Agoraphobia Disorder Essay Example

Agoraphobia is a disease that is closely connected with the Panic Disorder. People with such disease are afraid to go into places or events where they have experienced panic or stress attack and anticipate it to happen again. Usually, a person who suffers from agoraphobia avoids visiting public places because he/she feels a need to escape or expects to be physically offended. Shopping centers, public transport and sports areas are the taboo places, which sick people refuse to visit. This paper discusses the clinical evolutionary learning of agoraphobia, its relation to PD and PA and causes of AG development.

This paper explores six historical and social background publications that report on results from explorations conducted on different indications and classifications of agoraphobia disorder. However, the paper varies in DSM characteristics and AG relation to PA and PD neurosis. Wittchen et al. (2010) mentioned that only 23,5% of people suffering from PA developed agoraphobia and 50% developed PD. Despite various attempts to specify the features of agoraphobia, the assumptions still exclude each other. This paper discusses the clinical evolutional learning of agoraphobia, its relation to PD and PA and the contextual influences on AG development.

Agoraphobia in Revision of the DSM and ICD

The mid-80s were distinct by performed striking differences, such as self-rating tools, unstructured system and diagnostic without symptomatic focus. Panic attacks were directly associated with various disorders (substance and mood disorders, anxiety are actually not key identifications of agoraphobia or panic disorder). In addition, here is no large risk for PD or PA to be a result of agoraphobia disorder. According to DSM-IV-TR, only 2,4% of sick people developed PD and 11,6% developed PA. (Wittchen et al., 2010, p. 118).

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A number of issues caused medical interest towards fears and phobias, including agoraphobia. First, it is connected with the high percentage of agoraphobia disorder among others forms of phobias. Second, the structural composition of the phobias is not constant. It is noticeable along with the affective, sensory, vegetative and dietary components. Third, agoraphobia is a disease that hardly passes without any treatment. The disease is more inclined to progression and needs a long-term treatment.

The first time agoraphobia was mentioned in 1871 (Westphal’s classical description) as a paradigm for nervous disorders. Until the introduction of DSM-III-R, AG was identified in the medical literature as a regular phobia or neurosis. In 1970s agoraphobia was codified as a distinctive syndrome of multiple fears (ICD-9) and it retains the same codification today (ICD-10). In the USA, the agoraphobia within DSM system was considered a result of subdividing phobic nervous and anxiety disorder (DSM-III). The DSM-III has such symptoms as fear of being alone, avoidance of public places or panic attack when being there (especially under assumption of unavailable help in case of sudden incapacitations). In fact, the DSM definition is not very different from other learned disorders and the ICD explanation of agoraphobia, which is one of the disadvantages of the system.

In 1980, agoraphobia was rather considered a form of panic attack (PA) than a special form of phobia. It was explained by temporary panic attacks on the initial phase of agoraphobia development and diagnostics omissions. The person developed an increased anticipatory fear of having panic attack and, therefore, in different ways tried to escape or avoid the indicators that cause them. The diagnosis of AG without panic attacks was made when the history of panic attacks was lost.

Beginning from DSM-III-R, AG was described as a typical response to cases when PA had occurred. In addition, the AG in DSM-III-R was seen exclusively as a secondary complication and it was attached to panic attacks and panic disorders as an opposition to popular clinical and experimental achievements. According to Wittchen et al., “with consecutive DSM revision, the residual status of AG within the construct of PA and PD has been increasingly more pronounced” (2010, p. 115). DSM-IV-TR recognizes agoraphobia as impossible to code disorder. Alternatively, the panic disorder with agoraphobia or agoraphobia without the history of PD was provided within code disorders of agoraphobia similarity. The DSM-IV-TR is represented by complex differential diagnostic description with important considerations. It restricts the disease to people, who have AG related to fear of PD symptoms (e.g. diarrhea or dizziness). Thus, the specific diagnosis prescription was based on the definition of two syndromes, including panic attacks (a complex of mental disorders) and agoraphobia (as a part of panic disorder or AG without the history of PD).

