Understanding Agoraphobia
The impact that negative emotions produced on health and life of a person was huge. Anxiety disorders were psychological disorders born of the negative emotions. In this class came the “panic disorders, phobias, posttraumatic stress disorders and obsessive-compulsive disorders” (Gluck et al, p 382).
An alteration of the fear response was the essential entity in phobias and posttraumatic stress disorders. Emotions were presumed to have three responses: physiological, overt and conscious feelings. In essence emotion was a body response to a stimulus or significant event. An interesting point was that responses to triggers have evolved over the years because the human beings were considered “biologically predisposed” to fears (Gluck et al, p 382).
Gluck’s definition of phobia is thus: “A phobia is an excessive and irrational fear of an object, place or situation” (412). The situations were mostly familiar ones and previous experiences modulated their present response; this was termed classical conditioning which was a significant component of fear responses. Some people were afraid of closed spaces and this was claustrophobia.
Others feared open spaces and this was agoraphobia which is my subject of discussion. Emotions were dependent on the different areas of the brain (Gluck, 412). Strong emotion stimulated the amygdala which regulated the storage of the emotional matter in the cortex and the hippocampus.
Amygdala damage caused lesser emotionality and interfered with enhanced memory storage and the learning of conditioned responses. Memory storage in the cortex and hippocampus occurred independent of the amygdala but the association of the emotional component enhanced the memory formation (Gluck, 412). This paper focuses on three studies which have agoraphobia as a basic subject of discussion.
Epidemiology
Agoraphobia was a common mental health problem which disabled the patients. The prevalence of this illness in the US was 11% (Phobia overview, Health communities.com). UK had a prevalence ranging between 1-4% (Lovell, 624). An epidemiological program in Hungary estimated the prevalence of various anxiety and phobic disorders where agoraphobia showed a prevalence of 10.5% while panic disorders were only 3.1%. (Maj and Akiskal, p. 104).
Earlier research
Depressed patients who had comorbidity with panic disorder or agoraphobia had more severe symptoms than when depression occurred alone (Brown et al, 310). Earlier research by Van Valkenberg et al, Grunhaus et al and Brown et al indicated that the comorbidities produced markedly pronounced agitation, with feelings of guilt and inadequacy (Brown et al, 310).
Fawcett et al found that suicide and panic attacks were strongly correlated (Brown et al, 310). Norton et al reported that suicide was a more common association of panic disorder than those without the disorder; however this study had a limitation in that the participants were college students and so generalization in the population requiring therapy was not possible.
Grunhaus also found more association of suicide with patients who had both depression and panic disorder than in patients who were only depressed with no comorbidity (Brown, 311). This study had a limitation in that there was no control for the severity of depression. Panic disorder associated with agoraphobia was closely related to the history of suicidal attempts.
This finding was considered significant in that the history of past attempts was a predictor for future ones as indicated by Oquendo (Brown, 311). Suicide attempts were at more risk in patients who had both anxiety and mood disorders than in those who had only mood disorders in Oquendo’s study. Limitation in this study was that only outpatients were participants and some patients had bipolar disorder (Brown, 311).
Another study had completely different findings: that comorbidity was not the relating factor to suicidal ideation. It found that major depression alone was sufficient for the risk of suicides (Placidi et al in Brown, 311). Placidi also found that anxiety symptoms were protective against suicidal attempts. Psychomotor agitation had been associated with suicides by other researchers; this was directly against the earlier research findings of Placidi.
Literature had also been found on the therapeutic aspects of agoraphobia. Interventions using a self-help manual, computer –assisted therapy and a therapist were compared for the outcomes that occurred.
Differences were not seen in this study of Ghosh and Marks in 1987 at follow-ups or after the therapy (Lovell et al, 624). Other researches in the 1980s showed that tremendous improvement was possible with self-help information even though the therapist contact was reduced drastically (Jannoun et al and Matthews et al in Lovell et al, 624).
Sharp et al in 2000 investigated the benefits of the therapist contact against self –help materials. It was found that therapist contact of 6 hours produced more benefits than with contact of 2 hours or with self-help materials whether the panic disorder was associated with agoraphobia or not (Lovell et al, 624).
