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.
