Agoraphobia with panic attacks or panic disorder with agoraphobia?
Literature review and presentation of the evidence of the Mental Health Center of Kavala


Agoraphobia and panic disorder are frequent among the general population and very often coexist. They are remarkably incapacitating disorders, because they affect both working ability and social activities and are most frequent in young adults. Epidemiological surveys estimate the lifetime prevalence of agoraphobia and panic from 1,2 to 6% of the population with a clear predominance of women, almost three times more than men. Furthermore these two conditions are aggravated with considerable comorbitity especially with depression. For the etiology and pathogenesis of panic disorder, the cognitive-based catastrophic misinterpretation model of D. M. Clark and the neurobiological false suffocation alarm theory of D. F. Klein have been proposed, with the former having remarkable research support. A psychodynamic model has also been proposed. Stressful life events have been found to play a role in the emergence of panic attacks in a certain number of cases.

There is a discrepancy concerning diagnosis between ICD-10 and DSM-IV when panic disorder and agoraphobia coexist, with DSM giving priority to panic, while ICD considers panic as a consequent provided that agoraphobia preexists. Various surveys have tried to verify the impression that agoraphobia develops as a complication of panic disorder, but the results are not consistent with this supposition, although a considerable percentage of cases of agoraphobia have a history of panic attacks.

Among the 697 psychiatric adult cases of the years 1997 to 2003 at the Mental Health Center of Kavala we identified 55 cases of agoraphobia and panic disorder. They represent 18.45% of all the anxiety disorders, and their mean age and sex distribution is significantly different from the total of cases, being younger and almost equally distributed according to sexes. 18 of these patients have panic disorder, 10 have agoraphobia and 27 suffer of both disorders. Their comorbitity with other anxiety disorders is 36.36%, and with depression 12.72%. Formal diagnoses vary: according to ICD-10 we have 37 agoraphobics with or without panic, and 18 cases of panic disorder, whereas according to DSM-IV, 45 cases of panic disorder with or without agoraphobia, and 10 cases of agoraphobia. After examining the history of each case we found that a slightly greater percentage of patients with agoraphobia have a history of panic attacks (56.75) and an also slightly greater percentage of patients who start with panic disorder will eventually develop agoraphobia (53.84), with both of them not being statistically significant. A smaller percentage of agoraphobics develop panic attacks later. Comparing our survey with others in the international literature we come to conclusion that (1) the diagnostic system used by any survey must be clearly stated in order to allow the results be comparable, (2) a careful examination of what appears to be a panic attack or agoraphobia is needed before case identification is made, and (3) more prospective studies are needed to establish whether agoraphobia develops as a result of panic disorder or not.

Key words: Agoraphobia, panic attacks, panic disorder, comorbidity.