Panic disorder when associated with agoraphobia had increased recurrences following remissions according to Keller, 1994; Bruce, 2005 and Francis, 2007 (Marcks et al, 823). Extensive impairment and occupational problems were associations of panic disorder (Siegel et al in Marcks et al, 823). Well-being was affected (Mendlowicz and Stein in Marcks et al, 823). Poor quality of life was also seen (Stein in Marcks et al, 823 ). Prevalence in primary settings was 4-6% (Marcks et al, 823).
Details of studies and Summary of Findings
Brown and her colleagues examined further the relationship of the comorbidity of panic disorder and agoraphobia with suicidality which had been suggested in earlier research (310).
This quantitative study was intended for investigating further the relationship of suicidality with hospitalized depression patients who had comorbidity with panic-agoraphobia. The finding of earlier researches that suicidality was more with the comorbidities rather than the depression occurring alone was confirmed once again here. The sample consisted of 121 patients.
Exclusion criteria included cognitive impairment and bipolar disorder (Brown, 311). Those who had a history of substance abuse were excluded. Persons with borderline personality problems who had suicidal tendencies were also eliminated. The therapy instituted for the randomly selected patients were 3: “drug therapy, drug therapy with cognitive behavior therapy and drug therapy with family therapy” (Brown et al, 311).
The Hospital patients who had the comorbidity of depression and panic-agoraphobia tended to show greater suicidality when compared to patients with only depression. This was inconsistent with Placidi’s study which did not indicate a relationship. MDD (major depressive disease) and (PAS) Panic-agoraphobic syndrome indicated higher previous suicidality.
The MDD did not show this. The MDD+PAS group also showed similar ideation when hospitalized but the MDD group was not so affected. The tendency remained even after controlling for depression, borderline diagnoses and standard of education (Brown et al, 313). The suggestion was that MDD+PAS group had the suicidal ideation not only because of severe depression. Norton and Sareen had similar results with nonhospitalized participants.
Grunhaus had the same results with inpatients and outpatients while Norton had the results with college students. Placidi however had different results and had found no relationship. Brown’s study of 2010 had turned out to be the only one which investigated the combination of “depression, panic/agoraphobia and suicidality in hospital-patients after controlling for the depression” (Brown et al, 313).
Limitations of Brown’ study consisted of the small sample which was made up of mainly females who were seeking therapy. Family members were also included as participants so generalization was not possible. Sub-groups could not be formed as the sample had been small to investigate whether differences existed in them (Brown, 314)
Lovell’s study investigated the effect on patients of a self-help manual which was developed for the study. The rationale for the study depended on the cognitive behavioral therapy, the national policy, the delivery of better service, the use of trained nurses in practice and development of a good treatment manual.
The uncontrolled repeated measures design was used. Inclusion criteria demanded that agoraphobia should have been diagnosed by DSM-IV criteria in the patients at least six months prior to the study, age between 16 and 65 and written consent (Lovell, 625).
Exclusion was based on the patient having brain disease, short-term treatment with antidepressants, psychosis, substance abuse, and severe depression. The eighteen patients in the sample from 3 NHS (UK) centers completed the therapy which was made up of weekly sessions of 30 minutes for 10 continuous weeks. The integrity of therapy was ensured by the participation of a therapist and the use of a self-help manual. Ethical requirements were followed.
The outcome measures used were the Fear Questionnaire, Problem and Target ratings (self and assessor findings), the Beck Depression Inventory, Work and Social Adjustment, General Health Questionnaire, Client Satisfaction and Acceptability of Treatment. They were applied before the treatment, after it and at follow-ups. Lovell’s study revealed the success of treating chronic agoraphobia by utilizing mental health nurses and a self-help manual through the assistance of the therapist (629).
The limitations were the small sample, absence of a control group and the shorter duration of follow-ups (Lovell, 629). A short period of training to convey the message of the self-help manual would be less costly when compared to the long-term training for administration of cognitive behavior therapy.
Marcks’ study was a longitudinal study of the naturalistic type of panic disorder patients who had and did not have agoraphobia (823). It was intended to investigate the features of psychiatric treatment in the two groups. These 235 patients were from clinics in different settings; 150 with agoraphobia and 85 without it.
