Panic Disorder with Agoraphobia

Panic disorder and agoraphobia are two separate anxiety disorders, but they usually occur together. This article reviews the facts of these devastating disorders.

Panic disorder is an anxiety disorder characterized by sudden attacks of overwhelming fear and anxiety. These panic attacks go well beyond nervousness; they are often random and unexpected and accompanied by significant physical symptoms. The mental and physical symptoms feel so severe that the individuals often believe they may die.

Agoraphobia is the irrational and excessive fear of situations where escape may not be possible, or where it would be embarrassing to experience panic symptoms. This fear usually develops after a person has experienced one or more panic attacks, which is why they develop a fear of having a panic attack in front of people.

Although they are separate entities, it is natural that panic disorder and agoraphobia usually occur together. Panic attacks are physically, mentally and emotionally disquieting and a visual spectacle for outside observers. For someone who has anxiety, the thought of having a panic attack in a situation where there are people around or escape is not possible or difficult is highly anxiety-provoking, and they will understandably avoid those situations.

Panic Disorder Symptoms

In between panic attacks, people with panic disorder may be symptom-free, although they often experience some degree of anxiety. These individuals are often especially anxious about having panic attacks and will go to great lengths to avoid panic attack triggers.

Symptoms of panic disorder are related to the panic attacks, the symptoms of which are a mixture of mental and physical symptoms:

• Shortness of breath
• Chest pain
• Diaphoresis (profuse sudden sweating)
• Heart palpitations
• Muscle tension and spasms
• Irritability
• Intense fear of the stimulus that caused the panic attack (if any) and of dying from the panic attack

These are the most typical symptoms of a panic attack; virtually any physical symptoms can accompany panic. Some of the more common ones include:

• Neurological Symptoms: Numbness, loss of feeling in the lips or limbs or weakness in the limbs
• Abdominal Symptoms: Stomach pain, nausea or vomiting
• Visual Symptoms: Tunnel vision or scintillating lights

Agoraphobia Symptoms

The symptom that defines agoraphobia is the persistent fear and anxiety of having a panic attack in a situation where the individual cannot escape or get help or where the panic attack would be embarrassing. This fear causes them to persistently avoid such situations.

This pathological fear and avoidance behavior causes disruption of the affected individuals’ ability to function in life to varying degrees, depending on the severity of their symptoms. Some cannot leave their homes. Others are higher functioning but either totally avoid or suffer significant anxiety in specific situations, such as:

• Not being accompanied by a trusted friend or family member
• Crowds and line-ups
• Public transportation
• Shopping malls or large stores

For most people with agoraphobia, situations where they will come to people’s social attention – such as public speaking, their own wedding or their own birthday party – are avoided at all costs.

Diagnosing Panic Disorder with Agoraphobia

People experiencing panic attacks frequently seek emergency medical attention, either to have their panic attack treated or because they are afraid that their physical symptoms might be due to a life-threatening medical problem. The physical symptoms of panic attacks are typical of a heart attack, which makes panic attacks difficult to diagnose and treat. All physical causes must be ruled out prior to diagnosing the panic attack.

After general medical conditions and substance use have been ruled out (a requirement prior to diagnosing virtually any mental health disorder), a diagnosis is made according to the DSM-5 criteria for panic disorder with agoraphobia. The American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5) is the standard diagnostic manual for all mental health disorders.

Since there is no diagnostic test to confirm anxiety disorders, individuals are diagnosed when interviews or questionnaires confirm that they meet the panic disorder with agoraphobia criteria outlined in the DSM-5.

For purposes of health insurance coverage, the diagnosis must also satisfy the ICD-10 panic disorder with agoraphobia criteria. The International Classification of Diseases, Tenth Edition (ICD-10) – soon to be replaced by the ICD-11 – is a clinical cataloging system created by the World Health Organization (WHO) and used by the U.S. health care industry for documentation and billing purposes. The diagnostic criteria for panic disorder with agoraphobia are less restrictive than those included in the DSM-5.

