Bipolar Support Groups.com blog

Description

Literally, agoraphobia is a “fear of open spaces”. A clinical definition is “a fear of open spaces, especially those in which getaway may be difficult, which leads to avoidance of the situation”. Being in the provoking situation usually leads to an anxiety attack.

There are three basic elements:
•Phobia.
•Avoidance of situations that might provoke the anxiety.
•Severe anxiety.

It can involve a number of phobias which may overlap – eg, presence of crowds or travelling alone. Once patients are in the provoking situation, they develop sudden and severe anxiety – the anxiety is what they try to avoid. Some patients can manage to continue their daily lives (with difficulty), whilst others are severely affected and may even become incapacitated.

Epidemiology
•Epidemiological data in the UK are hard to find. One study of the recording of anxiety diagnoses and symptoms from 361 UK general practices found that between 1998 and 2008 the incidence of GP-recorded anxiety diagnoses fell.[1] However, the recording of anxiety symptoms had risen. They didn’t analyse subgroups which would have included agoraphobia.
•One American study found agoraphobia to be the least common of the anxiety disorders.[2]
•It tends to affect females more than males. The study of the recording of UK general practice anxiety diagnoses found anxiety disorders were twice as common in females and they were also more common in deprived areas.[1]
•The most common age of occurrence is 25-35 years.
•Prevalence rates of panic disorder have been quoted around the 1-5% level – suggesting it to be a chronic and common disorder which is probably underdiagnosed, so that the prevalence is much higher.[3]
•Agoraphobia affects up to one third of patients with panic disorders and occurs before the onset of an attack.[3]

Diagnosis

Panic attacks and agoraphobia are underdiagnosed and therefore a high index of suspicion is required. Diagnosis requires the following:

•Avoidance of situations that provoke the anxiety (prominent feature). In the case of agoraphobia this involves not going out of the house and avoiding open spaces.
•Symptoms (psychological and physical) arise mainly from anxiety and the anxiety is not secondary to other underlying psychiatric problems – eg, depression.
•Anxiety manifests primarily in two or more of the following: crowds, public places, travelling alone or away from home.

Useful questions for a GP to ask the patient (or by proxy a carer) might thus be:
•What situations cause you anxiety or embarrassment?
•What symptoms do you get?
•Do you get the symptoms in places or situations from which escape might be difficult or embarrassing?
•Do you get the symptoms in situations in which help might not be available?
•Do you get the symptoms when travelling on public transport, standing on a bridge, being in a crowd or being in a queue? (NB: if symptoms develop in a limited number of situations – eg, travelling in a car but not a train, using a lift – consider specific phobia; if symptoms are limited to social situations, consider social anxiety disorder.)
•Do you avoid certain situations (eg, travel) because you feel panicky?
•Do you ever need the help of a companion in certain situations (eg, travel)?
•What particularly worries you about the situation? (This may reveal another diagnosis – eg, if the patient says that they fear contamination with dirt, this might indicate an underlying obsessive-compulsive disorder.)
•Have you had a traumatic event in the past (eg, fear of travelling in a car after a car accident)? (Consider post-traumatic stress disorder (PTSD).)
•Are you anxious about what is going on at home? Do you get panicky when you leave your family? (Consider separation anxiety disorder.)

Consider using a validated screening test such as the Beck’s Anxiety Inventory, General Health Questionnaire, Hamilton Anxiety Scale (HAS) or the Hospital Anxiety and Depression Scale (HADS). The evidence base supporting the routine use of questionnaires in diagnosis and evaluation of treatment is limited but they are sometimes useful in assessing the severity and range of symptoms and to obtain a baseline against which future progress can be measured.[4]

If the patient’s agoraphobia is so severe that they are unable to attend for an assessment, the GP will need to consider a home visit.

PatientPlus o

Panic Disorder
Psychotherapy and its Uses
Cognitive and Behavioural Therapies
Social Anxiety Disorder

Differential diagnosis

This includes:[5]
•Social anxiety disorder.
•Generalised anxiety disorder.
•Depression, PTSD.
•Physical disorders – eg, ischaemic heart disease.

Management

The National Institute for Health and Care Excellence (NICE) recommends a stepped care approach.[6]

Step 1: recognition and diagnosis

This has been dealt with in the introductory section and the ‘Diagnosis’ section, above.

