Agoraphobia

a. Description of the disorder including characteristics and diagnostic features, also

a mnemonic to help with revision (e.g., GAD and Mr FISC).
Agoraphobia is an
anxiety disorder
characterised by anxiety in situations where
the sufferer perceives the environment to be dangerous, uncomfortable, or where
they perceive that they have little control. These situations can include wide-open
spaces, closed spaces, uncontrollable social situations, and unfamiliar places. A
sufferer of agoraphobia fears the onset of a panic attack or something embarrassing
happening to them in such situations and fear that no-one will be able to help them
if/when something terrible happens, and also that they will be unable to escape.
Most people develop agoraphobia after having experienced a panic attack, causing
them to fear further attacks and avoid the situation in which the attack occurred
.
Panic symptoms are any of the thirteen criteria listed for a panic attack within the
DSM 5 including, dizziness, faintness, fear of dying. Embarrassing symptoms which
people fear include vomiting in public, being incontinent, and falling over.
People
with agoraphobia may need help from a companion in order to go to public places,
and may
go to great lengths to avoid those situations, in severe cases becoming
unable to leave their homes or safe havens.
Main characteristics:
Anxiety around fear of being unable to escape or fear of help being
unavailable if beginning to panic in a situation
Such situations are actively avoided including: open spaces, enclosed spaces,
being alone in a crowd, public transport and generally being out of home
alone.
People fear having a panic attack or that something embarrassing will happen
to them.
A companion is often required in order to be in such situations
Significant distress and anxiety can occur from these situations
Symptoms need to have been present for 6 months or more

F
ear
Un
able
T
o Escape
O
r
P
anic attack

Mnemonic to help with revision:

C
ompanion
O
ut of house
C
an make
H
ousebound

b. Must include DSM 5 classificatory criteria for the disorder

A. Marked fear or anxiety about two (or more) of the following five situations:
1. Using public transport
2. Being in open spaces
3. Being in enclosed places
4. Standing in a line or being in a crowd
5. Being outside of the home alone
B. The individual fears or avoid these situations because of thoughts that escape
might be difficult or help might not be available in the event of developing
panic-like symptoms or other incapacitating or embarrassing symptoms (e.g.,
fear of falling in the elderly; fear of incontinence).
C. The situations almost always provoke fear or anxiety
D. Situations are actively avoided, require presence of a companion or are
endured with intense fear or anxiety
E. The fear or anxiety is out of proportion to the actual danger posed by the
situation
F. The fear, anxiety or avoidance causes clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
G. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or
more.
H. if another medical condition is present, the fear, anxiety or avoidance is
clearly excessive
I. the fear, anxiety or avoidance is not better explained by the symptoms of
another mental disorder

c. Differential diagnosis information (i.e., key ways to distinguish it from other

conditions)
Specific phobia, situational type.
Differentiating agoraphobia from situational
specific phobia can be challenging in some cases, because these conditions share
several symptom characteristics and criteria. Specific phobia, situational type, should
be diagnosed versus agoraphobia if the fear, anxiety, or avoidance is limited to one
of the agoraphobic situations. Requiring fears from two or more of the agoraphobic
situations is a robust means for differentiating agoraphobia from specific phobias,
particularly the situational subtype. Additional differentiating features include the
cognitive ideation. Thus, if the situation is feared for reasons other than panic-like
symptoms or other incapacitating or embarrassing symptoms (e.g., fears of being
directly harmed by the situation itself, such as fear of the plane crashing for
individuals who fear flying), then a diagnosis of specific phobia may be more
appropriate.
Separation anxiety disorder.
Separation anxiety disorder can be best differentiated
from agoraphobia by examining cognitive ideation. In separation anxiety disorder,
the thoughts are about detachment from significant others and the home
environment (i.e., parents or other attachment figures), whereas in agoraphobia the
focus is on panic-like symptoms or other incapacitating or embarrassing symptoms in
the feared situations.

Social anxiety disorder (social phobia).

Agoraphobia should be differentiated from
social anxiety disorder based primarily on the situational clusters that trigger fear,
anxiety, or avoidance and the cognitive ideation. In social anxiety disorder, the focus
is on fear of being negatively evaluated.

Panic disorder.
When criteria for panic disorder are met, agoraphobia should not be
diagnosed if the avoidance behaviors associated with the panic attacks do not
extend to avoidance of two or more agoraphobic situations.
Acute stress disorder and posttraumatic stress disorder.
Acute stress disorder and
posttraumatic stress disorder (PTSD) can be differentiated from agoraphobia by
examining whether the fear, anxiety, or avoidance is related only to situations that
remind the individual of a traumatic event. If the fear, anxiety, or avoidance is
restricted to trauma reminders, and if the avoidance behavior does not extend to
two or more agoraphobic situations, then a diagnosis of agoraphobia is not
warranted.
Major depressive disorder
. In major depressive disorder, the individual may avoid
leaving home because of apathy, loss of energy, low self-esteem, and anhedonia. If
the avoidance is unrelated to fears of panic-like or other incapacitating or
embarrassing symptoms, then agoraphobia should not be diagnosed.
Other medical conditions.
Agoraphobia is not diagnosed if the avoidance of
situations is judged to be a physiological consequence of a medical condition. This
determination is based on history, laboratory findings, and a physical examination.
Other relevant medical conditions may include neurodegenerative disorders with
associated motor disturbances (e.g., Parkinson's disease, multiple sclerosis), as well
as cardiovascular disorders. Individuals with certain medical conditions may avoid
situations because of realistic concerns about being incapacitated (e.g., fainting in an
individual with transient ischemic attacks) or being embarrassed (e.g., diarrhea in an
individual with Crohn's disease). The diagnosis of agoraphobia should be given only
when the fear or avoidance is clearly in excess of that usually associated with these
medical conditions