Additionally, the discrepancy between DSM and ICD increased. The ICD-9 and ICD-10 retained agoraphobia as a separate disorder, not a form of PA or PD. The DSM-IV-TR defines agoraphobia in a different way than it was done before. In classical variations, the diagnosis was tied to PA or PD concepts. The DSM-IV-TR defined panic attack as a symptom. According to Barlow, “this conceptual development was based mainly on the observation in some studies, which use DSM-III-R criteria, AG patients without PA or extremely panic-rare features” (Barlow, 2002, p. 30). Thus, the assessment instruments and diagnostic criteria suspect the opinion that agoraphobia cannot be diagnosed without the context of panic-like symptoms or primary panic attacks. The implicit hierarchical DSM-IV made impossible to create systematic scheme as a productive solution, since the different diagnostic interviews and two discrepant medical criteria regress the treatment.
It is important to mention that both panic attacks and PD are comorbid with agoraphobia. Some AG patients may develop their disease under the influence of panic-like symptoms and PA. On the other hand, the agoraphobia is an independent disease, the PA and PD are causally linked to agoraphobia and the clinical utility diagnoses AG as a separate disease. In addition, the researches on how to specify the explicit criteria to agoraphobia continue.

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One of the treatment disadvantages is that there is an undefined solution of how to diagnose patients whose DSM-IV-TR required symptoms of PD or PA were not noticed. There is a discussion whether in such cases it is better to diagnose NOS (anxiety disorder) or a DSM phobia. The general definition of the agoraphobia needs more specific characterization “and cues beyond the occurrence or fear of panic-like symptoms” like phobias (Wittchen et al., 2010, p. 115).

A mistaken omission makes it impossible to specify mandatory criteria. For instance, when a person recognizes that his fear is unreasonable, excessive and notices the exposure cases and impairment symptoms. A characteristic cluster must be defined when the agoraphobia syndrome covers two to four prototypical situations (as stipulated in the ICD-10 demand). DSM-IV-TR has no such characteristic that is why the DSM studies define the diagnosis without constant compulsory symptoms (Social or Specific Phobia).
Overall, the DSM-III modified the diagnostic qualification of the agoraphobia. It was critically reexamined as overinclusive, since it did not restrict agoraphobia to obvious avoidance behavior. In DSM-III-R, agoraphobia was diagnosed, when a person experienced anxiety about having panic attacks, and avoided to be alone or in distress. Nevertheless, this idea can be neglected, because a person can travel alone despite the need of having somebody near. In addition, the classification of AG levels was omitted, including none, mild, moderate, severe.
DSM-IV “is no longer the case with situational avoidance of equal footing with distress and use of companions” in establishment of the dichotomous diagnosis of agoraphobia (whether it is present or absent) (APA, 2000, p. 18). Schmidt and Cromer (2008, p. 161) criticized it, because the reduction of the agoraphobia specification from 4-point scale to present/absent dichotomous means that the last one is superior and has better organized assessment of phobias. As a result, the clinical utility and predictive value decreased. Thus, both opinions left the issue unresolved.

One of the advantages is that now there are few options outline the key positions on agoraphobia in DSM-V. First, agoraphobia must be excluded as a classification diagnosis and become an additional part of PD. Second, AG must be recognized as a specific phobia. Then, the existing diagnostic categories must retain panic disorder without agoraphobia, panic disorder with agoraphobia, and agoraphobia without the history of PD. Finally, there must be more explicit diagnostic criterion for agoraphobia as a separate category.

Clinical Evidence

Since 1980s, the global medical explorations concentrated on the modified examination of panic disorder, panic attack and agoraphobia across the world. The criteria were chosen by the models of DSM-III, III-R and DSM-IV. The result demonstrated a spontaneous tendency that rates of agoraphobia without PD are higher than the ones with panic disorder. This factor includes both children and adults. In addition, it was found out that more than a half of the people who suffer from agoraphobia have no panic attacks. The studies had various amount of criteria, which caused assessment and methodological variations, but did not provide a definition of the true differences (like space and cultural influences). Thus, the studies of 1980’s (Diagnostic Interview Schedule – DIS, when even one AG case defined the diagnosis, were changed by the CIDI (Composite International Diagnostic Interview) were influential on the understanding of the agoraphobia. CIDI requires more than the case for DSM-IV-R criteria, which caused the AG decrease by half and revealed less cases of panic disorder with agoraphobia.
The USA studies demonstrate moderation of clinical settings, which has positive progressive impact on further treatment. The clinical practice rarely meets the cases of agoraphobia without the history of PD. C. Faravelli defined eight clinical studies, “seven with low sample sizes, citing four studies with not a single case of AG without panic and four studies reporting 2-31% of PA among AG patients” (Wittchen et al., 2010, p. 117).

