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Agoraphobia With Panic Disorder in a Psychiatric
Setting: A Case Report
Emmanuel Omamurhomu Olose
University of Calabar
Cecilia Oluwafunmilayo Busari
Leeds Beckett University
Godwin Akepu Anake
University of Calabar
Andrew Orovwigho
Federal Neuropsychiatric Hospital
Israel Obedjemurho Ugoma
University of Delta
Case Report
Keywords: Agoraphobia, Panic attacks, Cognitive behavioral therapy
Posted Date: April 12th, 2024
DOI: https://doi.org/10.21203/rs.3.rs-4237375/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License.
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Additional Declarations: No competing interests reported.
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Abstract
Background:
Agoraphobia diagnosis has largely remained unchanged, with its criteria based on persistent fear and
avoidance of certain clusters of situations. The controversial diagnosis of Agoraphobia with or without a
history of panic disorder has also been retained in classication systems; with the understanding that
patients either generally have never fully met or meet the diagnostic criteria for panic attacks.
Case report:
A 49-year-old female presented to an outpatient Psychiatric clinic with a 12-year history of fear of
enclosed spaces which was precipitated by an unstable relationship with a male partner who frequently
assaulted, abused, and neglected her because she refused to terminate an unplanned pregnancy, she had
for him. According to ICD-11, she was diagnosed with Agoraphobia with panic attacks, she was treated
with Tab. Fluoxetine 20mg and Cognitive Behavioural Therapy and in the past two years she improved
signicantly with appropriate consistency in her follow-up visits.
Conclusion:
This case report shines a beam of light on the very few reported cases of agoraphobia and its
incapacitating course on those who suffer from it. In Nigeria, there is scanty literature on agoraphobia, for
multiple reasons such as stigma, the embarrassing nature of the illness, and no disclosure of illness.
1. Introduction
Agoraphobia is the fear of or anxiety regarding places from which escape might be dicult, rigidly
avoiding situations in which it would be challenging to obtain help. [1]It is a condition characterized by
marked and excessive fear or anxiety occurring in response to multiple situations where escape might not
be possible or help might not be available in situations such as being outside the home, being in crowds,
or public transportation. [2] The individual will consistently be anxious about these situations due to fear
of specic negative outcomes, either having panic attacks or other embarrassing physical symptoms.
A signicant number of patients develop fear and avoidance of situations associated with previous panic
attacks or fear situations where escape would be dicult or embarrassing, or where help might not be
available.[3] A cluster of situations associated with agoraphobic avoidance from factor analytical studies
includes typically – Public transportation (e.g. buses, trains, planes); riding in or driving a car, especially
on heavily travelled roads, crowds (e.g. cinemas, a football match, large shopping centers), shopping
(especially in supermarkets), particularly where one must stand in queues, bridges, tunnels, elevators, and
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other enclosed spaces.[3] These symptoms persist for several months and signicantly cause distress or
impairment in various of the individual’s life.
Often the leading type of phobias accounts for up to 50–80% of the phobic population seeking
professional help and about 2% of the general psychiatric population.[4, 5] It is the most disabling of
phobic disorders because it can signicantly interfere with an individual’s ability to function in work and
social situations outside the home in severely affected patients. They develop a preference to be
accompanied by a friend or a family member when leaving home, especially if their destination is
crowded or closed-in.
Heritability for agoraphobia is about 60% and has the strongest and most specic association with
genetic factors representing it proneness to phobia.[6]Early onset Agoraphobia may constitute a familiar
subtype and necessarily does not indicate increased clinical severity or disability, as opposed to other
psychiatric disorders.[5]
In Sub-African and Nigeria studies; there is a reported wide variation in the rates of mental disorders,
[7]with substantially observed lower Anxiety disorder rates owed to demographic factors, with specic
phobia the most common disorder.[7]
Often agoraphobia coexists with panic disorder, in that patients are afraid to leave the safety of home lest
they experience a panic attack in a public place.
This article discusses a unique and severe case of agoraphobia after well-informed consent was
obtained from the patient to proceed with this publication.
2. Case Presentation
Mrs. E. is a 49-year-old married female and Civil servant who presented in the outpatient psychiatric clinic
of the University of Calabar Teaching Hospital accompanied by her daughter with chief complaints of
Fear of enclosed spaces of 12 years duration. About 12 years before the onset of symptoms and
presentation she reported to be involved in an unstable relationship with her male partner where she
became pregnant which was not planned and undesired.
