Copyright Harvard Health Publications
In May 2013, the American Psychiatric Association released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, known as DSM-5. This newest edition considers panic disorder and agoraphobia as two separate mental health conditions. Before, mental health clinicians diagnosed panic disorder as occurring with or without agoraphobia.
There are several good reasons for this change:
- Panic disorder only sometimes leads to agoraphobia.
- Many people with agoraphobia don’t have symptoms of panic disorder.
- The two disorders occur at different rates in the population.
- Each disorder is significant on its own and can be quite disabling.
- Panic disorder and agoraphobia tend to have different treatments.
A person who has symptoms of agoraphobia and panic disorder is diagnosed with both conditions.
Perhaps the best reason for the change is that the new approach is simpler. It should help people get the most effective treatment for their specific condition. Let’s take a look at these two conditions.
Agoraphobia is the fear of open or public places. The word comes from the Greek word agora, which means “marketplace.” People with agoraphobia get severe anxiety or feel helpless when they are in public places. They fear losing control, so they tend to avoid public transportation, crowds or any situation where they have no way to escape.
In the most severe cases, people with agoraphobia become afraid to leave home at all.
We don’t know why agoraphobia develops. Like other forms of anxiety, agoraphobia is partly learned. One theory is that a person develops agoraphobia after experiencing anxiety in a crowded or unfamiliar place. Afterwards, the person starts to fear that similar situations will trigger another bad experience.
Sometimes, a person has a more specific phobia that may be a source of embarrassment and is keeping him or her home. For example, a person may be nervous about social interactions or may have been the victim of a crime. Either could lead a person to avoid situations that can spark emotional difficulty.
Treatment depends on the particular symptoms and their severity, but usually starts with talk therapy. A therapist may help the person recognize distorted feelings about anxiety-provoking situations. A technique called exposure therapy may be helpful.
Relaxation techniques are usually also taught as a way of managing the problem. This approach might begin with visualization exercises, in which the clinician helps the patient to relax and then asks him or her to imagine a fear-provoking situation (such as riding the subway or going to a crowded mall). In some cases a clinician might actually accompany the patient as he or she ventures into those situations. The goal is to desensitize the patient to the situation so that it is no longer so scary.
These techniques can help many people with agoraphobia to learn to manage their fear. But some people will also need medication. They are often treated with the same medications given for panic disorder.
A person with panic disorder has panic attacks. They can come on unexpectedly. Symptoms may include a pounding heart, sweating, trembling or shaking, shortness of breath, feeling like choking, chest pain, stomach distress, dizziness or tingling. The person may feel unreal or depersonalized, may feel as if losing control, going crazy or dying.
A person suffering with panic disorder may live in constant fear of having the next dreaded attack. This anticipation adds to the problem.
Although the person with panic attacks may be able to identify triggers, often there is no known situation or thought associated with the symptoms. That can make it harder to treat with psychotherapy.
In contrast to agoraphobia, a person with panic disorder may start treatment with medication. Many medications that treat depression are effective for treating panic disorder. These include selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac) and sertraline (Zoloft). Also, the older tricyclic antidepressants, such as nortriptyline (Aventyl, Pamelor) and imipramine (Tofranil) are effective, as are some newer antidepressants.
Antianxiety drugs known as benzodiazepines are also helpful. These drugs affect another chemical messenger at work in the brain’s fear response system, gamma aminobutyric acid (GABA). Examples of benzodiazepines are clonazepam (Klonopin) and lorazepam (Ativan). These drugs are often prescribed for a relatively short time because the body can become used to the drug’s effect. That is, benzodiazepines may provide less relief as time goes on. And withdrawal reactions can occur if you stop the drug suddenly.
One common strategy is to prescribe a benzodiazepine and SSRI together. The benzodiazepine is taken short term because it works quickly. As the positive effects of the SSRI kick in, the benzodiazepine can be tapered and stopped.
Agoraphobia and panic disorder often overlap. Medications to treat panic disorder are sometimes given to people with agoraphobia. Similarly, the psychotherapy techniques used for agoraphobia can often be quite helpful to the panic disorder sufferer.
For the average person wondering about these disorders, it’s best not to get too hung up on diagnosis. If you suffer with symptoms that sound like either disorder or if you’re having trouble functioning, consult with your doctor.