Medication

Selective serotonin reuptake inhibitors (SSRIs)

were originally developed to treat
depression, but they've subsequently proved effective in helping treat other mood
disorders, such as anxiety, feelings of panic and obsessional thoughts.
SSRIs can also be used to treat people with certain other conditions, such as premature
ejaculation, premenstrual syndrome (PMS), fibromyalgia and irritable bowel syndrome
(IBS).
An SSRI called
Sertraline
is usually recommended for people with agoraphobia. Other
SSRIs which cab be used to treat agoraphobia include:
Paroxetine
and
Fluoxetine
.
If sertraline fails to improve symptoms, patients may be prescribed an alternative SSRI or a
similar type of medication known as
serotonin-norepinephrine reuptake inhibitors (SNRIs).
Examples of SNRIs include:
Duloxetine
and
Efexor
.
The length of time someone will have to take an SSRI (or SNRI) for will vary depending on
their response to treatment. Some people may have to take SSRIs for six to 12 months or
more.
Note.
If someone is unable to take SSRIs or SNRIs for medical reasons, or you experience
troublesome side effects, another medication called
Pregabalin
may be recommended.
Dependent on the individual If a particularly severe flare-up of panic-related symptoms, a
short course of
Benzodiazepines
may be prescribed. These are tranquillisers that are
designed to reduce anxiety and promote calmness and relaxation.

Contra-Indications
SSRIs
SSRIs are not suitable for everyone. They are not usually recommended if you are
pregnant, breastfeeding or under 18 because there is an increased risk of serious side
effects, although exceptions can be made if the benefits of treatment are thought to
outweigh the risks.
SSRIs also need to be used with caution if you have certain underlying health problems,
including diabetes, epilepsy and kidney disease.
Some SSRIs can react unpredictably with other medicines, including some over the counter
painkillers and herbal remedies such as St Johns wort. Always read the information leaflet
that comes with your SSRI medication to check if there are any medications you need to
avoid.
SNRIs
Due to the effects of increased norepinephrine levels and, therefore, higher Noradrenergic
activity, pre-existing hypertension should be controlled before treatment with SNRIs and
blood pressure periodically monitored throughout treatment. Duloxetine has also been
associated with cases of hepatic failure and should not be prescribed to patients with
chronic alcohol use or liver disease. Patients suffering from coronary artery disease should
avoid the use of SNRIs. Furthermore, due to some SNRIs' actions on obesity, patients with
major eating disorders such as anorexia nervosa or bulimia should not be prescribed SNRIs
SNRIs should be taken with caution when using St John's wort, as the combination can
lead to the potentially fatal serotonin syndrome. They should never be taken within

24-hours of any other antidepressant, especially with monoamine oxidase inhibitors

(MAOIs), as combinations of SNRIs with MAOIs can cause hyperthermia, rigidity,
myoclonus, autonomic instability with fluctuating vital signs, and mental status changes
that include extreme agitation progressing to delirium and coma.

Mechanism of action
SSRIs
It is thought that SSRIs work by increasing the levels of a chemical called serotonin in the
brain. Serotonin is a neurotransmitter (a messenger chemical that carries signals between
nerve cells in the brain). It's thought to have a good influence on mood, emotion and
sleep.
After carrying a message, serotonin is usually reabsorbed by the nerve cells (known as
'reuptake'). SSRIs work by blocking ('inhibiting') reuptake, meaning more serotonin is
available to pass further messages between nearby nerve cells.
It would be too simplistic to say that depression and related mental health conditions are
caused by low serotonin levels, but a rise in serotonin levels can improve symptoms and
make people more responsive to other types of treatment, such as CBT.
SRNIs
Serotonin and norepinephrine reuptake inhibitors ease depression by affecting chemical
messengers (neurotransmitters) used to communicate between brain cells. Like most
antidepressants, SNRIs work by changing the levels of one or more of these naturally
occurring brain chemicals.
SNRIs block the absorption (reuptake) of the neurotransmitters serotonin and
norepinephrine in the brain. They also affect certain other neurotransmitters. Changing
the balance of these chemicals seems to help brain cells send and receive messages, which
in turn boosts mood. Medications in this group of antidepressants are sometimes called
dual-action antidepressants.

Side effects
SSRIs
Most people will only experience a few mild side effects when taking SSRIs. These can be
troublesome at first, but most will generally improve with time.
Common side effects of SSRIs can include:
o
o
o
o
o
o
o

feeling agitated, shaky or anxious

feeling or being sick
dizziness
blurred vision
low sex drive
difficulty achieving orgasm during sex or masturbation
in men, difficulty obtaining or maintaining an erection (erectile dysfunction)

SNRIs
Because the SNRIs and SSRIs both act similarly to elevate serotonin levels, they
subsequently share many of the same side-effects, though to varying degrees. The most
common include loss of appetite, weight, and sleep. There may also be drowsiness,
dizziness, fatigue, headache, increase in suicidal thoughts, nausea/vomiting, sexual
dysfunction, and urinary retention. There are two common sexual side-effects: diminished
interest in sex (libido) and difficulty reaching climax (anorgasmia), which are usually
somewhat milder with the SNRIs in comparison to the SSRIs. Elevation of norepinephrine
levels can sometimes cause anxiety, mildly elevated pulse, and elevated blood pressure.
People at risk for hypertension and heart disease should have their blood pressure
monitored.

Useful Information
http://www.nhs.uk/Conditions/Agoraphobia/Pages/Treatment.aspx