PA, PD and AG Temporal Relationship

Some studies attempted to define whether agoraphobia has constant relation to spontaneous panic attacks or panic-like symptoms. The clinical and epidemiological experiments and observations demonstrated no evidence for this assumption. The major amount of agoraphobics never experienced panic-like symptoms, PD or any other type of neurotic diseases that preceded the onset of AG.
Furthermore, clinical retrospective studies used sensory methods to find prior clinical symptomatology. As a result, before the first panic attack more than a half of patients with agoraphobia had prodromal symptoms such as general anxiety and hypochondriasis. In addition, the research found considerable degree of discrepancy that failed. Nevertheless, it was observed that in up to 50% of all suffering from the AG, PA precedes agoraphobia, “providing some support for the assumed aetiopathogenic pathway implied in DSM-IV-R” (Wittchen et al., 2010, p. 118). In fact, the concept of panic-agoraphobia spectrum was not taken into consideration with further assuming of reciprocal connection (this aspect is not supported by epidemiological evidence). In advance, the prospective clinic investigations rarely can succeed. One of them described systematical symptoms of agoraphobia, panic disorder and panic attacks.

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Critical Methodology

The evidence that panic-like symptoms and panic attacks frequently play an important pathogenic role in agoraphobia progression was not supported by epidemiological studies. The new methodological grounds proved that the diagnostic interviews were not valid. The experts suppose that those diagnostic tools that are based on background observations that agoraphobia without panic attack and panic disorder is rarely a priori in clinical samples are not able to assess panic issues with sufficient accuracy.
Since 1900, a few publications partly neglected CIDI criteria. The main idea of the new algorithmic is requirement of minimum two reported situations before AG diagnosis prescription. A smaller amount of such cases is classified as phobia NOS. As a result of such modification, the general rates of agoraphobia, panic arracks and panic disorders were substantially reduced. Despite such methodological appraisals are considerably sophisticated, some researchers believe that there are omissions in this conception.

Age, Gender and Socio-Demographic Issues

There is no systematized and generalized description of age and gender difference between agoraphobia and panic disorder. There are few differences between such characteristics of PD and PA with and without agoraphobia. Female preponderance within AG without panic attacks was higher than for panic disorder (American Psychiatric Association, n. d.). The retrospective cross-sectional studies made a conclusion that two thirds of all panic disorder cases appear before 35 years old. There is a rare substantial incidence risk in childhood and adolescence. There are differences between PD with agoraphobia and AG without panic attacks, but there is no notable difference between agoraphobia and panic disorder under the age and gender context.
It was noticed, that people who suffer from agoraphobia without panic disorder and PD/AG in most cases have no jobs or they are disable. This conclusion allows assuming that agoraphobia is more widely spread in developed countries with busy and stressful life styles. Thus, a powerful impact of stress a person can experience due to some situations has a very strong influence on nervous system with harsh consequences.

Genetic and Familiar Factors

The anxiety neurosis and panic disorders are different and, thus, the genetic factors cannot be always an indicator of the possible disease within defined family. Nevertheless, the parental history of agoraphobia and panic disorders can take the core role in further development of panic symptoms in the next generations. Moreover, it can cause development of other diseases or disorders that can be harder to treat due to the factors mentioned above.
During the last few decades of medical investigations, it was notified that the higher risk of blood relatives to become AG patients is not confined to agoraphobia. There is a gap in differential algorithm of familial aggregation of agoraphobia and PA/PD. Additionally, the risk for panic disorder might be higher than for agoraphobia. Moreover, agoraphobia and liability of panic attacks cannot be suggested to be on one AG-panic continuum, since agoraphobia is not closely associated with PD aggregation. In more simple way, without any symptoms of PD, agoraphobia cannot be revealed. On the other hand, any parental panic disorder or hard agoraphobia increases the risk to develop anxiety symptoms in offspring.
Wittchen et al. (2010) estimated heritability in 61% for agoraphobia and 43-48% for panic disorder (p. 121). The female disorders are more frequent due to possible physiological and hormonal peculiarity, which causes higher heritability.

