Agoraphobia:an unsolved problem

Summary Objective In the last few decades, there has been much controversy concerning the correct classification and definition of agoraphobia (AG). In the present review, the historical evolution of the concept of AG, as well as the problem of the relationships between AG and panic disorder (PD) are addressed through a revision of the most relevant studies published on this issue. Method Medline and PubMed databases were searched for English language articles using the keywords agoraphobia, panic disorder, anxiety disorders, epidemiology, community surveys. Results The term “agoraphobia” was firstly used by the German neurologist Westphal. In his article, “Agoraphobia: a neuropathic phenomenon”, published at the end of the XIX century, he described patients who feared to cross open spaces and to go to crowded places such as squares, theatres and churches. During the XX century, several authors attempted to give an explanation of AG according to different theoretical approaches (i.e. biological, ethological, psychoanalytic). In the modern classifications of the mental diseases, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the International Classification of Diseases 10th Revision (ICD-10), AG was firstly included in the section of phobias. However, since the publication of the DSM-III, which included AG in the chapter of panic disorder (PD), the relationship between AG and PD has always been controversial. On one hand, North American psychiatrists, in line with data coming from studies carried out on clinical samples, consider AG as a consequence of panic attacks (PAs) and deny its existence without panic. On the other hand, consistently with the most part of the community surveys, the European position maintains the existence of AG without PAs. In this contest, the ICD-10, in line with the “European” position, includes AG without PAs in the chapter of phobias, whereas the DSM-IV considers the association PAs-AG as a form of PD and specifies that AG without PAs is a consequence of limited panic symptoms or of an isolated full-blown PA. However, in the general population AG seems to occur also in subjects who never experienced PAs. We found 24 studies reporting the lifetime prevalence of AG without a history of PAs: on a total number of 159,130 subjects, the calculated rates of prevalence were of 3.16%, varying between 0.17% and 11.1% (Tab. I). Sixteen studies have reported the one-year prevalence of the disorder: on a total number of 139,092 subjects, the calculated rates of prevalence were of 1.07%, varying between 0.05% and 6.3% (Tab. II). Conclusion AG seems to exist also in the absence of history of PAs; the one-way relationship between the occurrence of PAs and a subsequent development of AG, postulated by the last version of the DSM, is open to criticism. A more stable definition of AG, totally independent of PA, should be considered for future classifications