Agoraphobia

Agoraphobia is a fear of being in places where help might not be available. It usually involves fear of crowds, bridges, or of being outside alone.

Causes
Agoraphobia often accompanies another anxiety disorder, such as panic disorder or a specific phobia. If it occurs with panic disorder, it usually starts in a person's 20s, and women are affected more often than men.

Symptoms

• Anxiety or panic attack (acute severe anxiety)
• Becoming housebound for prolonged periods of time
• Dependence on others
• Fear of being alone
• Fear of being in places where escape might be difficult
• Fear of losing control in a public place
• Feelings of detachment or estrangement from others
• Feelings of helplessness
• Feeling that the body is unreal
• Feeling that the environment is unreal
• Unusual temper or agitation with trembling or twitching
Additional symptoms that may occur:
• Abdominal distress that occurs when upset
• Breathing difficulty
• Chest pain
• Confused or disordered thoughts
o Intense fear of dying
o Intense fear of going crazy
• Dizziness
• Excessive sweating
• Heartbeat sensations
• Lightheadedness, near fainting
• Nausea and vomiting
• Numbness and tingling
• Skin flushing

Exams and Tests
The individual may have a history of phobias. Family, friends, or the affected person may tell the health care provider about agoraphobic behavior.
Signs include:
• High blood pressure
• Rapid pulse (heart rate)
• Sweating

Treatment
The goal of treatment is to help you function effectively. The success of treatment usually depends on the severity of the phobia.

Systematic desensitization is a technique used to treat phobias. You are asked to relax, then imagine the things that cause the anxiety, working from the least fearful to the most fearful. Gradual exposure to the real-life situation also been used with success to help people overcome their fears.

Anti-anxiety and antidepressant medications are often used to help relieve the symptoms of phobias.

Outlook (Prognosis)
Phobias tend to be chronic, but respond well to treatment.

Possible Complications
Some phobias may affect job performance. People with this disorder may become housebound for years, which is likely to hurt their social and interpersonal relationships.

When to Contact a Medical Professional
Call for an appointment with your health care provider if you develop symptoms of agoraphobia.

Prevention
As with other panic disorders, prevention may not be possible. Early intervention may reduce the severity of the condition.

References
Moore DP, Jefferson JW. Agoraphobia (panic disorder with agoraphobia and agoraphobia without history of panic disorder). In: Moore DP, Jefferson JW, eds. Handbook of Medical Psychiatry. 2nd ed. Philadelphia, Pa: Mosby Elsevier;2004:chap 84.

Katon W, Geyman JP. Anxiety disorders. In: Rakel RE, ed. Textbook of Family Medicine. 7th ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 57.
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OCD
Obsessive-compulsive disorder is an anxiety disorder in which people have thoughts, feelings, ideas, sensations (obsessions), or behaviors that make them feel driven to do something (compulsions). A person may have both obsessions and compulsions.
Causes

Obsessive-compulsive disorder (OCD) is more common than was once thought. Most people who develop it show symptoms by age 30.

There are several theories about the cause of OCD, but none have been confirmed. Some reports have linked OCD to head injury and infections. Several studies have shown that there are brain abnormalities in patients with OCD, but more research is needed.

About 20% of people with OCD have tics, which suggests the condition may be related to Tourette syndrome. However, this link is not clear.

Symptoms

• Obsessions or compulsions that are not due to medical illness or drug use
• Obsessions or compulsions that cause major distress or interfere with everyday life
An example of obsessive-compulsive disorder is excessive, repeated handwashing to ward off infection.
The person usually recognizes that the behavior is excessive or unreasonable.

Exams and Tests
Your own description of the behavior can help diagnose the disorder. A physical exam can rule out physical causes, and a psychiatric evaluation can rule out other mental disorders.

Questionnaires, such as the Yale-Brown Obsessive Compulsive Scale, can help diagnose OCD and track the progress of treatment.

Treatment
OCD is treated using medications and therapy.

The first medication usually considered is a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI). These drugs include:

• Citalopram (Celexa)
• Fluoxetine (Prozac)
• Fluvoxamine (Luvox)
• Paroxetine (Paxil)
• Sertraline (Zoloft)

If an SSRI does not work, the doctor may prescribe an older antidepressant called clomipramine. Clomipramine is the oldest medication for OCD. It works better than SSRI antidepressants in treating the condition, but it has unpleasant side effects, including:

• Difficulty starting urination
• Drop in blood pressure when rising from a seated position
• Dry mouth
• Sleepiness

In some cases, an SSRI and clomipramine may be combined. Other medications such as benzodiazepines may offer some relief from anxiety, but they are generally used only with the more reliable treatments.
Psychotherapy is used to:

• Provide effective ways of reducing stress
• Reduce anxiety
• Resolve inner conflicts

Behavioral therapy may include exposure/response prevention: You are exposed many times to a situation that triggers anxiety symptoms, and learn to resist the urge to perform the compulsion.

Outlook (Prognosis)
OCD is a long-term (chronic) illness with periods of severe symptoms followed by times of improvement. However, a completely symptom-free period is unusual. Most people improve with treatment.

Possible Complications
Long-term complications of OCD have to do with the type of obsessions or compulsions. For example, constant handwashing can cause skin breakdown. However, OCD does not usually progress into another disease.

When to Contact a Medical Professional
Call for an appointment with your health care provider if your symptoms interfere with daily life, work, or relationships.

Prevention
There is no known prevention for this disorder.

Alternative Names
Obsessive-compulsive neurosis; OCD

References
Moore DP, Jefferson JW. Handbook of Medical Psychiatry. 2nd ed. St. Louis, Mo: Mosby; 2004:167-170.
Rakel RE, ed. Textbook of Family Practice. 6th ed. Philadelphia, Pa: WB Saunders; 2005:1348-1350.

Koran LM, Hanna GL, Hollander E, Nestadt G, Simpson HB, et al. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Am J Psychiatry. 2007;164:5-53.

Denys D. Pharmacotherapy of obsessive-compulsive disorder and obsessive-compulsive spectrum disorders. Psychiatr Clin North Am. 2006;29:553-584.