Step 2: treatment by the GP

General
•Try to establish a rapport with the patient.
•Assure them that you will treat them in a non-judgemental manner and will respect their confidentiality and privacy.
•Explore their worries in order to get a perspective on how the condition is affecting their life.
•Assure them that decision-making is a shared process and try to achieve a joint agreement as to the best way to manage the problem.
•Provide information (verbal and written) in a way the patient and their family/carers can understand. This should include contact numbers and information about what to do and whom to contact in a crisis, as well as local and national self-help organisations and support groups, in particular where they can talk to others with similar experiences.
•Advise avoiding anxiety-producing substances – eg, caffeine.
•It is important to exclude alcohol or drug misuse as a factor and to treat these problems if present. Reassessment after successful management of substance-related issues will reveal if this is true panic disorder. Response to pharmacological/psychological therapies is likely to be poor in the face of alcohol/drug misuse or dependence.

Offer the following interventions (listed as per NICE in the order – according to the evidence base – of duration of efficacy):
•Refer for cognitive behavioural therapy (CBT).
•Education – help the patient to understand the problem.
•Lifestyle changes – avoid alcohol and illicit drugs and stimulants.
•Self-help groups – focus on relaxation and breathing exercises.

Medication

General principles •Before prescribing, consider age, previous treatment, tolerability, other medication, comorbidities, personal preference, cost and risk of self-harm (selective serotonin reuptake inhibitors (SSRIs) are less dangerous than tricyclics in overdose).
•Inform the patient about possible side-effects (including a temporary increase in anxiety at the start of treatment), delay in onset of effect, possible discontinuation symptoms, the length of treatment and the need to follow dosage instructions.
•Provide written information appropriate to the patient’s needs.
•Start with a low dose to minimise side-effects.
•Some patients may need long-term treatments and a dose at the upper end of the range.
•Benzodiazepines, sedative antihistamines and antipsychotics are not recommended for panic disorder and, given agoraphobia’s close relationship to this condition, these should be avoided.

The following advice has been given by NICE for the management of panic disorder – with or without agoraphobia:
•Antidepressant drugs have been shown to be effective in reducing the amplitude of panic, reducing frequency of, or eliminating, panic attacks and improving quality-of-life measures in this group of patients.
•Offer an SSRI licensed for this indication first-line unless contra-indicated.
•Consider imipramine or clomipramine if there is no improvement after 12 weeks and further medication is indicated (NB: neither is licensed for this indication in the UK, so document informed consent).
•Review the patient after two weeks to check for side-effects and efficacy, and at 4, 6 and 12 weeks.
•If there has been an improvement after 12 weeks, continue for 6 months after the optimum dose has been reached.
•If medication is used for longer than 12 weeks, review at 8- to 12-weekly intervals.
•Follow the summary of product characteristics of the individual drugs for other monitoring requirements.
•Use self-completed questionnaires to monitor outcomes where possible.
•At the end of treatment, withdraw the SSRI gradually, as dictated by patient preference, and monitor monthly for relapse for as long as appropriate to the individual.

Self-help
•Give the patient details of books based on CBT principles, and contact details of any available support groups. With the patient’s permission, give relatives or carers details of support groups which can be useful in bolstering the patient’s support network as well as patients themselves.There is evidence that self-help interventions are an effective option for people with panic disorder.[7]
•Promote exercise as part of good general health. There is some evidence of a reduction in anxiety symptoms following exercise. A systematic review suggested that the effect is not as great as antidepressants but it could be a useful adjunct.[8]
•Monitor the patient on a regular basis, usually every 4-8 weeks, preferably using a self-completed questionnaire.

Step 3

Reassess the condition and consider another intervention.

Step 4

If two interventions have been offered without benefit, consider referral to specialist mental health services. Specialist treatment may include management of comorbid conditions, structured problem solving, other types of medication and treatment at tertiary centres.

When should a GP consider urgent referral?
Consider urgent referral to mental health services if there is: •A risk of self-harm or suicide.
•Significant comorbidity, such as substance misuse, personality disorder or complex physical health problems.
•Self-neglect.

Management may sometimes be complicated by the fact that the patient’s condition prevents them from leaving the house to access treatment. If options cannot be selected which can be pursued at home (eg, self-help treatment), discuss the patient with mental health services. There may be local options (eg, domiciliary therapy by a community psychiatric nurse) which may be available.

For more details on management, see the separate article Panic Disorder.

Prognosis

Some patients may improve; however, relapses are common. 1 in 3 patients have underlying depression and 1 in 5 will attempt suicide.

Results
By Mayo Clinic Staff

Psychotherapy may not cure your condition or make an unpleasant situation go away. But it can give you the power to cope in a healthy way and to feel better about yourself and your life.

