History

Fact Explanation
Attacks of intense fear and anxiety in stereotypical situations: away from home or when alone [1] Agoraphobia is a phobic anxiety disorder, causing difficulty in leaving the house but there is no avoidance of social contact unlike in social phobia and schizophrenia. [1]
Anxiety occurs in specific situations: crowded places, open spaces or on public transport [1] Anxiety develops with the fear of not having an emergency escape and fear of getting lost. [1] The person feels less anxious when accompanied by another person, and this may lead to dependency. [1]
Females are the most affected [1,2] Agoraphobia usually begins in early or mid twenties. Females are twice more affected than males. [1]
Avoidance of situations which cause anxiety [1] A characteristic feature of phobic anxiety disorder. This is a maladaptive behavior.as the condition progresses patients tend to avoid these situations more and more. [1]
Anticipatory anxiety [1] Anxious thoughts about fainting or losing control. May be severe and appear several hours before the person enters the situation. [1]
Variation of symptoms on a case by case basis: anxiety symptoms such as chest pain, palpitations, depersonalization and derealization, choking sensation and dizziness may predominate. [1] Occurs due to excessive activation of fear net work( involvement of serotonin, noradrenalin, adenosine, GABA and cholecystokinin-4) which involves the amygdala. [3]
References
  1. PHILIP COWEN.PAUL HARRISON.TOM BURNS. Shorter Oxford Textbook of Psychiatry. Sixth edition. Oxford. Oxford University Press. 2012.
  2. BJORNSSON AS, SIBRAVA NJ, BEARD C, MOITRA E, WEISBERG RB, BENíTEZ CI, KELLER MB. Two-year course of generalized anxiety disorder, social anxiety disorder, and panic disorder with agoraphobia in a sample of latino adults. J Consult Clin Psychol [online] 2014 Apr 14 [viewed 16 May 2014] Available from: doi:10.1037/a0036565
  3. JOHNSON MR, LYDIARD RB, BALLENGER JC. Panic disorder. Pathophysiology and drug treatment. Drugs [online] 1995 Mar, 49(3):328-44 [viewed 18 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/7774510

Examination

Fact Explanation
Physical examination As patients present with physical symptoms it is important to rule out an organic pathology. [1] A detailed search of the cardiovascular and central nervous systems should be performed.
Mental State Examination: Appearence Patient appears tense and sweaty.
Mental State Examination: Speech Unaffected. [1,2]
Mental State Examination: Mood and Affect Patient may show complications of the illness like depression. [1,2]
Mental State Examination: Thought and Perception Unaffected. [1,2]
Mental State Examination: Attitude and Insight Unaffeced [1,2]
Mental State Examination: higher functions and cognition The specific cognitive functions of alertness, language, memory, constructional ability, and abstract reasoning are the most clinically relevant. these are usually not affected. [1,2]
References
  1. PHILIP COWEN.PAUL HARRISON.TOM BURNS. Shorter Oxford Textbook of Psychiatry. Sixth edition. Oxford. Oxford University Press. 2012.
  2. MARTIN DC. The Mental Status Examination. In: Walker HK, Hall WD, Hurst JW, ed. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 207. Available from: http://www.ncbi.nlm.nih.gov/books/NBK320/

Differential Diagnoses

Fact Explanation
Social phobia [1] Some social phobics avoid buses or shops when thee places are crowded. A detailed inquiry in to the pattern of avoidance and the symptoms, is needed in order to exclude this possibility. [2]
Generalized anxiety disorder [1] Patients experience anxiety in public places, but it is not situational like in agoraphobia. [2]
Schizophrenia [1] Patients with paranoid delusions may avoid some situations. Mental state examination will help in making diagnosis. [1]
Depressive disorder [1] Patients with depressive disorder avoid social contacts because of low mood and lack of interest in interacting with people. Agoraphobic patients do not fear social interactions. [1]
References
  1. PHILIP COWEN.PAUL HARRISON.TOM BURNS. Shorter Oxford Textbook of Psychiatry. Sixth edition. Oxford: Oxford University Press. 2012
  2. TAYLOR CT, POLLACK MH, LeBEAU RT, SIMON NM. Anxiety disorders: panic, social anxiety, and generalized anxiety. In: STERN TA, ROSENBAUM JF, FAVA M, BIEDERMAN J, RAUCH SL ed. Massachusetts General Hospital Comprehensive Clinical Psychiatry. First edition. Philadelphia, Pa: Mosby Elsevier;2008.

Investigations - for Diagnosis

Fact Explanation
Diagnostic criteria for agoraphobia According to DSM-$ criteria, the diagnosis of Agoraphobia without Panic disorder should Include severe fear or anxiety in two or more of the following situations: 1. Using public transportation, such as a bus or plane; 2. Being in an open space, such as a parking lot, bridge or large mall; 3. Being in an enclosed space, such as a movie theater, meeting room or small store; 4. Waiting in a line or being in a crowd; 5. Being out of home alone. In addition, diagnostic criteria for agoraphobia should also fulfill the following: 1. Fear or anxiety that almost always results from exposure to a situation; 2. Avoidance of the situation, needing a companion to go with you or endurance of this situation with extreme distress; 3. Fear or anxiety which is out of proportion to the real danger posed by the situation; 4.Significant distress or problems with social situations, work or other areas in your life caused by the fear, anxiety or avoidance; 5. Persistent phobia and avoidance, lasting six months or longer [1]
References
  1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington DC, American Psychiatric Association,1994.

