Anxiety Disorders ____________________________________________________________________________
AGORAPHOBIA Agoraphobia is defined as the fear of panic attacks occurring in places or situations from which escape might be difficult or embarrassing or where help may not be available. These situations can include crowds, going outside the home, or using public transportation and are either avoided or endured with significant personal distress [3]. Agoraphobia can become severely disabling, and more than 33% of patients diagnosed with agoraphobia cannot endure leaving their home environ- ment. Roughly 66% of patients with panic disorder develop agoraphobia [2]. In the DSM-5, agoraphobia was de-aggregated from panic dis- order and is now classed as a separate diagnostic entity. The former DSM-IV diagnoses of panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without history of panic disorder are now replaced by two diagnoses with separate criteria: panic disorder and agoraphobia. Co- occurring panic disorder and agoraphobia are also coded as two diagnoses. This change recognizes that a substantial number of individuals with agoraphobia do not experience panic symptoms, although clinical prevalence is much lower than community prevalence. The diagnostic criteria for agoraphobia are derived from the DSM-IV descriptors, with endorsement of fears from two or more agoraphobia situations now required to more effectively distinguish agoraphobia from specific phobias. The criteria for agoraphobia are also extended to concord with criteria sets for other anxiety disorders [102]. Diagnosis is based on marked fear or anxiety about two or more of the following [2]: • Public transportation (e.g., traveling in planes, automobiles, buses, trains, ships) • Open spaces (e.g., parking lots, market places, bridges)
The symptoms must not be attributable to substance-related effects, other medical conditions, or other psychiatric disor- ders. Up to 70% of patients report a history of at least one noc- turnal panic attack [106]. Patients may present with symptoms suggestive of heightened sympathetic nervous system activity such as palpitations, increased systolic blood pressure, hyper- ventilation, sweating, or flushing. Other common symptoms include chest pain and discomfort, dizziness, and paraesthesias, while gastrointestinal symptoms such as nausea and vomiting are more common among men [2; 107]. The severity of distress during panic attacks by patients with panic disorder with or without agoraphobia is increasingly seen as traumatic. Panic attacks are frequently experienced as life threatening, and patients with panic disorder can experience PTSD symptoms in relation to their panic attacks. Patients with panic disorder/agoraphobia or PTSD were found to relive their trauma or panic attacks with equal frequency, report comparable bodily reactions and distress associated with trauma or panic attack memories, and avoid trauma or panic attack reminders (i.e., places and things associated with trauma or panic attacks). Trauma-like symptoms surrounding panic attacks are common, and panic attacks may be processed similarly to trauma in PTSD [108]. Intense, disorganized recollections, a core symptom of PTSD, are thought to result from inadequate processing of trauma information. A first panic attack resembles trauma; both are unexpected, frightening, and subjectively life-threatening events. Like PTSD, panic disorder with agoraphobia also involves fear conditioning after the first event. Therefore, panic attack and trauma processing may be similar, with panic attack and PTSD trauma memories sharing the characteristics of reliving and disorganization. A comparison of panic memories and PTSD trauma memories did not find differences between groups in reliving intensity and disorganization levels, sug- gesting that panic attacks may affect information processing similarly to a traumatic event [109; 110]. Patients with panic disorder exhibit considerably worse overall mental well-being than individuals with cancer, diabetes, heart disease, arthritis, hypertension, and other chronic physical conditions [111]. Current panic disorder is also related to worse quality of life and physical function and an elevated risk of attempting suicide [112]. These effects are similar to or greater than those associated with major depression. A study found that nearly 33% of these patients in primary care had seen three or more healthcare professionals and almost 20% had visited emergency departments [113]. Another study found that although the majority of individuals with panic disorder first present to the primary care setting, only 38% of those with panic disorder with agoraphobia and 24% of those with panic disorder without agoraphobia were receiving appropriate treatment, and the use of empirically supported interventions was rare [114].
• Being in shops, theatres, or stadiums • Standing in line or being in a crowd
• Being outside of the home alone in other situations The individual with agoraphobia fears or avoids these situa- tions due to thoughts that escape might be difficult or help might not be available in the event of panic-like symptoms. These situations almost always provoke fear or anxiety and are actively avoided, require presence of a companion, or are endured with marked fear or anxiety. The fear or anxiety is out of proportion to the actual threat posed by an agoraphobic situation. The fear, anxiety, or avoidance is persistent, typically lasting at least six months, and causes clinically significant dis- tress or impaired functioning. Avoidance symptoms in PTSD differ in that the situations avoided are trauma-associated, such as a park or street where an assault occurred or riding in a car after a motor vehicle accident [2].
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