Getting the most out of psychotherapy

Take steps to get the most out of your therapy and help make it a success.
•Make sure you feel comfortable with your therapist. If you don’t, look for another therapist with whom you feel more at ease.
•Approach therapy as a partnership. Therapy is most effective when you’re an active participant and share in decision making. Make sure you and your therapist agree about the major issues and how to tackle them. Together, you can set goals and measure progress over time.
•Be open and honest. Success with psychotherapy depends on your willingness to share your thoughts, feelings and experiences. It also depends on your willingness to consider new insights, ideas and ways of doing things. If you’re reluctant to talk about certain things because of painful emotions, embarrassment or fears about your therapist’s reaction, let your therapist know.
•Stick to your treatment plan. If you feel down or lack motivation, it may be tempting to skip psychotherapy sessions. Doing so can disrupt your progress. Try to attend all sessions and to give some thought to what you want to discuss.
•Don’t expect instant results. Working on emotional issues can be painful and may require hard work. It’s not uncommon to feel worse during the initial part of therapy as you begin to confront past and current conflicts. You may need several sessions before you begin to see improvement.
•Do your homework between sessions. If your therapist asks you to document your thoughts in a journal or do other activities outside of your therapy sessions, follow through. These homework assignments can help you apply what you’ve learned in the therapy sessions to your life.
•If psychotherapy isn’t helping, talk to your therapist. If you don’t feel that you’re benefiting from therapy after several sessions, talk to your therapist about it. You and your therapist may decide to make some changes or try a different approach that may be more effective.

Your first therapy session

Your first psychotherapy session is usually a time for the therapist to gather information about you and your needs. The therapist may ask you to fill out forms about your current and past physical and emotional health. It might take a few sessions for your therapist to fully understand your situation and concerns and to determine the best approach or course of action.

The first session is also an opportunity for you to interview your therapist to see if his or her approach and personality are going to work for you. Make sure you understand:
•What type of therapy will be used
•The goals of your treatment
•The length of each session
•How many therapy sessions you may need

Don’t hesitate to ask questions anytime during your appointment. If you don’t feel comfortable with the first psychotherapist you see, try someone else. Having a good fit with your therapist is critical for psychotherapy to be effective.

Starting psychotherapy

A therapist may have an office in a medical clinic or an office building or have a home office. You’ll probably meet with your therapist once a week or every other week for a session that lasts 45 to 60 minutes. Psychotherapy, usually in a group session with a focus on safety and stabilization, also can take place in a hospital if you’ve been admitted for treatment.

Types of psychotherapy

There are a number of effective types of psychotherapy. Some work better than others in treating certain disorders and conditions. In many cases, therapists use a combination of techniques. Your therapist will consider your particular situation and preferences to determine which approach may be best for you.

Although many subtypes and variations on therapies exist, some psychotherapy techniques proven to be effective include:
•Cognitive behavioral therapy, which helps you identify unhealthy, negative beliefs and behaviors and replace them with healthy, positive ones
•Dialectical behavior therapy, a type of cognitive behavioral therapy that teaches behavioral skills to help you handle stress, manage your emotions and improve your relationships with others
•Acceptance and commitment therapy, which helps you become aware of and accept your thoughts and feelings and commit to making changes, increasing your ability to cope with and adjust to situations
•Psychodynamic and psychoanalysis therapies, which focus on increasing your awareness of unconscious thoughts and behaviors, developing new insights into your motivations, and resolving conflicts
•Interpersonal psychotherapy, which focuses on addressing problems with your current relationships with other people to improve your interpersonal skills — how you relate to others, such as family, friends and colleagues
•Supportive psychotherapy, which reinforces your ability to cope with stress and difficult situations

Psychotherapy is offered in different formats, including individual, couple, family or group therapy sessions, and it can be effective for all age groups.

During psychotherapy

For most types of psychotherapy, your therapist encourages you to talk about your thoughts and feelings and what’s troubling you. Don’t worry if you find it hard to open up about your feelings. Your therapist can help you gain more confidence and comfort as time goes on.

Because psychotherapy sometimes involves intense emotional discussions, you may find yourself crying, upset or even having an angry outburst during a session. Some people may feel physically exhausted after a session. Your therapist is there to help you cope with such feelings and emotions.

Your therapist may ask you to do “homework” — activities or practices that build on what you learn during your regular therapy sessions. Over time, discussing your concerns can help improve your mood, change the way you think and feel about yourself, and improve your ability to cope with problems.

