Agoraphobia treatment

Anxiety disorders are characterized as chronic in nature with low rates of spontaneous symptom remission and high rates of relapse. Research illustrates that symptoms of anxiety disorders tend to wax and wane, with less than a third of patients remitting spontaneously.7 In a 12-year follow-up study of anxiety disorder patients, recurrence rates were similar between PD with and without agoraphobia (56% and 58%, respectively) despite great differences seen in reported rates of remission (48% and 82% with treatment, respectively).8 Fifty-eight percent of treated GAD patients experienced symptom remission, with 55% experiencing recurrence during the follow-up period. While individuals with SAD had the lowest remission rate with treatment (37%), those who did respond had the lowest rate of recurrence (39%) compared with patients with other anxiety disorders. 

Treatment options include medication, psychotherapy (e.g., CBT preferred), or a combination of both. In some cases, pharmacotherapy will follow psychotherapy treatments when full response is not realized. Patients with panic symptoms without agoraphobia may respond to pharmacotherapy alone. Agoraphobic symptoms generally take longer to respond than panic symptoms. The acute phase of PD treatment lasts about 12 weeks and should result in marked reduction in panic attacks, ideally total elimination, and minimal anticipatory anxiety and phobic avoidance. Treatment should be continued to prevent relapse for an additional 12 to 18 months before attempting discontinuation. 6 49 Patients who relapse following discontinuation of medication should have therapy resumed.49... 

Standardized cognitive behavioral therapy manuals, which ensure adherence to a treatment protocol, have been developed for many different anxiety disorders, including phobias, generalized anxiety, panic, social anxiety, Agoraphobia,... 

Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Panic Disorder and Agoraphobia (2003). Australian and New Zealand clinical practice guidelines for the treatment of panic disorder and agoraphobia. Australian and New Zealand Journal of Psychiatry 2003 37 641-656. 

Panic disorder Treatment of panic disorder, with or without agoraphobia (alprazolam immediate-release, extended-release, and orally disintegrating clonazepam). 

Godemann E, Butter C, Lampe F, et al. Panic disorders and agoraphobia side effects of treatment with an implantable cardioverter/defibrillator. Clin Cardiol. Jun 2004 27(6) 321-326. 

SSRIs have been approved for the treatment of the majority of anxiety disorders, except agoraphobia and specific phobia. The mechanisms of action responsible for SSRIs anxiolytic activity remain to be fully delineated. Understanding of pre- and postsynaptic receptor regulation with chronic treatment and cross-system effects are critical in furthering our imderstanding of these drugs. Increasing specificity may improve clinical efficacy. 

Antidepressant drugs, such as the tricyclic antidepressants and the selective serotonin reuptake inhibitors (SSRIs), are very important for the treatment of psychotic depression (see Chapter 34). They have been shown to be effective when used in the treatment of several anxiety disorders, including general anxiety, obsessive-compulsive disorder, and several phobias, including agoraphobia. Because the SSRIs are less toxic than the tricyclic antidepressants, their use in the treatment of anxiety is safer and less likely to produce serious side effects. 

Panic disorder. Sixty-six panic disorder patients were included in a study. All of whom met the DSM-IV diagnosis of panic disorder (n = 45) or panic disorder with agoraphobia ([PDA] n = 21). Twenty-four patients experienced their first panic attack within 48 hours of cannabis use and then went on to develop panic disorder. All the patients were treated with paroxetine (gradually increased up to 40 mg/day). The two groups responded equally well to paroxetine treatment as measured at the 8 weeks and 12 months follow-up visits. There were no significant effects of age, sex, and duration of illness as covariates with response rates between the two groups. In addition, panic disorder or panic disorder... 

Because many antidepressant compounds are also effective in panic disorder, we performed a trial of inositol in panic (Benjamin et al. 1995). Twenty-one patients with panic disorder with or without agoraphobia completed a double-blind, random assignment crossover treatment trial of inositol 12 g/ day versus placebo, with 4 weeks in each treatment phase. Frequency of panic attacks and severity of panic disorder and of agoraphobia declined significantly more on inositol than on placebo the effect was comparable to that of imipramine in previous studies. Side effects were minimal. 

Bakish D, Hooper CL, Filteau MJ, et al A double-blind placebo-controlled trial comparing fluvoxamine and imipramine in the treatment of panic disorder with or without agoraphobia. Psychopharmacol Bull 32 135-141, 1996 Bakish D, Hooper CL, Thorton MD, et al Fast onset an open study of the treatment of major depressive disorder with nefazodone and pindolol combination therapy. Int Clin Psychopharmacol 12 91-97, 1997 Baldwin DS Depression and sexual function. J Psychopharmacol 10 (suppl l) 30-34, 1996... 