However, she insisted on keeping the pregnancy to the displeasure of the partner, though not married, but
co-habiting with him for the past seven (7) years, he constantly pressured her to have an induced abortion
done, which she refused. Consequently, on several occasions, she had been neglected, assaulted, and
abused (physically, verbally, and emotionally) by her partner for refusing to terminate the pregnancy.
During and following this incident, she subsequently developed an intense fear of enclosed spaces,
especially places where she had no possession of the Keys. Other occasions and examples include
occasions when she visits the bank, where she will persistently insist the bank securities does not allow
the electronic door to the banking hall to be closed in order for her to be comfortable and relaxed,
otherwise, she will become restless, agitated and will occasionally scream.
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She also couldn’t travel in a plane, as she would start panicking as well as becoming breathless.
She only feels comfortable when she owns the keys to any enclosed space, she nds herself in.
Other reported diculties encountered include poor interaction with other people; very rare visits to places
of family relatives and friends, especially outside the connes of her home.
She reported no history of persistent feelings of sadness, low energy, suicidal Ideations or self-harm to
suggest a depressive condition. No history of elated or irritable mood, increased energy, or inated self-
worth. There is no history of any hallucinatory experiences or experience of control by an external
agent/force.
There was no reported history of care (medical, traditional, etc.) received by the patient since the onset of
her illness
She has no previous history of mental illness nor family history suggestive of symptoms of mental
illness. There is a medical history of Hypertension diagnosed about 2 years prior to presentation and
currently on prescribed oral antihypertensive with good drug adherence. No signicant surgical history,
nor known allergies. There is also no history of use of alcohol or any form of psychoactive substances
before the onset of symptoms.
Her childhood history revealed no childhood emotional problems or abuse; Her sexual orientation is
heterosexual, and her past relationship history is not contributory.
Currently, she is married and maintains a cordial relationship with her partner, however distant as her
partner is based in another city, and not close to the patient. They have two children together, a 12-year-
old female and a 6-year-old male both living with the patient.
Pre-morbidly she describes herself as cheerful, her predominant mood is happy, enjoys singing as an
interest of leisure.
Her Mental state Examination ndings at presentation revealed a well-groomed and kempt woman;
Psychomotor agitation and restlessness; no abnormality in her Speech; mood was anxious; Affect
congruous with the mood and reactive; Attention and concentration (tested with serial 7’s) was arousable
and sustained; and had full insight to her condition.
A diagnosis of Agoraphobia (with comorbid panic disorder) using the ICD-11 diagnostic criteria was
made. She was psycho-educated on the nature of the illness, treatment modalities available to ameliorate
the symptoms, and self-help strategies that could be employed to relieve symptoms and distress,
She was started on Fluoxetine 20mg daily (mane), in addition, offered behavioral therapies such as
Relaxation therapy/technique; Music therapy, and Cognitive therapy for a weekly session for the next few
four (4) months. CBT was helpful and effective as it helped the patient become less afraid with fewer
attacks.
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Followed up for a duration of six months, she showed marked improvement within one (1) month of
commencement of treatment with reported signicant improvement in her mood, behavior, and somatic
symptoms with a reduction of anxiety to feared situations. She has sustained her follow-up visit
afterward and has returned to her premorbid state of functioning.
She has returned to her premorbid state of functioning with improvement in her social interactions and
occupational functioning two years later.
3. Discussion and Conclusion
Agoraphobia is considered the most disabling of phobias because it can signicantly interfere with an
individual’s ability to function in work and social situations outside the home.[1] It is a condition
characterized by fear of or anxiety about places where escape might be dicult and will rigidly avoid
situations where it will be challenging to obtain help. Several situations might cause such anxiety to
occur, usually involving crowds; open spaces such as markets and shopping centers, and parks; also
conned spaces as oces, stores, public transportation, and so on.
Often, they usually opt for company by a friend, colleague, or family member when leaving home,
especially when their destination is closed-in or crowded. In severe conditions, affected patients will
refuse to leave the house. A study by Habibeh and colleagues[8]found leaving home alone, being in a
crowd, standing in line, and using public transportation as the most common agoraphobic situations.
Literature has extensively demonstrated the nature and relationship between Agoraphobia and panic
attacks[4, 8–10] Agoraphobia may be accompanied by panic attacks, either in response to environmental
stimuli or arising spontaneously.