Confidentiality

Except in very specific circumstances, conversations with your therapist are confidential. However, a therapist may break confidentiality if there is an immediate threat to safety or when required by state or federal law to report concerns to authorities. These situations include:
•Threatening to immediately or soon (imminently) harm yourself or commit suicide
•Threatening to immediately or soon (imminently) harm or take the life of another person
•Abusing a child or a vulnerable adult (someone older than age 18 who is hospitalized or made vulnerable by a disability)
•Being unable to safely care for yourself

Length of psychotherapy

The number of psychotherapy sessions you need — and how frequently you need to see your therapist — depends on such factors as:
•Your particular mental illness or situation
•Severity of your symptoms
•How long you’ve had symptoms or have been dealing with your situation
•How quickly you make progress
•How much stress you’re experiencing
•How much your mental health concerns interfere with day-to-day life
•How much support you receive from family members and others
•Cost and insurance limitations

It may take only weeks to help you cope with a short-term situation. Or, treatment may last a year or longer if you have a long-term mental illness or other long-term concerns.

You might decide on your own that you want to try psychotherapy, or a doctor, relative, friend or someone else may suggest psychotherapy to you. Here’s how to get started:
•Find a therapist. Get a referral from a doctor, health insurance plan, friend or other trusted source. Many employers offer counseling services or referrals through employee assistance programs (EAPs). You can also find a therapist on your own — for instance, in the phone book or on the Internet, or through a local or state psychological association.
•Understand the costs. If you have health insurance, find out what coverage it offers for psychotherapy. Some health plans cover only a certain number of psychotherapy sessions a year. Also, talk to your therapist about fees and payment options.
•Review your concerns. Before your first appointment, think about what issues you’d like to work on. While you also can sort this out with your therapist, having some sense in advance may provide a good starting point.

Check qualifications

Before seeing a psychotherapist, check his or her background, education, certification, and licensing. Psychotherapist is a general term, rather than a job title or indication of education, training or licensure.

Trained psychotherapists can have a number of different job titles, depending on their education and role. Most have a master’s or doctoral degree with specific training in psychological counseling. Medical doctors who specialize in mental health (psychiatrists) can prescribe medications as well as provide psychotherapy.

Examples of psychotherapists include psychiatrists, psychologists, licensed professional counselors, licensed social workers, licensed marriage and family therapists, psychiatric nurses, or other licensed professionals with mental health training.

Make sure that the therapist you choose meets state certification and licensing requirements for his or her particular discipline. The key is to find a skilled therapist who can match the type and intensity of therapy with your needs.

http://www.bipolar4lifesupport.co

In general, there’s little risk in having psychotherapy. But because it can explore painful feelings and experiences, you may feel emotionally uncomfortable at times. However, any risks are minimized by working with a skilled therapist who is able to match the type and intensity of therapy with your needs. The coping skills you learn can help you manage and conquer negative feelings and fears.

http://www.bipolar4lifesupport.co

Psychotherapy can be helpful in treating most mental health problems, including:
•Anxiety disorders, such as obsessive-compulsive disorder (OCD), phobias, panic disorder or post-traumatic stress disorder (PTSD)
•Mood disorders, such as depression or bipolar disorder
•Addictions, such as alcoholism, drug dependence or compulsive gambling
•Eating disorders, such as anorexia or bulimia
•Personality disorders, such as borderline personality disorder or dependent personality disorder
•Schizophrenia or other disorders that cause detachment from reality (psychotic disorders)

Not everyone who benefits from psychotherapy is diagnosed with a mental illness. Psychotherapy can help with a number of life’s stresses and conflicts that can affect anyone. For example, it may help you:
•Resolve conflicts with your partner or someone else in your life
•Relieve anxiety or stress due to work or other situations
•Cope with major life changes, such as divorce, the death of a loved one or the loss of a job
•Learn to manage unhealthy reactions, such as road rage or passive-aggressive behavior
•Come to terms with an ongoing or serious physical health problem, such as diabetes, cancer or ongoing (chronic) pain
•Recover from physical or sexual abuse or witnessing violence
•Cope with sexual problems, whether they’re due to a physical or psychological cause
•Sleep better, if you have trouble getting to sleep or staying asleep (insomnia)

In some cases, psychotherapy can be as effective as medications, such as antidepressants. However, depending on your specific situation, psychotherapy alone may not be enough to ease the symptoms of a mental health condition. You may also need medications or other treatments.