Agoraphobia Without Panic: Case Illustrations of an Overlooked Syndrome

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Despite inclusion in the DSM for almost 15 years (American Psychiatric Association, 1980, 1987, 1994), agoraphobia without history of panic disorder (AWHPD) remains a poorly understood diagnostic category. Anxiety treatment clinics report comparatively low rates of agoraphobia without panic (Barlow, 1985; Pollard et al., 1989; Swinson, 1986; Thyer et al., 1985; Turner et al., 1986; Williams, 1987) and there is evidence that epidemiological data may overestimate the prevalence of this disorder in the general population (Horwath et al., 1993). Nonetheless, AWHPD is occasionally seen by mental health professionals (Pollard et al., 1989) and may be somewhat more common in nonpsychiatric medical settings (Lydiard, 1992; Pollard et al., 1993; Spirings et al., 1989).A number of different symptom attacks have been associated with agoraphobia, including headache, vomiting, dizziness, and loss of bladder or bowel control. The attacks are disturbing, have a sudden onset, and are perceived as relatively unpredictable or uncontrollable. Furthermore, the individual fears the attack is acutely dangerous beyond the immediate discomfort of the symptoms. Catastrophic consequences feared to result from the attack include death, insanity, and humiliation.We were unable to find any prior publications illustrating the various clinical presentations of AWHPD. The purpose of this report is to present case examples of four presentations of agoraphobia without panic, each of which was associated with a different symptom attack. Each case met DSM-III-R criteria for AWHPD: a) a clear pattern of agoraphobic avoidance; b) fear of experiencing a symptom attack (other than panic) in situations where escape would be difficult or humiliating; and c) no history of DSM-III-R-defined panic attacks.Case ReportsAgoraphobia with fear of headache. A 46-year-old married woman presented for treatment with a primary complaint of severe migraine headache and agoraphobic symptoms including extreme fear and avoidance of social contact, including talking on the telephone and leaving home because of the possibility of experiencing headache. Phobic avoidance had progressed over a 15-year period since migraine onset to the point that the patient's husband was her only daily contact. She was reliant on Tylenol with codeine and had become increasingly depressed. Initial treatment was inpatient and focused on the control of physical symptoms. Narcotics were administered on a time interval schedule and were gradually eliminated. The patient received intensive training in biofeedback techniques directed at aborting migraine onset by controlling autonomic reactivity. Physical therapy was used to stretch cervical muscles contributing to myofascial components of headache pain. Although headache symptoms improved, agoraphobia persisted. The patient was taught relaxation techniques to manage anxiety and received graduated imaginal and in vivo exposure to previously avoided situations such as being alone. At discharge, headaches were reduced in severity and frequency and the patient was able to engage in most previously avoided social activities with relative comfort. At 6-month follow-up, improvement was maintained in all spheres and the patient had become involved in a full range of activities.Agoraphobia with fear of spontaneous bowel movements. The patient was a 36-year-old married man who avoided activities in which he did not have ready access to a restroom because of a fear of experiencing spontaneous and uncontrollable bowel movements. Feared activities included walking in the park, taking boat rides, riding in a car with people other than his immediate family, and attending business meetings in which he felt he would be unable to leave if he needed to use the restroom. He reported no history of panic attacks, but responded to “butterflies” or “knots” in his stomach with anxiety.

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