Panic Disorder and Agoraphobia

Clinical Feature

Panic Disorder is another form of anxiety disorder that is characterized by recurrent and unexpected panic attacks, which are sudden surges of severe fear or discomfort that heighten significantly within minutes. Whereas agoraphobia is a different type of anxiety disorder in which individuals fear and avoid places or situations that might cause them to panic and make them feel trapped, helpless or embarrassed. In many cases but not at all, panic disorder is accompanied by agoraphobia. The former version of DSM i.e. IV panic and agoraphobia were integrated as a one disorder but DSM 5 has listed them as two different disorders.

There’s multiple evidence that individuals may have panic disorder without ever experiencing agoraphobia and vice versa. But there are also cases where individuals may experience panic disorder with agoraphobia. Thus these both disorders are closely related to each other despite different clinical descriptions.  

Panic attacks occur suddenly. Symptoms can vary for different people, but they tend to hit their peak within 10 minutes. Panic attack is very brief; it may strike for a few minutes to maximum 30 minutes. Series of panic attacks leads to panic disorder. Whereas people with agoraphobia avoid places or situations fearing they will have panic attacks.

Christina remembered her first panic attack like it was yesterday. It was very hard for her to recall the anxious situation she had experienced but this was like nothing she would ever experience. She was at a volleyball game about 6 months ago. Big crowd was cheering for their team and the Nepal women’s team was getting hammered by the Indian women’s team. She felt that she was being choked, and couldn’t get out of it easily. It was blue everywhere; she felt pain in her chest and had shortness of breath. She could ask for help, she felt that she was having a heart attack and was going to die.

She remembered her aged parents for the last time and got anxious about what will happen to them after her death, they would never see her again. Her friend noticed Christina was trembling and sweating, she pushed her out of the crowd and immediately took her out and searched for an ambo. Admitted to the emergency room of Gangalal hospital, she was discharged within an hour without being diagnosed with several problems. Ever since she has never been to any athletics event, fearing that she would experience a similar crisis. 

In the case of Cristina and volleyball match, she had a panic attack with agoraphobia. Her panic attack is very brief in nature, this may be normal in nature as most people experience panic attacks in their life. Cristina however developed agoraphobia which is fear of getting panic attacks again if she attends volleyball matches again. In some cases even after experiencing a panic attack they would not ever avoid the situation or place. 

Diagnostic Criteria (DSM)

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur;

1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
12. Fear of losing control or “going crazy.”
13. Fear of dying.
14. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

B. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).

C. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having    panic attacks, such as avoidance of exercise or unfamiliar situations).

D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).

E. The disturbance is not better explained by another mental disorder. 

Diagnostic criteria for Agoraphobia

A. Marked fear or anxiety about two (or more) of the following five situations:

1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).
2. Being in open spaces (e.g., parking lots, marketplaces, bridges).
3. Being in enclosed places (e.g., shops, theaters, cinemas).
4. Standing in line or being in a crowd.
5. Being outside of the home alone.

B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly;fear of incontinence).

C. The agoraphobic situations almost always provoke fear or anxiety.

D. The agoraphobic situations are actively avoided, require the presence of a companion,or are endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the socio cultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease)is present, the fear, anxiety, or avoidance is clearly excessive.

I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder

Comorbidity 

The majority of individuals with panic disorder and agoraphobia will also have other mental disorders. Anxiety disorders are common, panic disorder individuals will have especially agoraphobia. Major depression, bipolar disorder, and possibly mild alcohol use disorder is common in panic disorder whereas disorders (e.g., specific phobias, panic disorder, social anxiety disorder), depressive disorders (major depressive disorder), PTSD, and alcohol use disorder is common in agoraphobia.

