relapse rate. Drawing from the experiences of depression researchers, it seems likely that such combinations are not uniformly necessary and are probably more cost-effective when reserved for patients with more complex, complicated, severe, or comorbid disorders. The benefits of multimodal therapies for anxiety need further study.Comparing medications and psychological treatments, and determining how well they work in combination, is the goal of several NIMH-supported studies. The largest of these is a 4-year clinical trial that will include 480 patients and involve four centers at the State University of New York at Albany, Cornell University, Hillside Hospital/Columbia University, and Yale University. This study is designed to determine how treatment with imipramine compares with a cognitive-behavioral approach, and whether combining the two yields benefits over either method alone.

Psychodynamic Treatment

This is a form of "talk therapy" in which the therapist and the patient, working together, seek to uncover emotional conflicts that may underlie the patient's problems. By talking about these conflicts and gaining a better understanding of them, the patient is helped to overcome the problems. Often, psychodynamic treatment focuses on events of the past and making the patient aware of the ramifications of long-buried problems.

Although psychodynamic approaches may help to relieve the stress that contributes to panic attacks, they do not seem to stop the attacks directly. In fact, there is no scientific evidence that this form of therapy by itself is effective in helping people to overcome panic disorder or agoraphobia. However, if a patient's panic disorder occurs along with some broader and pre-existing emotional disturbance, psychodynamic treatment may be a helpful addition to the overall treatment program.