Panic disorders (PD), in which individuals experience severe, unexpected panic attacks. They may think they’re dying or otherwise losing control. In many cases but not all, PD is accompanied by a closely related disorder called agoraphobia, which is fear and avoidance of situations in which a person feels unsafe or unable to escape to get home or to a hospital in the event of a developing panic symptoms or other physical symptoms, such as loss of bladder control. People develop agoraphobia because they never know when these symptoms might occur. In severe cases, people with agoraphobia are unable to leave the house, sometimes for years on end.
Clinical Description of Panic disorders & Agoraphobia.
In DSM-IV, panic disorder and agoraphobia were integrated into one disorder called panic disorder with agoraphobia, but investigators discovered that many people experienced panic disorder without developing agoraphobia and some people develop agoraphobia in the absence of panic disorder.
To meet criteria for panic disorder, a person must experience an unexpected panic attack and develop substantial anxiety over the possibility of having another attack or about the implications of the attack or its consequences. In other words, the person must think that each attack is a sign of impending death or incapacitation.
Agoraphobia is an appropriate term because the agora, the Greek marketplace, was a busy, bustling area. One of the most stressful places for individuals with agoraphobia today is the shopping mall, the modern-day agora. Most agoraphobic avoidance behavior is simply a complication of severe, unexpected panic attacks.
Agoraphobic avoidance seems to be determined for the most part by the extent to which you think or expect you might have another attack rather than by how many attacks you actually have or how severe they are. Thus, agoraphobic avoidance is simply one way of coping with unexpected panic attacks.
Other methods of coping with panic attacks include using (and eventually abusing) drugs and/or alcohol. Some individuals do not avoid agoraphobic situations but endure them with “intense dread.” For example, people who must go to work each day or, perhaps, travel as part of the job will suffer untold agonies of anxiety and panic simply to achieve their goals.
Diagnostic Criteria for Panic Disorders.
A. Recurrent unexpected panic attacks are present.
B. At least one of the attacks followed by 1 month or more of one or both of the following:
- (a) Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”), or
- (b) A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).
C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).
D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder).
Diagnostic Criteria for Agoraphobia.
A. Marked fear or anxiety about two or more of the following five situations: Public transportation, open spaces, enclosed places, standing in line or being in a crowd, being outside the home alone.
B. The individual fears or avoids these situations due to thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly, fear of incontinence).
C. The agoraphobic situations almost always provoke fear or anxiety.
D. The actively avoided agoraphobic situations, require the presence of a companion, or endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations, and to the sociocultural context.
F. The fear, anxiety or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety or avoidance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
H. If another medical condition is present (e.g., inflammatory bowel disease, Parkinson’s disease) is present, the fear, anxiety or avoidance is clearly excessive.
I. The fear, anxiety or avoidance is not better explained by the symptoms of another mental disorder, e.g., the symptoms not confined to specific phobia, situational type; do not involve only social situations (as in social anxiety disorder). They are not related exclusively to obsessions (as in obsessive-compulsive disorder). It perceived deficits or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (as in separation anxiety disorder).
It is not possible to understand panic disorder without referring to the triad of contributing factors- biological, psychological, and social. Strong evidence indicates that agoraphobia often develops after a person has unexpected panic attacks (or panic-like sensations). But whether agoraphobia develops and how severe it becomes seem to be socially and culturally determined.
Biological, psychological, and social factors may contribute to the development and maintenance of anxiety and to an initial unexpected panic attack. We all inherit some more than others a vulnerability to stress. It is a tendency to be generally neurobiologically overreactive to the events of daily life (generalized biological vulnerability). But some people are also more likely than others to have an emergency alarm reaction (unexpected panic attack) when confronted with stress-producing events. These may include stress on the job or at school, death of a loved one, divorce, and positive events that are nevertheless stressful, such as graduating from school and starting a new career, getting married, or changing jobs. (Remember that other people might be more likely to have headaches or high blood pressure in response to the same kinds of stress.)
One hypothesis that panic disorder and agoraphobia evolve from psychodynamic causes suggested that early object loss and/or separation anxiety might predispose someone to develop the condition as an adult. Separation anxiety is what a child might feel at the threat of separation or on actual separation from an important caregiver, such as the mother or the father.
Patients who have panic disorder or agoraphobia experienced separation anxiety during childhood more often than individuals with other psychological disorders.
David H. Barlow, V. Mark Durand. Abnormal Psychology, An Integrative Approach. (7th ed).