AGORAPHOBIA AND PANIC

Agoraphobia is a condition very closely related to panic. Agoraphobia is the fear of wide-open spaces and also usually involves the fear of being in locations such as shopping centers, stadiums, or arenas, where you might feel that there is no escape. Many patients with agoraphobia tend to stay in their homes for long periods, often finding someone to bring them food and do their shopping. If they do go out, patients with agoraphobia tend to do much better if they go to a familiar place, go to a location at times when it is not excessively busy, or take a trusted companion with them when they leave the house.

In panic disorder with agoraphobia, the patient has unexplained panic attacks. It is important to remember that nothing has to happen to cause a panic episode. It can come "out of the blue" for no apparent reason. Usually the panic episode, whether associated with agoraphobia or not, involves many physical findings. These include tightness and pain in the chest; rapid, shallow breathing; shortness of breath; and a pounding, rapidly beating heart. Many patients have described the feeling that "their heart will come out of their chest" because it is beating so hard and fast. In addition, patients usually have diffuse sweating and a feeling that something bad, which cannot be prevented, is about to happen. When they experience these episodes, many patients feel they are dying and often go to the emergency room, believing they are having a heart attack.

Panic disorder with agoraphobia is more common in women, and usually begins in the late teenage years or in early adulthood. Although subsequent episodes do not involve a stimulus, the initial episode often occurs within 3 to 6 months after a significant life event, such as a death, a move, an engagement, a marriage, or a change in job status. Agoraphobia is actually a form of fear related to panic disorder, and it can lead the patient to become house bound and debilitated. The presence of agoraphobia makes panic disorder even more serious; patients will often avoid situations that they feel might cause increased anxiety, or areas where they might feel trapped and unable to escape. Typical agoraphobic situations include being alone, traveling far from home, using public transportation, going over bridges or through tunnels, or being in crowded places or restaurants, department stores, malls, theaters, churches, or other public places, especially if the individual perceives that escape may be difficult. Ultimately, patients with agoraphobia are often socially isolated, have difficulty initiating new relationships, and have a significant problem with self-esteem and self-confidence.

The treatment of panic disorder with agoraphobia initially involves education. There are many different types of treatment, but the immediate goal is to decrease the subjective feelings of panic and to improve the patient's quality of life. For treatment to be successful, it is very important that patients have a trusting relationship with their doctor.

Medications are very effective in the treatment of panic disorder with agoraphobia. Although many medications can be used for this condition, it seems that the benzodiazepines, especially alprazolam (Xanax) and lorazepam (Ativan), are very effective. Other drugs that have been used effectively include serotonin drugs, such as paroxetine (Paxil), fluoxetine (Prozac), and sertraline (Zoloft). The use of benzodiazepines, the so-called minor tranquilizers, may not be possible if the patient has significant liver or lung disease, or if there is a history of alcohol abuse or abuse of similar medications. Imipramine, a tricyclic antidepressant, has also been used to treat panic. Medications commonly prescribed for panic disorder have some side effects, including jitteriness; fast heartbeat; insomnia; some gastrointestinal distress, (especially nausea, vomiting, and diarrhea) and a decrease in sexual interest and function. You should also be aware that most of these medications, especially the antidepressants, do not produce immediate resolution of the panic disorder; it usually takes about 2 to 3 weeks before improvement is seen. You may get more immediate benefit from a drug such as alprazolam (Xanax); however, its major disadvantage is the potential for physical addiction, as well as the occurrence of withdrawal symptoms when it is discontinued after long periods of use. Occasionally your doctor may combine an antidepressant and an antianxiety drug to treat your panic disorder. Another drug called BuSpar has been used in some cases to treat panic, but it is probably less effective than the benzodiazepines, the tricyclic antidepressants, or the other antidepressants. The advantage of BuSpar is that it is not physically addicting. In addition to treatment with medication, psychosocial treatment is very effective and is often used in conjunction with medication. Psychosocial treatment involves gradually exposing the patient to the feared situation; teaching relaxation training, deep breathing exercises, and meditation; and helping the patient to overcome thought processes that might be contributing to the panic and agoraphobia. Of course, psychosocial treatment by itself has no side effects. Psychosocial treatment usually involves about 12 sessions and has been found to provide full panic relief in the majority of the patients.

• Avoid medications that might produce or increase anxiety, including those that contain large amounts of caffeine or sugar. Drugs such as cocaine, phencyclidine (PCP), and amphetamines should also be avoided. Limit your intake of coffee or tea, especially during the evening hours. Exercise might be of some benefit in panic because it provides an outlet for the overwhelming anxiety some patients have.

• You should not take any medications that are not prescribed by your doctor. You should not use prescribed addictive medications more frequently or in higher dosages than your doctor recommends.

• You should call your physician if the medication he has prescribed is not working; if you experience overwhelming episodes of pain, anxiety, or an increase in agoraphobia; or if you are thinking about suicide. It is important to remember that although panic is a very disabling condition, especially if associated with agoraphobia, and can lead to a patient becoming a virtual recluse in his own home, this condition is treatable.

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