miércoles, 15 de mayo de 2019

Agoraphobia: Causes, Symptoms, Diagnosis & Treatment

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By Dr. Sanchari Sinha Dutta, Ph.D.Reviewed by Dr. Jennifer Logan, MD, MPH

Agoraphobia is an anxiety disorder wherein affected persons feel extremely anxious to leave their comfort zone, such as home, or to be in a situation where they cannot easily leave if they were to experience panic. Such people often feel unsafe to go to places where they feel helpless, uncomfortable, or stuck. In general, people develop agoraphobia before the age of 35 years, and women are two times more likely to develop the disorder than men.

People with extreme agoraphobia may consider their home to be the only safe place and will avoid going outside the home for days, months, or even years. People with agoraphobia may have a history of panic attack and fear having a subsequent attack and not being able to get help or escape. They often seek companions to go outside their home. If left untreated, agoraphobia patients can develop more serious complications, such as alcohol or drug addiction, depression, and other mental disorders.

Causes of agoraphobia

Although the exact etiology of agoraphobia is not fully known, it is believed that specific brain centers that are associated with fear response may play a significant role. Moreover, genetic factors may be involved, because people having a family member with agoraphobia are at higher risk of developing the disorder.

People who suffer from panic disorder (another type of anxiety disorder) or other phobias are also at higher risk of developing agoraphobia. However, according to the diagnostic and statistical manual of mental disorders (DSM-5), panic disorder and agoraphobia are separate entities and no longer considered interrelated. This change was made because a significant number of people with agoraphobia do not suffer from panic symptoms.

Agoraphobia may occur following specific stressful life events, such as the death of a parent or close relatives, a relationship breakup, abuse, or attack. In addition, people with nervous or anxious personalities are more likely to develop agoraphobia.

Signs and symptoms of agoraphobia

To meet criteria for agoraphobia, a person must experience fear in two or more of these situations: going outside their home alone, taking public transportation, going to open or confined places, or standing in a queue or crowed place. People try to avoid specific places or situations where they had panic attacks previously.

The fear/anxiety is often out of proportion to the actual adversity of the condition and lasts for 6 months or more, leading to deterioration in quality of life and ability to perform day-to-day activities.

In cases where agoraphobia is present together with panic disorder, patients can experience sudden, highly intense panic attacks for short durations. The fear of having another panic attack greatly prevents patients from being into the similar situation or place where the attack happened previously.

Agoraphobia patients who have panic attacks mostly suffer from rapid heart rate, breathing difficulties, chest pain, excessive sweating, diarrhea, or dizziness. A feeling of loss of control and fear of death may also occur.

In most of the cases, patients are reluctant to leave their home or other confortable places because of the anticipation of anxiety. In case of severe anxiety, patients may suffer from low self-esteem, low confidence level, and depression.

Agoraphobia diagnosis

Diagnosis of agoraphobia is mainly symptom-based. Initially, mental health professionals thoroughly investigate the signs and symptoms by interviewing the patient. A physical examination or other relevant lab tests is sometimes necessary to rule out possibilities associated with panic symptoms (such as hyperthyroidism or substance use).

According to DSM-5, specific agoraphobia situations are as follows:

Using public transportation
Being in open spaces
Being in enclosed places
Standing in line or being in a crowd
Being outside the home alone

An experience of fear from two or more of these situations is required for the accurate diagnosis of agoraphobia. In addition, the presence of symptoms for at least 6 months is necessary for the diagnosis.

Agoraphobia treatment

Agoraphobia is a treatable disorder, and the treatments mainly include psychotherapy and/or medications.

Psychotherapy or ‘talk therapy’ should be directed at specific fears/anxieties of a patient. A psychotherapist mainly works with the patient to teach him/her practical skills to reduce the anxiety-related symptoms. Cognitive behavioral therapy (CBT) is one type of psychotherapy that is suitable for treating agoraphobia patients. This short-term therapy teaches patients the skills to improve thinking ability, behavioral pattern, and ability to challenge agoraphobia-causing places or situations. It also teaches patients the social skill to improve their social behavior.

There are two types of CBT: cognitive therapy and exposure therapy. Cognitive therapy primarily focuses at recognizing, challenging, and finally counteracting the underlying causative factors of agoraphobia; whereas, exposure therapy aims at teaching patients how to gradually reduce their anxiety level by remaining in the stressful situations/places. It helps patients perform activities that they used to avoid previously due to fear or anxiety. Exposure therapy is sometimes performed along with relaxation exercises, counseling, and self-esteem therapy for better efficacy.

CBT can be applied to one patient or a group of patients with similar problems/symptoms. A therapist may also assign tasks to the patients that they need to practice between sessions.

Besides psychotherapy, mental health professionals prescribe medicines to reduce the intensity of symptoms. However, these medicines sometimes interact with certain substances, such as caffeine, over-the-counter cold and flu medicines, and some herbal compounds. Certain types of medications are associated with dependence, so patients and providers should only consider these for short-term use to make anxiety manageable so that psychotherapy treatment can be optimized. Thus, before taking these medicines, patients should discuss with the doctor about their medical history and details of routine medicines that they may be taking for other health conditions.

To achieve the maximum benefit from medicines, doctors should work with the patients on choosing the appropriate medicine, dose, and duration of treatment. Since the efficacy of medicines varies from person to person, doctors may prescribe several medicines before selecting the right one. Because of the adverse effects of some drugs, doctors mostly prefer to start with low drug dose and gradually increase it until reaching the optimal dose. To reduce the risk of drug resistance, an intermittent treatment plan is often more effective than a continuous one.

The most commonly prescribed psychiatric medicines are anti-anxiety and antidepressant drugs and beta-blockers. Anti-anxiety drugs are generally prescribed to lessen anxiety-related symptoms, panic attacks, and severe fear. However, chronic consumption of these medicines can develop a certain level of tolerance; patients may also develop drug dependency. In such cases, a significantly higher dose of drug is needed to achieve a noticeable effect.

Antidepressant medicines such as selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are used to treat both anxiety-related symptoms and depression. These medicines help modulate the level and activity of certain brain chemicals that are important for regulating emotional behaviors. Patients who are under the age of 25 years may develop suicidal tendency at the beginning of antidepressant therapy. Thus, it is very important to observe the patient closely, particularly during first few weeks of the treatment.

Beta blockers are mainly used to treat the physical symptoms of panic attack, such as rapid heart rate, breathing difficulties, etc.

Self-management tips for agoraphobia

Living with agoraphobia can significantly impact a person’s quality of living. It often confines a person from surroundings, which may cause social isolation. Besides seeking medical help, certain self-help strategies are vital for reducing the symptom intensity and improving the efficacy of treatment.

When undergoing treatment, a person must stick to the treat regimen and should not avoid the places/situations that cause fear. Try avoiding caffeine, alcohol, and other illicit substances that can worsen anxiety symptoms.

A good sleep, healthy diet, and daily physical activity significantly improve the conditions related to agoraphobia. Certain relaxation methods, such as yoga, meditation, and hypnotherapy, are also helpful.

Since hyperventilation or rapid breathing is associated with panic attack, a conscious effort to practice slow breathing is very effective in reducing the symptoms of panic attack.

To improve the efficacy of exposure therapy, a person should start facing the fearful condition gradually in a controlled way. One should begin with the least feared condition and be there with a trusted person or therapist as a companion until the fear subsides. This method is called desensitization. Regular practice of this method significantly helps cope the situation and regain the confidence.

Several in-person or online support groups are also available to connect patients with anxiety disorders. These groups can be used as a platform to share personal experiences and discuss coping strategies.