Onset of panic disorder with agoraphobia. Toward an integrated model
P. Lelliott, I. Marks, G. McNamee and A. Tobena
Institute of Psychiatry, London, England.
Of 57 patients with panic disorder with agoraphobia, more had their first
panic in late spring and summer than in fall and winter, and in warm
weather than in cold weather. In the month before the first panic 52% of
the patients had prodromal depression or anxiety. Agoraphobic avoidance
preceded the first panic in 23%, began within days after the first panic in
32% (without prodromal anxiety or depression in only 20%), and after more
than one panic (1 week to 11 years later) in 41%. The site of the first
panic was from the agoraphobic cluster (public places) in 81%, at work or
school in 11%, and inside the home in 8%. Thirty-eight percent of patients
were with a familiar adult at the time. Many features of the syndrome can
be explained by an integrated model with several interacting factors
contributing in varying degrees to the different routes by which it
develops. To the learning and biological factors already suggested we add
an evolutionary factor to explain why most first panics occur outside the
home and mainly in public places. Certain extraterritorial cues
constituting an agoraphobic cluster seem to be prepotent and prepared
triggers or modifiers of fear during stress.