AG Treatment

Few studies examined possible opportunities for optimized and effective treatment of all three conditions. The adequate treatment is a financial topic for discussion, because only 42, 1% of agoraphobia diagnosed without PD and 41, 2% of suffering from PD gets enough help. In addition, there are obvious differences between AG without PD patients and PD group, who are not supported by the governmental health care system and psychiatric treatment. Moreover, the panic disorders are more frequent than agoraphobia, which also influences patients to seek for different professionals, since each disease has different complications and characteristics. Furthermore, the situation depends on type and methods of the health care system. For example, the USA and Germany created a structure in a way that the psychotherapists care about AG without PA treatment, whereas PD is a specialization of psychiatrists.

Panic disorder and panic attack rarely exist in pure forms. Both are closely associated with other common or somehow related diseases, such as mood, substance and somatoform disorders. In the context of possible transitions from one disorder to another, it was noticed that PAs are strongly connected with psychopathology, but not necessarily characteristic to PD, agoraphobia or other neurotic disorders. Moreover, some commonwealths were found to use substances for psychotic and anxiety disorders. In opposition, agoraphobia is rather connected with the depression and highest probability of anxiety neurosis.

Thus, with regard to the issues within PD without AG, AG and PD, the epidemiological studies demonstrate the conclusion that agoraphobia (without panic attacks) and panic-like disorders reveal common disability findings. The most impairing and frequent conditions are PD/AG. There is little evidence of specific differences between agoraphobia without PD and PA. The special observations demonstrated that agoraphobia rather belongs to phobias category, and PA and PD are comorbid disorders.

Previously, the treatment was general: there were typical clinical courses of establishments of the space limited type for those who were not able to get better. Sometimes such people were considered as the ones mentally sick who only pretend of being scared. In contrast, the clinical agoraphobia treatment is considered as persistent (SSRI, Benzodiazepines). The clinical agoraphobia treatment is considered as persistent. First, the treatment includes antidepressants (both short and long-term usage). Another important issue is connected with the treatment controversy, because some meta-analysis is biased to CBT alone rather than to pharmacotherapy. The domestic treatment of agoraphobia can be also used to treat PD with AG. In some medical traditions, it was found that pharmacological placebo is significantly more effective than relaxation or alprazolam. The exposure treatment of agoraphobia causes subsequent escape from panic and amelioration. Thus, the pharmacological tools are lacking in panic or AG neurosis treatment. Alternatively, it can be reduced by psychotherapeutic cognitive approaches.
Agoraphobia developed among many famous people. For example, Horace Leonard Gold (a science fiction writer and editor) had a harsh form. After his wartime trauma, his disease did not allow him to leave an apartment for two decades. Only after hard non-traditional treatment he succeeded. Another person Brian Wilson (singer) also had AG and schizophrenia, but his treatment did not give any result. Those examples demonstrate that this disease can attack anybody and there is no guarantee it will be treated.

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Axis Issues

The Axis model includes five parts that in complex provide a comprehensive diagnosis with full description of the symptoms and factors that affect mental condition. The Axis I describes general depressive/nervous disorder (major characteristics and observation). The Axis II is dedicated to identifying the frequency of disorder attacks. The third Axis describes physical problems that may be related to mental disorders and worsen the condition of the patient (panic, trauma or physical violation). The Axis IV is connected with any kind of threats and dangers (for example, a job loss). The Axis V estimates an ability to function in every fay life (occupational, social and psychological accommodation).
Speaking about the multiaxial distinction of Axis I-III, there is no big difference in conceptualization. Physical or biological factors are not related to phobias or neurotic disorders. In addition, medical condition does not directly depend on physical peculiarities. Sometimes they can be controversial, a high-rated diagnosis result of the body functioning does not guarantee impossibility of mental disorder development.

Practically, it can be observed in the information provided by the American Psychiatric Association. This establishment monitors the facts, treatment process and results of the AG diagnosis and treatment programs. An important issue is that the conception represents various groups of people whose disorder progressed (by age, gender, surrounding, occupation). For example, one of the hardest forms of agoraphobia was developed in Rita Clark’s social escape. The treatment included complex Axis diagnostics and after 20 years of panic and fear, a woman returned to normal life (American Psychiatric Association, n. d., n. p.).

Agoraphobia is an independent form of phobia, characterized by frequent panic attacks, when a person appears in an uncomfortable surrounding. The DSM conceptions tried to conduct a constant algorithm of the symptoms and consequences of agoraphobia disorder. The studying process caused various discussions about the psychological relation of AG to PA or PD. Meanwhile, five phases of Axis were formulated, which allowed providing full diagnosis of the patient simultaneously. The treatment analysis demonstrated that the treatment must include both medical and psychological methods.