Ballenger JC, Post RM Therapeutic effects of carbamazepine in affective illness preliminary report. Communications in Psychopharmacology 2 159-175, 1978 Ballenger JC, Burrows GD, Dupont R, et al Alprazolam in panic disorder and agoraphobia results from a multicenter trial, I efficacy in short term treatment. Arch Gen Psychiatry 45 413-422, 1988... 

Maddock RJ, Carter CS, Blacker KH, et al Relationship of past depressive episodes to symptom severity and treatment response in panic disorder with agoraphobia. J Clin Psychiatry 54 88-95, 1993... 

In some cases, anxiolytics serve a transitional purpose. For example, for a patient with acute-onset panic disorder, severe anticipatory anxiety, and a family history of depression, administration of an antidepressant medication that also has antipanic effects may be the optimal treatment, but this will not help the patient for several weeks, during which time there is a risk of progression to agoraphobia. For this patient, starting antidepressant therapy and also attempting to obtain acute symptom relief with a benzodiazepine may be helpful. After 4 weeks, the benzodiazepine dose should be slowly tapered so that the patient s condition is controlled with the antidepressant alone. 

It is used in the management of generalised anxiety disorder or the short term relief of symptoms of anxiety. It is also indicated for the treatment of panic disorders with or without agoraphobia. 

It is also indicated for the treatment of panic disorder with or without agoraphobia. 

Lesser IM, Rubin RT, Pecknold JC, et al. Secondary depression in panic disorder and agoraphobia. I. Frequency, severity, and response to treatment. Arch Gen Psychiatry 1988 45 437-443. 

Pollack MH, Tesar GE, Rosenbaum JF, et al. Clonazepam in the treatment of panic disorder and agoraphobia a one-year follow-up. J Clin Psychopharmacol 1986 47 475-476. 

Marks I, O Sullivan G. Dmgs and psychological treatments for agoraphobia/panic and obsessive-compulsive disorders a review. Br J Psychiatry 1988 153 650-658. 

Imipramine has been the most widely studied TCA for the treatment of PD and agoraphobia, with excellent data to show that it is an effective antipanic agent ( 89, 90). Other TCAs reported to have therapeutic efficacy in PD include the following ... 

Paroxetine was the first SSRI approved for the treatment of PD with or without agoraphobia. Oral doses of 10 to 60 mg per day significantly reduce the frequency of panic attacks, and long-term therapy has been shown to be efficacious for the symptoms of PD ( IIQ). Long-term paroxetine therapy has also been shown not only to maintain efficacy but also to produce continued improvement. This is an important asset for antipanic pharmacotherapy in a chronic illness subject to relapse ( 111). 

Sheehan DV, Claycomb JB, Surnam OS. Monoamine oxidase inhibitors and alprazolam in the treatment of panic disorder and agoraphobia. Psychiatr Clin North Am 1985 8 49-62. 

Sheehan DV, Coleman JH, Greenblatt DJ, et al. Some biochemical correlates of panic attacks with agoraphobia and their response to a new treatment. J Clin Psychopharmacol 1984 4 66-75. 

Riziey R, Kahn RJ, McNair DM, et al. A comparison of alprazolam and imipramine in the treatment of agoraphobia and panic disorder. Psychopharmacol Bull 1986 22 167-172. 

Rosenbaum JF, Moroz G, Bowden CL. Clonazepam in the treatment of panic disorder with or without agoraphobia a dose-response study of efficacy, safety, and discontinuance. Clonazepam Panic Disorder Dose-Response Study Group. J Clin Psychopharmacol 1997 17 390-400. 

Mavissakalian M, Michelson L. Two-year follow-up of exposure and imipramine treatment of agoraphobia. Am J Psychiatry 1986 143 1106-1112. 

Mavissakalian M, Perel JM. Protective effects of imipramine maintenance treatment in panic disorder with agoraphobia. Am J Psychiatry 1992 149 1053-1057. 

Mavissakalian M, Perel J, Bowler K, et al. Trazodone in the treatment of panic disorder and agoraphobia with panic attacks. Am J Psychiatry 1987 144 785-787. 

Mavissakalian M, Michelson L, Dealy RS. Pharmacological treatment of agoraphobia imipramine versus imipramine with programmed practice. BrJ Psychiatry 1983 143 348-355. 

Telch MJ, Agras WS, Taylor CB, et al. Combined pharmacological and behavioral treatment of agoraphobia. Behav Res Ther 1985 23 325-335. 

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