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Panic Disorder |
Overcoming Anxiety (Home) > Panic Disorder > Agoraphobia Agoraphobia: Treatment, Test, Symptoms, Panic Attack and MedicationThe term agoraphobia was first coined by Westphal in his description of three males who experienced intense anxiety when walking across open spaces or through empty streets. The essential feature of Agoraphobia is anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having a Panic Attack or panic-like symptoms (e.g., fear of having a sudden attack of dizziness or a sudden attack of diarrhea). Other defining characteristics are physiological changes associated with accompanying panic attacks. These can include palpitations, lightness in the head, weakness, atypical chest pain, and dyspnea. Most agoraphobics also express fears of losing control, going insane, embarrassing themselves and others, dying and fainting. The anxiety typically leads to a pervasive avoidance of a variety of situations that may include being alone outside the home or being home alone; being in a crowd of people, traveling in a car, train, coach or aeroplane; or being on a bridge or in a lift. The level of discomfort may range from mild uneasiness (with no avoidance) to severe distress with marked avoidance. Some individuals are able to expose themselves to the feared situations but endure these experiences with considerable dread. Usually, an individual is better able to confront a feared situation when accompanied by a companion, even if this companion is clearly unable to provide any help, such as a small child or even a dog; other forms of support such as push-chairs and walking sticks can be helpful. When agoraphobia is severe the individuals’ avoidance of situations may seriously impair their ability to travel, to work, or to carry out homemaking responsibility. In its extreme form, agoraphobia is totally invalidating: the subject cannot go out of the house by any means and cannot stay at home alone either. Agoraphobia is therefore to be seen as a potentially severely disabling illness. In psychiatric samples 75% of patients with PD present some degree of agoraphobia, whereas in epidemiological surveys agoraphobia accompanies PD in 30–50% of the cases. All the clinical descriptions agree that almost invariably panic precedes agoraphobia. The onset of agoraphobia follows the first panic attack with a time lag varying from few days to several years. As Klein points out, PD starts with the initial panic attack, which is followed by the fear of subsequent attacks (anticipatory anxiety) and then by the avoidance of situations that are believed to trigger panic attacks or result in embarrassment and/or danger in case of a new attack. However, the relationship between panic and agoraphobia is still controversial. Roth first observed that, even though the first attack of panic often develops abruptly, ‘‘more detailed investigation will usually reveal that the disorder has not emerged out of an entirely clear sky and that the complex repertoire of avoidance behaviors and helpless dependence on others were not entirely without premorbid antecedents’’. Fava confirm Roth’s remarks: the large majority of patients (90%) suffered from mild phobic or hypochondriacal symptoms before the onset of panic attacks. Anxiety and hypochondriacal fears and beliefs were also exceedingly common. These findings are in accordance with several converging developments in agoraphobia research: it has been shown in epidemiological surveys that some individuals suffer from agoraphobia without panic attacks and some normal subjects report occasional panic attacks. Moreover, there is growing recognition of cognitive factors (catastrophic misinterpretations of certain bodily sensations) related to panic anxiety. It has been hypothesized that the perception of the panic attack as a catastrophic medical problem, rather than a manifestation of anxiety, results in an exaggerated fear of having subsequent panic attacks. This unrealistic and exaggerated fear results in raised anticipatory anxiety and in a stronger tendency to avoid situations that are believed to hasten additional panic attacks. The course of agoraphobia and its relationship to the course of panic attacks are variable. In some cases, a decrease or remission of panic attacks is followed closely by a corresponding decrease in agoraphobic avoidance and anxiety. In other cases, agoraphobics may become chronic regardless of the presence of panic attacks. Basically, there are three positions that gave rise to a strong debate:
Goisman found that patients with agoraphobia without a history of panic disorder seem to be on a continuum with patients with panic disorder with agoraphobia along a number of variables; they suggest that a more sensible approach would be that of seeing agoraphobia without a history of panic disorder simply as one variation among others in the array of disorders that present in various combinations of acute bursts of anxiety combined with chronic avoidance. Classification systems vary according to the relative prevalence of one of the previous positions. DSM-III considered three separate categories: panic disorder, agoraphobia with PD, and agoraphobia without PD. However, a number of investigators later began to argue that agoraphobia was not a separate entity but rather a secondary response to panic disorder. They reported that agoraphobia before the onset of panic attacks was uncommon and that panic disorder and agoraphobia were similar in their clinical presentation. Studies of familial transmission of panic disorder and agoraphobia further supported the concept of agoraphobia as a more severe variant of panic disorder, rather than a separate entity. Thus, consistent with this body of research, in 1987 DSM-III-R reclassified agoraphobia as mainly a sequel of panic disorder, which could present itself either with or without agoraphobia and this classification, is maintained in DSM-IV. Agoraphobia without panic remained in both classification systems because of the repeated reports that agoraphobia without panic, although non-existent in the clinical practice of psychiatry had continued to be reported as a fairly common diagnosis in community surveys. DSM-III-R and DSM-IV, therefore, privilege the interpretation of panic being the central feature with agoraphobia as a complication. ICD-10, conversely, classifies the association of panic and agoraphobia among phobic disorders, thus accepting the position that the phobic attitude is the core aspect of this disorder.
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