Panic disorder with agoraphobia

• Causes, incidence, and risk factors

  The exact cause of panic disorder is unknown, but it has to do with many different factors. Panic disorder can occur with or without agoraphobia, but agoraphobia develops in more than a third of cases.

  Agoraphobia may be a learned behavior, because it involves a fear of having panic attacks in unprotected settings. Sometimes, panic attacks occur in areas where they have happened in the past.

  Panic disorder can occur in children, but it usually starts around age 25. It can affect middle-aged and older adults as well. Studies have shown that women are 2 to 3 times more likely than men to be affected.

• Symptoms

  Panic attacks involve short periods of intense symptoms, such as those listed below, which peak within 10 minutes after they start:

  • Chest pain or discomfort
  • Choking
  • Dizziness or faintness
  • Fear of being out of control
  • Fear of dying
  • Fear of "going crazy"
  • Hot flushes or chills
  • Nausea or other stomach distress
  • Numbness or tingling
  • Palpitations
  • Shortness of breath
  • Sweating
  • Trembling

  Symptoms of agoraphobia include:

  • Anxiety about being in places where escape might be difficult
  • Avoiding situations with great stress or anxiety about having a panic attack
  • Becoming house-bound for long periods
  • Fear of being alone
  • Fear of losing control in a public place
  • Feeling detached or separated from others
  • Feeling helpless and dependent on others
• Signs and tests

  If your panic disorder has not been diagnosed, you may feel as if you are dying. Often, people will go to an emergency room or other urgent care center because they think they are having a heart attack.

  A physical examination and psychological evaluation can help diagnose this condition.

  The symptoms can be physical and the condition can be misdiagnosed. That's why it is important to rule out any medical disorders, such as problems involving the heart, hormones, breathing, nervous system, and substance abuse. These conditions can occur with panic disorders.

  Which tests are done depend on the symptoms.

• Treatment

  The goal of treatment is to help you function better. The success of treatment usually depends in part how severe the agoraphobia is.

  The standard treatment approach combines cognitive-behavioral therapy (CBT), which helps you understand and change the thoughts that are causing your condition, and an antidepressant medication. Selective serotonin reuptake inhibitors (SSRIs), such as Paxil, are usually the first choice of antidepressant.

  Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine (Effexor), are another choice. Other antidepressants and some antiseizure drugs may be used for severe cases.

  Other anti-anxiety medications may also be prescribed. The health care provider may recommend benzodiazepines when antidepressants don't help.

  Behavioral therapies that may be used together with drug therapy include:

  • Cognitive behavioral therapy
  • Pleasant mental imagery
  • Relaxation techniques

  Other counseling and therapy techniques may help you gain an understanding of the illness and the factors that protect against or trigger it.

  A healthy lifestyle that includes exercise, enough rest, and good nutrition can also help reduce the impact of anxiety.

• Expectations (prognosis)

  Most patients can get better with medications or behavioral therapy. However, without early and effective help, the disorder may become more difficult to treat.

• Complications
  • Panic disorder may occur with other anxiety disorders or depression.
  • You may abuse alcohol or other drugs while trying to self-medicate.
  • You may be unable to function at work or in social situations.
  • You may feel isolated or lonely, depressed, or suicidal.
• Calling your health care provider

  Call for an appointment with your health care provider if you have symptoms of panic attacks.

• Prevention

  If you are likely to get panic attacks, it's important to get help early to prevent agoraphobia, which may affect your ability to work or deal with social situations outside the home.

• References

  Moore DP, Jefferson JW. Handbook of Medical Psychiatry. 2nd ed. St. Louis, Mo: Mosby; 2004:162-163.

  Rakel RE. Textbook of Family Practice. 6th ed. Philadelphia, Pa: WB Saunders; 2005:1440.

  Schneier FR. Clinical practice: social anxiety disorder. NEJM. 2006;355:1029-1036.

  Katon WJ. Panic disorder. NEJM. 2006;354:2360-2367.

  Connolly SD, Bernstein GA; Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:267-283.

Review Date: 2/6/2008

Reviewed By: Christos Ballas, MD, Attending Psychiatrist, Hospital of the University of Pennsylvania, Philadelphia, PA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.