Agoraphobia Prepared by Stephanie Gilbert Summary

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1 Agoraphobia Prepared by Stephanie Gilbert Summary The Diagnostic and Statistical Manual of Mental Disorders, IV, cites the criteria for Agoraphobia as with, or without, the occurrence of Panic Disorder. Furthermore, the definition includes anxious feelings regarding confinement that cannot be escaped. This is often classified as anxiety regarding the onset of a Panic Attack with the inability to leave public settings. The behaviors exhibited as a result of this anxiety can be considered Agoraphobic in nature as long as other diagnoses for avoiding situations are not more adequate (DSM-IV, 1996). One-year prevalence rates of agoraphobia in American adults ages 18 to 54 are approximately 4.9% (US Department of Health and Human Services, 1999). The incidence is approximately 22.0 per 1000 per year (Eaton, 1995). The search engines used for the Agoraphobia data base development produced approximately one hundred fifty (148) articles for initial review. Approximately one hundred twenty were deleted for not meeting basic requirements of being a longitudinal study that is population based. Many originated from clinic samples, the sample size was too small to provide the generalizable results required, or the risk factors were not considered to be malleable. The final data base for review included a total of three studies. The studies that were included in this report for Agoraphobia are as follows: Early Developmental Stages of Psychopathology study (EDSP) by Wittchen et al. (2000), Children in the Community Study by Johnson et al. (2000), Breslau et al. (1992), the Epidemiologic Catchment Area Follow-up Study by Bienvenu et al. (2001). Each is a prospective, population based study except for the EDSP which was ambidirective. The risk factors for each study are unique for Agoraphobia and are not repeated with the exception for the odds reported for gender. The EDSP study was conducted in Munich, Germany and utilized government registries from 1994 to sample the population randomly. The CIDI was self administered to adolescents and young adults of ages 14 to 24 at baseline. Odds ratios were reported at the significant level of p-value = 0.05, but exact confidence intervals and p-values were not provided. All results provided were also adjusted for the presence of Major Depressive Disorder. Females, poor educational attainment, and parental anxiety are among the more prominent risk factors noted for the presence of Agoraphobia with each presenting an odds ratio of approximately 2.4 to 3.6. The Children in the Community Study was administered to a sample drawn from upstate New York that had a mean age of 14 years at baseline. This study was drawn from a larger sample that was selected by residence. The DISC was self administered to these young adults that were predominantly Caucasian and Catholic. Cigarette smoking was found to be a statistically significant risk factor for Agoraphobia ( OR = 6.79; 1.53,

2 30.17) with adjustments presented in the evidence table. The ECA Follow-up study uses a subset of the original cohort for an additional 3 year follow-up period using the SCAN with DSM III-R diagnostic criteria. As in the previous report, being female is a significant risk factor for Agoraphobia (OR = 4.92; 1.41, 17.1). Panic Disorder and MDD are also shown to be related to the presence of Agoraphobia, but not at a significant level according to the confidence intervals provided. Being an extravert and increasing in age are both slightly protective factors, however not at the significant level. One of the greatest needs for Agoraphobia research includes studies assessing Panic Disorder, Panic Attacks, and Agoraphobia simultaneously in a prospective design. Since the DSM IV makes it clear the criteria for Agoraphobia is contingent upon Panic Disorder, this would only lead to a better understanding of the diagnostics surrounding Agoraphobia and the fear of recurring panic attacks in the public arena.

3 Selection Figure for Agoraphobia 148 studies matching the keywords 120 excluded for not meeting criteria 28 studies reviewed for inclusion criteria 25 studies excluded primarily for wrong sampling methods and not being prospective in nature 3 Studies for inclusion

4 Evidence Table for Agoraphobia

5 Pub Study Sample Sample Follow-up Outcome Risk Factor OR/RR Estimate Author Date Design Description Size Period Criteria/Measure Measure Risk Factor (95% CI) Adjustment Wittchen, H-U, 2000 Ambidirective Early Developmental years CIDI Self report Female:Male OR = 2.4 (na) presence of MDD et al. population Stages of Psychopathbased study ology study (EDSP); years; Munich, Germany; government Poor education OR = 3.6 (na) presence of MDD registries used for attainment random sampling Early separation OR = 2.7 (na) presence of MDD events Parental Anxiety OR = 2.4 (na) presence of MDD Temperament (BI) OR = 18.0 (na) presence of MDD Johnson, J.G., 2000 Prospective, Children in the years DISC Self report Youth Cigarette smoking OR = 6.79 age, sex, difficult et al. population Community Study; ( ) childhood temp; based study Baseline mean age, 14; parental ed lvl, NY youth, White, smoking, psych; adol. Catholic alcohol & drug use & depressive disorders Bienvenue, O. J Prospective, ECA Follow-up Study, years SCAN; DSM III-R Semi-structured Panic Disorder OR = 2.49 unadjusted et al ECA population East Baltimore ( ) Follow-up Study based study household residents; Major Depression OR = 1.93 unadjusted subsample; mean age: ( ) 49.8 years Neuroticism OR = 1.27 n/a ( ) Extraversion OR = 0.91 n/a ( ) Age (Years) OR = 0.97 n/a: OR for every 10 ( ) yr increase. Female: Male OR = 4.92 n/a ( ) RR= Relative Risk, OR= Odds Ratio, HR= Hazard Ratio

6 Risk Factors for Agoraphobia Various Risk Factors Color Category Forest Plot Panic Disorder 1 MDD 1 Neuroticism 1 Extraversion 1 Risk Factors Age 1 Female: Male 1 Adol. Cig. Use 2 Female: Male 3 Poor Ed Attainment 3 CI Early Sep Events 3 Parental Anxiety 3 Temperament UL LL EST Relative Risk / Odds Ratio Bienvenu et al. (1), 2001: Odds Ratio. SCAN, DSM III-R. Johnson et al., (2) 2000: Odds Ratio. DISC Wittchen et al. (3), 2000: Odds Ratio. CIDI, DSM IV.

7 Agoraphobia Bibliography Bienvenu, O.J., Brown, C., Samuels, J.F., Liang, KY, Costa, P.T., Eaton, W.W., & Nestadt, G. (2001). Normal personality traits and comorbidity among phobic, panic and major depressive disorders. Psychiatry Research, 102, Breslau, N., & Davis, G.C. (1992). Migraine, major depression and panic disorder: a prospective epidemiologic study of young adults. Cephalalgia, 12, Eaton WW. (1995). Progress in the epidemiology of anxiety disorders. Epidemiologic Reviews, 17, 1-8. U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, Wittchen, H-U, Kessler, R.C., Pfister, H., & Lieb, M. (2000). Why do people with anxiety disorders become depressed? A prospective-longitudinal community study. Acta Psychiatr Scand, 102, Suppl 406,