Diagnostic classication systems, the International Classication Of Diseases 10th edition (ICD-10), the
Diagnostic and Statistical Manual Of Mental Disorders 5th edition (DSM-5), and more recently the ICD-11
have put through changes and modications to the case denition of agoraphobia and its relationship to
panic disorder[2, 6, 11]. ICD-10 considers agoraphobia as a primary disorder with panic attacks being
secondary, which indicates agoraphobia severity. In DSM-5, agoraphobia is separated from panic disorder
and distinguished from specic phobia, where the feared situations are avoided because the individual
believes escape might be dicult or help might not be available in the event of any distressing symptoms
(such as incontinence) not just only panic; however, with panic attacks as severity specier.[12]
This case report nding depicts an agoraphobic lady with a disabling severity of irrational fear of leaving
the connes of her home, avoiding crowds and public places or travelling away from home, and also
developing a panic attack when in such situations, the common presenting feature in this case. It is also
common for agoraphobics to become housebound, sometimes termed “housebound housewife
syndrome”, however, not all patients are necessarily housewives. With a combination of psychotherapy
and drug treatment, symptoms resolved signicantly with a return to functioning. Two years gone, she
has maintained active social participation and kept us the managing team updated on her progress.
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Overall, this case report shines a beam of light on the very few reported cases of agoraphobia, its
incapacitating course on those suffered by it, and the successes that could be accomplished from a
patient-centered prescribed treatment and management schedule with regular follow-up visits.
Declarations
Consent:An informed consent was obtained from the patient for publication of this case report. A copy of
the written consent is available for review by the Editor-in-Chief of this journal.
Acknowledgments:Not applicable.
Authors’ contributions: E.O. and G.A. conceived the study and participated in its design. E.O. and A.O.
participated in the coordination and drafting of the manuscript. E.O. and C.B contributed to drafting the
manuscript. E.O. and C.B. contributed to revising the manuscript critically. All authors read and approved
the nal manuscript.
Funding: Not applicable.
Availability of data and materials: Not applicable.
Ethics approval and consent to participate: Not applicable.
Consent for publication: AnInformed consent was obtained from the patient for the publication of this
case report.
Competing interests: The authors declare that they have no competing interests.
References
1. Robert Boland & Marcia Verduin. Kaplan & Sardock’s synopsis of Psychiatry. 12th ed. Robert Joseph
Boland & Marcia Verduin, editor. Wolters Kluwer;; 2022.
2. World Health Organization. International Classication of Diseases - Chap. 06 Mental, behavioural or
neurodevelopmental disorders. In: ICD-11. 2018, 32.
3. Burns LE, Thorpe G. The epidemiology of fears and phobias with particular reference to the national
survey of agoraphobics. he Jounal Int Med Res. 1997;5:1–7.
4. Foa EB, Steketee G, Young MC. Agoraphobia: phenomenological aspects, associated characteristics,
and theoretical considerations. Clin Psychol Rev. 1984;4(4):431–57.
5. Tibi L, Van Oppen P, Aderka IM, Van Balkom AJLM, Batelaan NM, Spinhoven P et al. An admixture
analysis of age of onset in agoraphobia. J Affect Disord [Internet]. 2015;180:112–5.
http://dx.doi.org/10.1016/j.jad.2015.03.064, Accessed 15th March 2024.
. American Psychiatric Association. Diagnostic and statistical manual of mental disorders - DSM-5.
5th ed. American Psychiatric Association; 2013.
Page 7/7
7. Gureje O, Lasebikan VO, Kola L, Makanjuola VA. Lifetime and 12-month prevalence of mental
disorders in the Nigerian Survey of Mental Health and Well-Being. Br J Psychiatry.
2006;188(MAY):465–71.
. Barzegar H, Farahbakhsh M, Azizi H, Aliashra S, Dadashzadeh H, Fakhari A. A descriptive study of
agoraphobic situations and correlates on panic disorder. Middle East Curr Psychiatry. 2021;28(1).
9. Horwath E, Lish JD, Johnson J, Hornig CD, Weissman MM. Agoraphobia without panic: Clinical
reappraisal of an epidemiologic nding. Am J Psychiatry. 1993;150(10):1496–501.
10. Yasgur BS. Agoraphobia: An Evolving Understanding of Denitions and Treatment.Psychiatry
Advisor, 2020. 1–14.
11. World Health Organisation. The ICD-10 Classication of Mental and Behavioural Disorders.
1992;55(1993):135–139.
12. Asmundson GJ, Taylor SSJ. Panic disorder and agoraphobia: an overview and commentary on DSM-
5 changes. Depress Anxiety. 2014;31(6):480–6.