Anxiety: Agoraphobia Flashcards
General management of phobias
The seriousness of the phobia is related to the level of disability – i.e. pilot fearing flying is a severe disability
- Social phobia and agoraphobia have the biggest impact on life
- NEVER treat anxiety with benzodiazepines as there is a high risk of dependence (short-term in specific phobia is ok)
- Specific Phobias do NOT respond well to antidepressants, but most people don’t need treatment as avoidance is better
Definition
ICD-10: a fairly well-defined cluster of phobias embracing fears of leaving home, entering shops, crowds and public places, or travelling alone in trains, buses or planes – literally means ‘fear of the marketplace’
- Classified WITH or WITHOUT a panic disorder
- Uniting fear = inability to escape to safe place -> overwhelming urge to return home to safety
- Problem situations = travelling (trains, buses, etc.), queueing, supermarkets, crowds, parks
N.B. some agoraphobics may have little anxiety because they can avoid specific triggers well
- Onset = 20-35yo, gradual or precipitated by a panic attack F>M
- Occurs in response to multiple situations when escape might be difficult or help might not be available (e.g. using public transport, being in crowds, being outside, home alone).
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 entered only under specific circumstances, e.g. in the presence of a trusted companion
The situations (or objects if indicated) are actively avoided or endured with intense fear or anxiety. Consistently occurs in ≥ 1 social situations such as social interactions, being observed, or performing in front of others.
The individual is concerned that they will act in a way, or show anxiety symptoms, that will be negatively evaluated by others
Epidemiology
Agoraphobia: onset usually in 20s to mid 30s
80% married and nearly all are unemployed/ homemakers
Aetiology
Genetics
Early experiences and life events
- Childhood adversity predisposes to anxiety disorders
- Life events can trigger anxiety disorders, especially if they are threatening
Neurochemical theories
- Central neurotransmitters such as serotonin, noradrenaline, GABA are dysregulated
- These are targets for drugs that successfully combat anxiety symptoms:
Serotonin- SSRIs
Noradrenaline- TCAs
GABA- benzodiazepines
Behavioural and cognitive theories
- Classical conditioning- repeated pairing of a neural stimulus with a frightening one
- Negative reinforcement-behaviours that relieve anxiety (e.g. running away) are repeated. This prevents habituation (getting used to the stimulus and calming down), so escaping from a fearful stimulus maintains the fear response.
- Cognitive theories- worrying thoughts are repeated in an automatic way which both induces and maintains the anxiety response
- Attachment theory- quality of attachment between children and their parents affects their confidence as adults (insecure attachment results in anxious adults)
Symptoms
Usually includes fear of open places and fear of situations that are confined and difficult to leave without attracting attention
Common problem situations include:
- Travelling on planes, trains, or buses
- Queuing
- Supermarkets
- Large crowds
- Parks
- Sitting in the middle row of the cinema
- Overwhelming urge to return to home to safety - home-bound
- Prospect of leaving home generates anxiety
- May present with panic attacks
- Severity may increase with increasing distance from home or difficulty returning
- Presence of a dependable companion (or sometimes car) increases range and makes otherwise avoided situations bearable
Symptoms persist for at least several months and are sufficiently severe to result in significant distress or impact in personal, family, social, educational, occupational or other important areas of functioning
Summary:
1. Panic attacks
2. Avoidance of phobic situations ± isolation behaviour
3. Associated features: depressive/obsessional symptoms, social phobias
Investigations
Cardiorespiratory examination
Rule out: ECG, TFTs, LFTs, U&Es, glucose, urine drug screen, urine VMAs
SPIN questionnaire for social phobia
Hospital Anxiety and Depression Scale
Collateral history
Social and occupational assessments for effect on QoL
Management
STEP 1: Recognition and Diagnosis
Identify any comorbidities, in particular panic disorder with depression or with substance misuse
Education, reassurance, and self-help
STEP 2: Offer Treatment in Primary Care
Low-Intensity Psychological Therapy
- Individual non-facilitated self-help
- Individual facilitated self-help
- Psychoeducational groups
Social Interventions
- Exercise benefits
- Encourage to rely on natural supports- friends, family faith groups
- Support groups: Anxiety UK, Mind, No Panic
- Befriending or rehabilitation programme
- Educational and employment support services
STEP 3: Review and Offer Alternative Treatment if Needed
Exposure Response Prevention (ERP):
- Background -> without actual harm, the body can only remain extremely anxious for <45m, after which habituation occurs, anxiety levels drop, and eventual fear dies out (extinction)
- Therapy -> ‘desensitisation approach’ = gradual/graded approach:
· (1) Pt. identifies goal (i.e. holding a slug) and constructs hierarchy of feared situations
· (2) Pt. tackles hierarchy from least to most frightening
· (3) Aim to stay in situation until anxiety subsided -> challenges existing thoughts
o CBT – reduce patient’s expectation of threat, and the behaviours that maintain threat-related beliefs:
- Explore the actual likelihood and impact of the anticipated catastrophe
- Test the feared situation and their belief in a catastrophic outcome using behavioural experiments
- Improve self-confidence of patient
Biological Treatment
Antidepressants
- 1st LINE: SSRI(citalopram or sertraline)
- 2nd Line: TCAs
STEP 4: Review and Offer Referral to Specialist Mental Health Services
If there have been TWO interventions provided and the person still has significant symptoms, then offer referral to specialist mental health services
STEP 5: Specialist Mental Health Services
Reassess individual and revaluate (especially the role of agoraphobia and avoidant symptoms)
Treatment of comorbidities
- Psychological Therapy: CBT, Home-based CBT can be offered if difficult to attend clinic
- Biological Treatment: Full exploration of pharmacotherapy
- Social Interventions: As above + day support to relive carers and family members
- Referral for advice, assessment or management to tertiary centres
- Triamphoverphobias website
NOTE: b-blockers are sometimes used to treat adrenergic symptoms that social phobia patients find disturbing e.g. tremor or palpitations
Complications/ Prognosis
Complications
- May become housebound, dependent on small circle of family or friends
- Depression is common
Prognosis
- 1/3 completely recover
- 1/3 improve partially
- 1/3 fare poorly, suffering considerable disability and poor QoL
