Part 4

• Agoraphobia


  Anxiety when away from home, in crowds, or in situations that cannot be left easily. Avoidance of these situations, anxiety when anticipating them.
• Agoraphobic patients


  • Experience panic attacks, whether in response to environmental stimuli or arising spontaneously
  • Have anxious cognitions about fainting and loss of control
• Situations agoraphobic patients avoid


  • Buses and trains
  • Shops and supermarkets
  • Places that cannot be left suddenly without attracting attention, such as the hairdresser's chair or a seat in the middle row of a theatre or cinema
• Onset of agoraphobia


  Typically first episode occurs while waiting for public transport or shopping in a crowded store. Suddenly become extremely anxious without knowing why, feel faint, and experience palpitations. Rush away from the place and go home or to hospital, where they recover rapidly.
• Theories of onset of agoraphobia


  • Cognitive hypothesis: Anxiety attack develops because the person is unreasonably afraid of some aspect of the situation or of certain physical symptoms
  • Biological theory: Initial anxiety attack results from chance environmental stimuli acting on an individual who is constitutionally predisposed to over-respond with anxiety
• Theories of spread and maintenance of agoraphobia


  • Learning theories: Conditioning could account for the association of anxiety with increasing numbers of situations, and avoidance learning could account for the subsequent avoidance of these situations
  • Personality: Agoraphobic patients are often described as dependent, and prone to avoiding rather than confronting problems. This dependency could have arisen from overprotection in childhood.
• Agoraphobia that has lasted for 1 year generally remains for the next 5 years, and usually the illness runs a chronic course
• Treatments for agoraphobia


  • Exposure treatment
  • Cognitive behaviour therapy
  • Anxiolytic drugs (benzodiazepines)
  • Antidepressant drugs (imipramine, clomipramine, SSRIs, venlafaxine)
• Panic disorder


  Sudden attacks of anxiety in which physical symptoms predominate, and they are accompanied by fear of a serious medical consequence such as a heart attack
• Symptoms of a panic attack


  • Palpitations
  • Choking sensations
  • Chest pain
  • Dizziness and faintness
  • Depersonalization
  • Derealization
  • Fear of dying, losing control, or going mad
• For a diagnosis of panic disorder, DSM-5 requires the presence of only four or more panic attack symptoms
• Important features of panic attacks


  • Anxiety builds up quickly
  • Symptoms are severe
  • Person fears a catastrophic outcome
• Symptoms of hyperventilation


  • Dizziness
  • Tinnitus
  • Headache
  • Feeling of weakness
  • Faintness
  • Numbness
  • Tingling in the hands, feet, and face
  • Carpopedal spasms
  • Precordial discomfort
  • Feeling of breathlessness
• Diagnostic criteria for panic disorder in DSM-5

  • Panic attacks occur recurrently (at least twice) and unexpectedly (i.e. not in response to an identified phobic stimulus)
  • At least one attack has been followed by 4 weeks or more of persistent fear of another attack and worry about its implications, and/or a significant maladaptive change in behaviour
• The National Comorbidity Survey Replication found a 12-month prevalence rate of DSM-IV panic disorder of 2.7% and a lifetime risk of 4.7%