A middle aged person repoed to Psychiatric OPD with the complaints of fear of leaving home, fear of travelling alone and fear of being in a crowd. He develops marked anxiety with palpitations and swelling if he is in these situations. He often avoids public transpo to go his place of work. The most likely diagnosis is: (A) Generalised anxiety disorder, (B) Schizophrenia, (C) Personality disorder, (D) Agoraphobia
Answer is D. D i.e. Agoraphobia Agoraphobia Patients with agoraphobia rigidly, avoid situations in which it would be difficult to escape or obtain help. They prefer to be accompanied by a friend or family member in busy streets, crowded stores, closed in places (eg. tunnels, bridges, and elevators), closed in vehicles (eg subways, buses, & air planes)Q. Patients may insist that they be accompanied every time they leave the house. Severely affected patient may refuse to leave house. The behaviour may result in marital discord. The situations are avoided (eg. travel is restricted) or else are endured with marked distress or anxiety about having a panic attack or panic like symptomsQ. The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as social phobia (eg. avoidance limited to social situations because of fear of embarrassment), specific phobias (eg. avoidance limited to single situation like elevators), OCD (eg avoidance of di in some one with an obscession about contamination), post traumatic stress disorder (eg avoidance of stimuli associated with severe stressor), or separation anxiety disorder (eg avoidance of leaving home or relatives), Agoraphobia is usually associated with panic disorder. Agoraphobia without a h/o panic disorder is often incapacitating & chronic, and depressive disorder and alcohol dependence often complicates its curse. Treatment of panic disorder, treats agoraphobia. Treatment is staed with SSRIs (paroxetine, seraline, or fluvoxamine). Benzodiazepines have the most rapid onset of action against panic, within first week. BDZs can reasonably be used as first agent while a SSRI is being slowly titrated to a therapeutic dose (after 4 -12 weeks it can be tapered).