Prevalence

Panic disorder (PD) lifetime prevalence rates range from 1.1% to 3.7% in the general population and 3.0% to 8.3% in clinic settings (Chiu, Kessler, Jin et.al, 2006). PD affects 6 million adults, or 2.7% of the U.S. population. Panic attacks (which can occur in disorders other than panic disorder) are much more common than panic disorder, occurring in up to one-third of individuals at some point in their lifetime (Katon, Vitaliano, Russo et al. 1987).

The age of onset for panic disorder is in early adult life between 20-24 (Kessler, Berglund, et.al, 2005).  Panic disorder is more common in women than in men i.e 2:1, with a 3:1 ratio in patients with agoraphobia and 2:1 in patients without agoraphobia (Szabo, 2013). About 75% or more of those who suffer from agoraphobia are women (Barlow, 2002). 

Lifetime prevalence rate of agoraphobia is 1.1 percent whereas lifetime prevalence rate of agoraphobia without panic disorder is lower, estimated at 0.8 percent (Chiu, Kessler, Jin et.al, 2006).

Etiology

Panic disorder and agoraphobia appears to be a genetically inherited and neurochemical dysfunction. Panic disorder, agoraphobia is like other anxiety disorders that appear to run in families. Families with a history of panic disorder and agoraphobia may have high chances that their first degree relatives or form dizygotic to monozygotic twins have risk of panic disorder.

However, genetic and linkage studies have robust findings. Functional MRI studies have found activity in hippocampus and parahippocampal gyrus, a part of the brain in people with panic disorder. Panic disorder and agoraphobia represents an inherited disturbance in the overall function of noradrenergic, serotoninergic or GABAergic systems in one or more of those central nervous system structures responsible for anxiety.

Evidence for an overactive hypothalamic–pituitary–adrenal (HPA) axis and auto-nomic hyperactivity in Panic Disorder exists (Craske, 1999).

Conditioning theories propose that panic attacks or agoraphobia both are classical conditioning responses to bodily sensations (Bouton, Mineka, & Barlow, 2001). Let us consider, child who has asthma. Asthma symptoms elicit fear and anxiety. Later, when the child experiences asthma attacks he or she may become anxious, fearful, and then experience a panic attack. Thus symptoms of panic here are conditioned stimuli, and the panic attack would be a conditioned response. Thus panic disorder has the potential to develop through classical conditioning. Similarly physical and medical conditions such as cardiac arrhythmias, asthma, chronic obstructive pulmonary disease and irritable bowel syndrome, are associated with panic disorder.

Cognitive factors also play an integral part in panic disorder. David Clark (1996) emphasizes that individuals may interpret ordinary bodily sensations catastrophically. For example, if a person detects an increase in heart beat after exercise they may interpret these subtle bodily changes catastrophically and in return would respond as a danger and feel a surge of anxiety and believe they are about to have a heart attack. 

Experiencing or living in negative life experiences can also trigger panic. Working or living in extremely stressful situations, if they have gone through childhood abuse, death of a family member or friend, have been associated with recurring panic attacks. 

Treatment

Panic disorder and agoraphobia can be effectively treated by either or combine treatment through medication or therapies. Cognitive Behaviour Therapy for panic disorder is the most effective and favorable treatment therapy among psychologists. CBT emphasizes on determining the thought and behavior patterns of causing the panic attack. CBT consists of components of psycho-education, cognitive restructuring, and behavioral interventions.

Exposure therapy exposes the individual to situations or places that cause panic attacks, when panic attacks cause physical sensation psychologists help individuals to learn better coping techniques. Teaching individuals to apply relaxation and breathing in anxiety trigger situations is proven beneficial.  

Eye movement desensitization and reprocessing also has been reported to be useful in treating panic attacks and phobias. It simulates rapid eye movements. These movements affect the way the brain processes information and can help individuals see things in a way that is less frightening.

Self help techniques for both panic disorder and agoraphobia focus can help to support their own mental wellbeing. This includes eating a healthy diet, exercising, sharing problems with family and friends, training in relaxation practices, seeking out support groups.