English-speaking participants more than 18 years old were selected. Patients with active psychiatric illness or were pregnant and without a telephone number or address were excluded. Measures for screening and diagnosis were the Anxiety Screening Questionnaire and the SCID-IV (Marcks, 824). The mental health treatment form was filled by the patients themselves.
It provided the general details of the earlier therapy. Specific details were obtained from the revised version of the Psychosocial Treatment Interview. Only a few patients had not received treatment previously. The group with agoraphobia had the panic disorder earlier than the other group. This group had worse functioning with excessive symptoms. Those with agoraphobia were having therapy already.
Many primary care patients were not taking psychiatric treatment (38%). The patients without the agoraphobia were higher in the nontreatment. Marcks’ study noted the variation between the two groups (827) in the treatment received. Of the patients from the primary care setting, 56% were receiving treatment. Of those with agoraphobia, 67% were having therapy while only 36% of those without agoraphobia had the therapy.
Treatment predictors and the reasons for patients refraining from seeking treatment were also investigated. The significant predictor was the possession of Medicare insurance. The main reason for not taking treatment was the notion that emotional problems did not need therapy (Marcks, 826). Psychotherapy was generally inferred to be less used by those who needed it. Cognitive behavior therapy which was the trend was rarely used. Barriers for therapy were found.
Implications for the future
Brown’s study inferred that clinicians could utilize the findings of this study in their practice (Brown, 314). They would be aware of the greater risk of suicidal ideation in comorbid patterns of illness. The significance of screening for suicidality and panic-agoraphobia in depression was obvious.
The management in hospital could include suicide prevention and after discharge, the panic-agoraphobic symptoms. Coping skills for the depression and panic-agoraphobia could be taught to the patients and this concept needed to be further researched. The factors which increased the suicidal risk must be addressed so that specific treatments could eliminate them (Brown, 314).
Brown’ study also emphasized that earlier suicide attempts were a feature of the comorbid patients. Other earlier studies had shown the relationship of previous suicidal attempts to future possibilities. Future research should also focus on bettering the psychosocial interventions for prevention of suicide.
Lovell’s study inferred that the mental health nurses learned to support patients to manage themselves (629). This study indicated the uses of trained nurses in facilitating cognitive behavioral therapy of the modern times through effective teaching of the self-help manual. Traditional therapy was to be abandoned. Future research was needed to better the manual details for self-help for various conditions of mental disorders. It should also investigate further whether the self-help manual worked for the other psychological disorders.
Marcks’ study identified barriers to therapy which could be addressed in future research. Efforts needed to be taken to improve the therapy acceptance. Interventions had to be made easily accessible for adaptation by the needy population.
Treatment options
Agoraphobia patients needed psychotherapy in the form of cognitive behavior therapy which needed to be easily accessible. The services of the mental health trained nurses and the therapist must be made available in the primary care settings too. Trained mental health nurses could teach the patients how to use a self-help manual which had been found to improve the therapy sessions. The inclusion of therapists helped the nurses to provide the best care possible for the patients.
Personal opinions
The agoraphobic patients are found extensively in the primary care settings. The policy makers need to understand the utmost necessity of providing adequate services at that level too. The availability of mental health nurses and therapists and easily accessible care settings would make a significant impact on the outcomes of psychiatric patients including agoraphobic ones.
References
Brown, L.A., Gaudiano, B. A., and Miller, I.W. The impact of panic agoraphobic comorbidity on suicidality in hospitalized patients with major depression. Depression and Anxiety, 27(2010): 310-315 Wiley Liss Inc,
Gluck, M.A., Mercado, E., Myers, C.E. Learning and Memory: From brain to behavior. Worth Publishers, New York. (2008).
Lovell, K., Cox, D., Garvey, R., Raines, D., Richards, D. and Conroy, P. et al. Agoraphobia: nurse therapist facilitated self-help manual. Journal of Advanced Nursing 43(6) (2003): 623-630
Marcks, A.B., Weisberg, R.B. and Keller, M.B. Psychiatric treatment received by primary care patients with panic disorder with and without agoraphobia. Psychiatric Services, 60: 823-830. (2009)
Maj, M. and Akiskal, H.S. Phobias. John Wiley and Sons (2004).