True agoraphobia is an invalidating disease but a paper by Giovanni A. Fava and associates of the University of Bologna, published in Psychotherapy and Psychosomatics, questions the excessive emphasis on panic which has been attributed in the past decade and the role of pharmaceutical industry in this attribution.

In studying the phenomenology of panic attacks, Argyle and Roth noticed that truly spontaneous attacks, not preceded by anxiety-provoking cognitions, were uncommon.

Patients meeting positive criteria for panic disorder suffered from the whole range of anxiety disorders, and a unique relationship with agoraphobia was not seen. Indeed, other diagnoses (particularly social phobia and generalized anxiety disorder) frequently predated the onset of panic. This was true also for agoraphobia.

If we conceptualize the onset of panic disorder as a stage of development of anxiety disorders (whether agoraphobia or social phobia or generalized anxiety disorder) and hypochondriasis, instead of a specific disease, we may increase our diagnostic sharpness and substitute undifferentiated treatment, which may leave substantial areas of non-response, with stage-guided therapeutic tools.

The staging method that Fava and colleagues applied to agoraphobia in their paper may also be appropriate for generalized anxiety disorder and social phobia and may yield a better longitudinal understanding than the cross-sectional definition of DSM.

Maj has recently raised concerns about differentiating true mental disorder and homeostatic reactions to adverse life situations. The rise in the popularity of the diagnosis of panic disorder in the past 2 decades was largely due to marketing strategies (e.g., alprazolam); research was frequently biased by conflict of interest and may qualify for disease mongering.

Citation: Fava, G.A.;Rafanelli, C.; Tossani, E.; Grandi, S. Agoraphobia Is a Disease: A Tribute to Sir Martin Roth. Psychother Psychosom 2008;77:133-138