Azim Arif Hashmi – 17400/43

Final Year MBBS – Batch G

Psychiatry Assignment Riphah International University

Agoraphobia

Agoraphobia is characterized by marked and excessive fear or anxiety that occurs in response to multiple situations
where escape might be difficult, or help might not be available. These situations include using public transportation,
being in crowds, being outside the home alone (e.g., in shops, theatres, standing in line). The individual is
consistently anxious about these situations due to a fear of specific negative outcomes (e.g., panic attacks, other
incapacitating or embarrassing physical symptoms). The situations are actively avoided, entered only under specific
circumstances such as in the presence of a trusted companion, or endured with intense fear or anxiety. The
symptoms persist for least several months and are sufficiently severe to result in significant distress or significant
impairment in personal, family, social, educational, occupational, or other important areas of functioning.

Signs and Symptoms:

Anxiety is the most common feature in phobic disorders. Manifestations include the following:
 Sweating
 Palpitations
 Elevated blood pressure
 Elevated heart rate
 Dyspnoea
 Dizziness
 Tremor
 Diarrhea
 Paresthesias

Prevalence, Age and Gender distribution:

Every year approximately 1.7% of adolescents and adults have a diagnosis of agoraphobia. Females are twice as
likely as males to experience agoraphobia. Agoraphobia may occur in childhood, but incidence peaks in late
adolescence and early adulthood. Twelve-month prevalence in individuals older than 65 years is 0.4%. Prevalence
rates do not appear to vary systematically across cultural/racial groups.

Aetiology:
Aetiology of agoraphobia is not known but several neurobiological and psychological theories, as well as familial
patterns, have contributed to understanding the underlying causes of this disorder.

Diagnostic Criteria (ICD-10):

All of the following criteria should be fulfilled for a definite diagnosis:
 The psychological or autonomic symptoms must be primarily manifestations of anxiety and not secondary to
other symptoms, such as delusions or obsessional thoughts.
 The anxiety must be restricted to (or occur mainly in) at least two of the following situations: crowds, public
places, travelling away from home, and travelling alone.
 Avoidance of the phobic situation must be, or have been, a prominent feature.

Differential Diagnosis:
Specific phobia, situational type:
Specific phobia, situational type, should be diagnosed if the fear, anxiety, or avoidance is limited to one of the
agoraphobic situations. Moreover, 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.
Social phobia:
Agoraphobia should be differentiated from social phobia based primarily on the situations that trigger fear, anxiety,
or avoidance and the cognitive ideation. In social phobia or social anxiety disorder, the focus is on fear of being
negatively evaluated.
Panic disorder:
The essential features of panic disorder are recurrent attacks of severe anxiety which are not restricted to any
particular situation or set of circumstances, and which are therefore unpredictable and differentiate it from
agoraphobia. A person however may avoid going out in public because of these panic attacks, in which case the
clinical picture will be similar to agoraphobia, but the diagnosis of panic disorder will be more appropriate.
Separation anxiety disorder:
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.
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 behaviour 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. For example, a person may avoid going out of house or traveling because of underlying cardiovascular
insufficiency. 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 more than that usually associated with these medical conditions.

Investigations:
There are no specific lab tests to diagnose agoraphobia, but certain baseline instigations and imaging studies (CT
scan/MRI) may be advised to rule out any organic disease or brain injury. Diagnosis is based on careful history and
ruling out the differentials. To rule out anxiety secondary to medical conditions, the following laboratory tests may
be helpful:
 Thyroid function tests - Hypothyroidism or hyperthyroidism
 Fasting glucose - Hypoglycaemia
 Calcium - Hyperparathyroidism
 24-hour urine for 5-hydroxyindoleacetic acid (5-HIAA) - Pheochromocytoma
 Drug screen - Substance-induced anxiety