Investigations - Fitness for Management

Fact Explanation
Full Blood Count Performed for the exclusion of anaemia, that can cause similar symptoms such as palpitations, dizziness. [1]
Electrocardiogram (ECG) Arrhythmias can cause similar symptoms. Therefore it is always important to exclude this possibility. [1]
References
  1. TAYLOR CT, POLLACK MH, LeBEAU RT, SIMON NM. Anxiety disorders: panic, social anxiety, and generalized anxiety. In: STERN TA, ROSENBAUM JF, FAVA M, BIEDERMAN J, RAUCH SL, ed. Massachusetts General Hospital Comprehensive Clinical Psychiatry. First edition. Philadelphia, Pa: Mosby Elsevier;2008.

Investigations - Followup

Fact Explanation
Assess social support [1,2] It is important in formulating a sustainable management plan. [2]
Identify co-morbid conditions [1] Depression is the commonest co-morbid condition. Panic attacks can also occur in situations with intense anxiety. [1]
Identify maladaptive behavior [1] Alcohol or benzodiazepines can be abused by the patient to cope with anxiety. This can result in harmful use or dependency. [1]
References
  1. COWEN Phillip, HARRISON Paul, BURNS Tom. Shorter Oxford Textbook of Psychiatry. Sixth edition. Oxford: Oxford University Press. 2012.
  2. TAYLOR CT, POLLACK MH, LeBEAU RT, SIMON NM. Anxiety disorders: panic, social anxiety, and generalized anxiety. In: STERN TA, ROSENBAUM JF, FAVA M, BIEDERMAN J, RAUCH SL, ed. Massachusetts General Hospital Comprehensive Clinical Psychiatry. First ed. Philadelphia, Pa: Mosby Elsevier;2008.

Investigations - Screening/Staging

Fact Explanation
Identify situations causing anxiety Record details of all the situations which caused anxiety. It is necessary to draw up a hierarchy in graded exposure. [1]
Assess severity of phobia Amount of interference with daily life, work and relationships are indicators of severity of phobia. [1]
Identify other coping mechanisms Agoraphobic patients may experience less anxiety when accompanied by another person. Use of alcohol or benzodiazepines should be identified as these are important in management of maladaptive behaviors. [1]
References
  1. COWEN Phillip, HARRISON Paul, BURNS Tom. Shorter Oxford Textbook of Psychiatry. Sixth edition. Oxford: Oxford University Press. 2012.

Management - General Measures

Fact Explanation
Determine goals of treatment General aim of treatment is to rid the patient of fear of specific situations, but it is important to define specific goals that describe the expected improvement from therapy. [1]
Educatiion of patient and family Treatment will not succeed unless patient is cooperative. Therefore patient must understand about the illness and the basis of treatment. [1]
Lifestyle modification Advise to follow a healthy lifestyle that includes exercise, enough rest and good nutrition can also help to improve the condition.
References
  1. COWEN Phillip, HARRISON Paul, BURNS Tom . Shorter Oxford Textbook of Psychiatry. Sixth edition. Oxford: Oxford University Press. 2012.

Management - Specific Treatments

Fact Explanation
Develop a hierarchy [1] Ask the patient to list all the situations in which he/she experiences anxiety. These are then arranged in ascending order as a hierarchy, on a scale from 1-10. [1]
Graded exposure [1] Exposure should be graded, repeated and prolonged. Exposure should be according to the hierarchy from the lowest anxiety causing situation and gradually increasing to the situations causing higher anxiety. Once one level is successfully completed go to next level. [1]
Psychoeducation and Cognitive Behavioral Therapy (CBT) [2] This consists of explaining the cognitive model of panic. It helps the patient to change the thoughts that cause his/her condition. Learning stress management and relaxation techniques can also be included. [1]
Specific Serotonin Re-uptake Inhibitors (SSRI) eg: Fluoxetine and Serotonin Noradrenaline Reuptake Inhibitors (SNRI) eg: venlafaxine SSRI's are usually the first choice of antidepressant due to efficacy and favorable side effect profile. Both SSRI and SNRI are started at a lower dose and increased after a week's duration depending on the response.
Anxiolytics Short term use of a benzodiazepines during the initial period is useful. Long term treatment may cause dependency. [2]
References
  1. COWEN Phillip, HARRISON Paul, BURNS Tom. Shorter Oxford Textbook of Psychiatry. Sixth edition. Oxford: Oxford University Press. 2012.
  2. BENNET, PN. BROWN, MJ. LAURENCE, DR. Clinical Pharmacology. Ninth edition. New York: McGraw-Hill. 2003.