Rates of Co-Occurrence

A large study that pooled data from multiple sources examined the prevalence of panic disorder compared to anxiety disorders in general. The study found that of adults around the world: 

 The lifetime prevalence of an anxiety disorder of any kind is 16.6%

• Prevalence rates of anxiety in North America are the highest in the world
• Women are nearly twice as likely to have an anxiety disorder as men
• Panic disorder has the lowest lifetime prevalence of all anxiety disorders (1.2%)
• Anxiety disorders are highly associated with substance use disorders, with up to 67% of people admitted for addiction treatment having an anxiety disorder

According to data collected by the U.S. National Institute of Mental Health, the prevalence of panic disorder and/or agoraphobia among people (age 18 and up) in the U.S. is as follows:

• Twelve-month prevalence of agoraphobia without panic disorder is 0.8%
• 40.6% of cases of agoraphobia are classified as “severe”
• Twelve-month prevalence of panic disorder is 2.7%
• The average age of onset of panic disorder is 24
• About 1 in 3 people with panic disorder develop agoraphobia

Treating Panic Disorder and Co-Occurring Agoraphobia

Treatment for agoraphobia with panic disorder usually involves medication and psychotherapy. The most effective approach is known to be the bio-psychosocial-behavioral approach, where the whole person is treated. That means that affected individuals should have all social, economic, psychological, physical and biological factors explored and addressed as part of treatment. 

Therapy

Cognitive-behavioral therapy (CBT) for panic disorder with agoraphobia is the main approach to psychotherapy for this disorder, and the most supported by research. This approach allows for the therapist to take a biopsychosocial approach to therapy. Combining CBT with medications has been shown to be more effective than using either CBT or medications alone.

Exposure therapy for panic disorder with agoraphobia is a method of allowing individuals to practice coping skills they have learned in therapy in situations where their anxiety may be triggered. Exposure therapy is dependent on three basic requirements to work properly:

• The exposure must be gradual, starting small and tapering up
• The exposure must become a habit and be used on a repetitive, ongoing basis
• The individual must remain in the exposure situation until their anxiety level drops

Exposure therapy is used for a number of mental health disorders, such as post-traumatic stress disorder and obsessive-compulsive disorder. Most studies looking at the effectiveness of exposure therapy have been focused on these more common mental health disorders. Overall, exposure therapy appears to be effective for treating panic disorder and agoraphobia, especially when combined with CBT.

Medication

Medications for panic disorder with agoraphobia work best when combined with psychotherapy and a holistic bio-psychosocial approach to care. There are four main classes of medications commonly used:

• Selective Serotonin Reuptake Inhibitors (SSRIs): Traditionally used for depression, these medications are also highly effective for treating anxiety disorders. SSRIs are usually the first-line treatment.
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Similar to SSRIs, but slightly different mode of action, SNRIs are less commonly used for anxiety than the SSRIs.
• Beta-Blockers: These medications help prevent some of the excitatory physical symptoms of panic attacks, such as rapid heart rate, high blood pressure, and sweating
• Benzodiazepines: These are used on an “as-needed” basis to stop panic attacks. 

Health care providers must be careful when prescribing anti-anxiety medications. Many people with anxiety disorders resort to substance abuse as they attempt to self-medicate their symptoms. Substance misuse actually counteracts the effects of SSRIs and SNRIs, and alcohol, in particular, nullifies the effectiveness of benzodiazepines. If there is a co-occurring substance use disorder present, it must be identified and treated at the same time as the panic disorder and agoraphobia.

The Recovery Village specializes in diagnosing, assessing and treating all types of substance use and co-occurring mental health disorders. We take a holistic approach to empower each individual to achieve optimal treatment outcomes. Please feel free to contact us for a confidential discussion with one of our representatives.

Editor – Megan Hull

Megan Hull is a content specialist who edits, writes and ideates content to help people find recovery. Read more

Medically Reviewed By – Dr. Andrew Proulx, MD

Andrew Proulx holds a Bachelor of Science in Chemistry, an MD from Queen's University, and has completed post-graduate studies in medicine. He practiced as a primary care physician from 2001 to 2016 in general practice and in the ER. Read more