Treatment:
Treatment of agoraphobia usually consists of psychotherapy, pharmacotherapy, or some combination.
Psychotherapy:
A combination of exposure therapy, relaxation, and breathing retraining are recommended psychological
interventions for panic disorder with and without agoraphobia. Furthermore, the inclusion of homework and a
follow-up program have been shown to improve outcomes. Early intervention is recommended on the grounds that
the shorter the duration of illness is, the better the response will be.
Pharmacotherapy:
Acute Treatment: Treatment for agoraphobia should be started with an SSRI at a low dosage (e.g., escitalopram,
citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline), which is then titrated to the minimum dosage that
effectively controls the patient’s panic. If the response is partial or absent at the highest SSRI dosage, the following
alternatives should be considered: Switch to a different SSRI or Switch to an agent from a different drug class like
SNRI antidepressant (venlafaxine), NRI antidepressant (reboxetine), or a TCA (clomipramine, imipramine).
Benzodiazepines (e.g., alprazolam, lorazepam, diazepam, and clonazepam) can be used either as an adjunct or as
primary treatment, but they have potential for abuse. The short acting agent may be considered for short-term use
to control acute symptoms of panic.
Long-term Treatment: Continuing an SSRI or TCA from 4 to 12 months results in increased treatment response rates.
For a patient with good response, treatment should be continued for 9-12 months before slow tapering of the
medications is considered. If symptoms recur after tapering, treatment should be resumed and continued
indefinitely.
 Fluoxetine
Dose: Initially 10 mg PO per day for first week, then 20 mg PO per day. May consider gradually increasing dose after
several weeks; not to exceed 60 mg.
Contraindications: Hypersensitivity, Concomitant pimozide or thioridazine, Breastfeeding
Adverse Effects: Insomnia, Nausea, Headache, Weakness, Diarrhea, Somnolence, Anorexia, Asthenia, Anxiety,
Nervousness, Tremor
Pregnancy: Category C (Use with caution if benefits outweigh risks. Animal studies show risk and human studies not
available or neither animal nor human studies done.)
Lactation: Contraindicated
 Sertraline
Dose: Initially, 25 mg PO once daily. May increase by 25 mg at 1-week intervals; not to exceed 200 mg once daily
Contraindication: Hypersensitivity, do not use disulfiram concomitantly with oral solution due to alcohol in
preparation, Concomitant pimozide: risk of long QT syndrome
Adverse Effects: Diarrhea, Nausea, Headache, Insomnia, Ejaculation disorder, Dizziness, Dry mouth, Fatigue,
Drowsiness
Pregnancy: Category C
Lactation: Distributed into milk; use caution
 Paroxetine
Dose: 20 mg PO once daily
Contraindication: Hypersensitivity, Concomitant pimozide
Adverse Effects: Nausea, Insomnia, Dry mouth, Headache, Asthenia, Constipation, Diarrhea, Dizziness, Ejaculation
disorder, Tremor
Pregnancy: Category D (Use in life threatening emergencies when no safer drug available. Positive evidence of
human foetal risk.)
Lactation: Excreted in breast milk; use caution
 Venlafaxine
Dose: 75 mg PO once daily (extended release)
Contraindication: Hypersensitivity, Coadministration with serotonergic drugs
Adverse Effects: Headache, Nausea, Insomnia, Asthenia, Dizziness, Ejaculation disorder, Somnolence, Dry mouth,
Diaphoresis, Anorexia, Nervousness, Anorgasmia
Pregnancy: Category C
Lactation: Enters milk; not recommended
 Clomipramine
Dose: 25 mg PO initially; gradually increase to 100 mg/day (divided with meals) over 2 weeks
Contraindication: Hypersensitivity, severe cardiovascular disorder, narrow angle glaucoma, any drugs or conditions
that prolong QT interval, acute recovery post-MI
Adverse effects: Xerostomia, Headache, Constipation, Ejaculation failure, Fatigue, Nausea, Impotence, Weight gain
Pregnancy: Category C
Lactation: Not recommended
 Alprazolam
Dose: 0.25-0.5 mg PO every 6-8hr; titrate to effect every 3-4Days; not to exceed 4 mg/day
Contraindication: Hypersensitivity, Acute narrow angle glaucoma, Concomitant use with CYP3A4 inhibitors
Adverse Effects: Drowsiness, Depression, Headache, Constipation, Diarrhea, Dry mouth
Pregnancy: Category D
Lactation: Enters breast milk/not recommended

References:
1. The ICD-10 Classification of Mental and Behavioural Disorders.
2. International Classification of Diseases 11th Revision (ICD-11). Chapter 06 - Mental, behavioural or
neurodevelopmental disorders.
3. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Washington, DC: American Psychiatric
Association; 2013.
4. https://emedicine.medscape.com/article/288016-overview