AIM: To conduct MINI (Mini-International Neuropsychiatric Interview)
AGORAPHOBIA : F40.0
In this condition, one is irrationally fearful of being in places that are far from the familiar surroundings of home. Despite being previously thought to be a fear of open spaces only, it now includes fear of open spaces, public places, crowded places, and anywhere else where there are no easy means of escape. It is the most common type of phobia encountered by clinicians. There are far more women than men suffering from agoraphobia in the West.
The patient is fearful of all the situations or places where escaping may seem difficult or help may not be available if he develops embarrassing or incapacitating symptoms. The classical symptoms of panic are embarrassing or incapacitating. A few symptoms (such as tachycardia or dizziness) may occur (agoraphobia without the panic disorder) or a full-blown panic attack may occur (agoraphobia with panic disorder).
Agoraphobia gradually limits daily activities as it becomes more severe. The person’s activities might become restricted to the point of self-imprison at home. Usually, one or two persons can be relied upon (relatives or friends), so that the patient can leave home with them. As a result, the patient becomes dependent on these phobic companions.
Diagnostic guidelines(ICD 10)
All of the following criteria should be fulfilled for a definite diagnosis:
- the psychological or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms, such as delusions or obsessional thoughts;
- the anxiety must be restricted to (or occur mainly in) at least two of the following situations: crowds, public places, traveling away from home, and traveling alone; and
- avoidance of the phobic situation must be or have been, a prominent feature.
Phobias are generally more common in women with onset in a late second decade or early third decade. Sudden onset is common without any apparent cause. The course is usually chronic with gradually increasing restrictions on daily activities. Sometimes, phobias are spontaneously remitting.
It’s important to remember that some agoraphobics suffer little anxiety because they consistently avoid their phobia-provoking situations. If other symptoms occur, such as depression, depersonalization, obsessional symptoms, and social phobias, this should not invalidate the diagnosis. A depressive episode may be an appropriate main diagnosis if the patient was already significantly depressed at the start of the phobic episode; this is more common in late-onset cases.
Most patients with phobic disorder rely on avoidance to manage their fears and anxieties. As long as they find ways to limit their lives within the limitations imposed by phobias, they experience little, if any, anxiety. When they are forced to face the phobic situation, anxiety mounts and they then seek treatment. Patients with more than one phobia and the presence of panic symptoms often seek treatment earlier. The treatment approach is usually multi-modal.
Behaviour Therapy: Usually successful when planned properly. Including various techniques like :
- Systematic desensitisation.
- Exposure and response prevention.
- Relaxation techniques.
Drug Treatment: The drugs used in the treatment of phobia are: Benzodiazepines are useful in reducing anticipatory anxiety. Alprazolam may result in anti-phobic, anti-panic and anti-anxiety properties. Among the antidepressants, SSRIs are currently drugs of choice, with paroxetine being the most widely used drug. Other SSRIs, such as fluoxetine and sertraline are also equally effective. Compared to other medications, fluoxetine has a longer half-life. Other antidepressants such as imipramine (TCA) and phenelzine (MAOI), are also helpful in treating the panic attacks associated with phobias, thereby decreasing the distress.
The Mini-International Neuropsychiatric Interview (MINI) is a standardized and structured diagnostic interview for DSM-IV and ICD-10 disorders developed jointly by psychiatrists and clinicians in the United States and Europe. The MINI takes 15 minutes to administer. A quick and accurate structured psychiatric interview was designed to be used in relation to multi-center clinical trials and epidemiology studies, used at the beginning of outcome tracking.
MINI measures the 17 most common mental health disorders. Disorders investigated are of primary importance to clinicians and researchers. Considering the prevalence rates in epidemiological studies of 0.5 or higher in the general population, the disorders were selected.
Mini was designed as a brief structured interview for the major Axis 1 psychiatric disorders in DSM-IV and ICD-10 MINI is divided into modules identified by letters, each corresponding to a diagnostic category. The screening questions corresponding to the main criteria of the disorders are presented at the beginning of each diagnostic module (except the psychotic disorders module). Each module ends with a diagnostic box that allows the clinician to indicate whether it meets diagnostic criteria.
How to score:
It is mandatory to rate each question. The rating for each question is done by circling either yes or no. When necessary, the clinician should ask for examples and the patient should be encouraged to ask for classification when needed.
Subject’s detail :
- Name – xyz
- Age – 24
- Sex – M
- Education – MBA
- Time – Morning
- Place – Gurugram
Examiner’s detail :
- Name – Nikita
- Age – 22
- Sex – F
- Education – M.Sc.
MATERIAL REQUIRED :
Mini-International Neuropsychiatric Interview (MINI), pen and pencil.
PROCEDURE & ADMINISTRATION :
After the establishment of the rapport, consent was taken and instructions were given to the subject for conducting the interview (MINI). The subject was asked several questions related to AGORAPHOBIA then on the basis of the responses scoring was been done. If the number of “yes” responses were more comparatively to “no” responses then the subject was likely to be diagnosed with agoraphobia.
The following instructions were given to the subject before conducting the test. ‘I will ask you some questions regarding the way you behave, feel or act. You have to answer yes/no according to your acting or feeling. There are no right or wrong responses. You just have to tell whatever suits you the best. You can ask clarification on any question that is not absolutely clear.’
- It was made sure that the subject understands each and every question that was been asked.
- The extraneous variables(noise, light, hunger, etc) were kept under control, so as to avoid any error.
- After the results been announced the subject was made clear with the problem he is facing, and what all measures could be taken in order to deal with effectively.
RESULT & DISCUSSION :
The subject fulfils the criteria for diagnosis of Agoraphobia current, without history of panic disorder, as the subject has answered ‘yes’ in E1, ‘yes’ in E2, and has answered most of the ‘questions as ‘yes’ of D5. Also the subject answered ‘no’ for the questions related to meet criteria of Panic disorder with agoraphobia current and panic disorder without agoraphobia current.
This means that the subject experience an irrational fear of being in places away from the familiar setting of the home, like shopping malls, movie theatres, and stores. It may be particularly difficult for people with agoraphobia to stand in a line. Worried they will have a panic attack or get sick, they fear being stuck in situations from which they can’t escape, or in which they cannot get immediate help.
Relaxation techniques, cognitive behavioural therapy, exposure response prevention, and psychotherapeutic methods can be suggested to the subject to deal with the problem.