Agoraphobia is an anxiety disorder characterized by anxiety in situations where the sufferer
perceives certain environments as dangerous or uncomfortable, often due to the environment's
vast openness or crowdedness. These situations include wide-open spaces, as well as uncontrollable
social situations such as the possibility of being met in shopping malls, airports,
and on bridges. Agoraphobia is defined within the DSM-IV TR as a subset of panic disorder,
involving the fear of incurring a panic attack in those environments. In the DSM-5, however,
agoraphobia is classified as being separate from panic disorder. The sufferer may go to
great lengths to avoid those situations, in severe cases becoming unable to leave their
home or safe haven. Although mostly thought to be a fear of public
places, it is now believed that agoraphobia develops as a complication of panic attacks.
However, there is evidence that the implied one-way causal relationship between spontaneous
panic attacks and agoraphobia in DSM-IV may be incorrect. Onset is usually between ages
20 and 40 years and more common in women. Approximately 3.2 million, or about 2.2%,
of adults in the US between the ages of 18 and 54, suffer from agoraphobia. Agoraphobia
can account for approximately 60% of phobias. Studies have shown two different age groups
at first onset: early to mid twenties, and early thirties.
In response to a traumatic event, anxiety may interrupt the formation of memories and
disrupt the learning processes, resulting in dissociation. Depersonalization and derealisation
are other dissociative methods of withdrawing from anxiety.
Standardized tools, such as Panic and Agoraphobia Scale, can be used to measure the severity
of agoraphobia and panic attacks and monitor treatment.
Signs and symptoms Agoraphobia is a condition where the sufferer
becomes anxious in environments that are unfamiliar or where he or she perceives that they have
little control. Triggers for this anxiety may include wide open spaces, crowds, or traveling.
Agoraphobia is often, but not always, compounded by a fear of social embarrassment, as the
agoraphobic fears the onset of a panic attack and appearing distraught in public. This is
also sometimes called 'social agoraphobia' which may be a type of social anxiety disorder
also sometimes called "social phobia". Not all agoraphobia is social in nature, however.
Some agoraphobics have a fear of open spaces. Agoraphobia is also defined as "a fear, sometimes
terrifying, by those who have experienced one or more panic attacks". In these cases,
the sufferer is fearful of a particular place because they have experienced a panic attack
at the same location in a previous time. Fearing the onset of another panic attack, the sufferer
is fearful or even avoids the location. Some refuse to leave their home even in medical
emergencies because the fear of being outside of their comfort area is too great.
The sufferer can sometimes go to great lengths to avoid the locations where they have experienced
the onset of a panic attack. Agoraphobia, as described in this manner, is actually a
symptom professionals check for when making a diagnosis of panic disorder. Other syndromes
like obsessive compulsive disorder or post traumatic stress disorder can also cause agoraphobia.
Essentially, any irrational fear that keeps one from going outside can cause the syndrome.
It is not uncommon for agoraphobics to also suffer from temporary separation anxiety disorder
when certain other individuals of the household depart from the residence temporarily, such
as a parent or spouse, or when the agoraphobic is left home alone. Such temporary conditions
can result in an increase in anxiety or a panic attack or feel the need to separate
themselves from family or maybe friends. Another common associative disorder of agoraphobia
is necrophobia, the fear of death. The anxiety level of agoraphobics often increases when
dwelling upon the idea of eventually dying, which they may consciously or unconsciously
associate with being the ultimate separation from their mortal emotional comfort and safety
zones and loved ones, even for those who may otherwise spiritually believe in some form
of divine afterlife existence. Panic attacks
Agoraphobia patients can experience sudden panic attacks when traveling to places where
they fear they are out of control, help would be difficult to obtain, or they could be embarrassed.
During a panic attack, epinephrine is released in large amounts, triggering the body's natural
fight-or-flight response. A panic attack typically has an abrupt onset, building to maximum intensity
within 10 to 15 minutes, and rarely lasts longer than 30 minutes. Symptoms of a panic
attack include palpitations, a rapid heartbeat, sweating, trembling, nausea, vomiting, dizziness,
tightness in the throat and shortness of breath. Many patients report a fear of dying or of
losing control of emotions and/or behavior. Causes
Although the exact causes of agoraphobia are currently unknown, some clinicians who have
treated or attempted to treat agoraphobia offer plausible hypotheses. The condition
has been linked to the presence of other anxiety disorders, a stressful environment or substance
abuse. Research has uncovered a linkage between agoraphobia
and difficulties with spatial orientation. Individuals without agoraphobia are able to
maintain balance by combining information from their vestibular system, their visual
system and their proprioceptive sense. A disproportionate number of agoraphobics have weak vestibular
function and consequently rely more on visual or tactile signals. They may become disoriented
when visual cues are sparse or overwhelming. Likewise, they may be confused by sloping
or irregular surfaces. In a virtual reality study, agoraphobics showed impaired processing
of changing audiovisual data in comparison with non-suffering subjects.
Substance induced Chronic use of tranquilizers and sleeping
pills such as benzodiazepines has been linked to onset of agoraphobia. In 10 patients who
had developed agoraphobia during benzodiazepine dependence, symptoms abated within the first
year of assisted withdrawal. Similarly, alcohol use disorders are associated with panic with
or without agoraphobia; this association may be due to the long-term effects of alcohol
misuse causing a distortion in brain chemistry. Tobacco smoking has also been associated with
the development and emergence of agoraphobia, often with panic disorder; it is uncertain
how tobacco smoking results in anxiety-panic with or without agoraphobia symptoms, but
the direct effects of nicotine dependence or the effects of tobacco smoke on breathing
have been suggested as possible causes. Self-medication or a combination of factors may also explain
the association between tobacco smoking and agoraphobia and panic.
Attachment theory
Some scholars have explained agoraphobia as an attachment deficit, i.e., the temporary
loss of the ability to tolerate spatial separations from a secure base. Recent empirical research
has also linked attachment and spatial theories of agoraphobia.
Spatial theory In the social sciences there is a perceived
clinical bias in agoraphobia research. Branches of the social sciences, especially geography,
have increasingly become interested in what may be thought of as a spatial phenomenon.
One such approach links the development of agoraphobia with modernity. Factors considered
contributing to agoraphobia within modernity are the ubiquity of cars, and urbanization.
These have helped develop the expansion of public space, on the one hand, and the contraction
of private space on the other, thus creating in the minds of agoraphobic-prone people a
tense, unbridgeable gulf between the two. Evolutionary psychology
An evolutionary psychology view is that the more unusual primary agoraphobia without panic
attacks may be due to a different mechanism from agoraphobia with panic attacks. Primary
agoraphobia without panic attacks may be a specific phobia explained by it once having
been evolutionarily advantageous to avoid exposed, large open spaces without cover or
concealment. On the other hand, agoraphobia with panic attack may be an avoidance response
secondary to the panic attacks due to fear of the situations in which the panic attacks
occurred. Diagnosis
Most people who present to mental health specialists develop agoraphobia after the onset of panic
disorder. Agoraphobia is best understood as an adverse behavioral outcome of repeated
panic attacks and subsequent anxiety and preoccupation with these attacks that leads to an avoidance
of situations where a panic attack could occur. In rare cases where agoraphobics do not meet
the criteria used to diagnose panic disorder, the formal diagnosis of agoraphobia without
history of panic disorder is used. Treatments
Cognitive behavioral treatments Exposure treatment can provide lasting relief
to the majority of patients with panic disorder and agoraphobia. Disappearance of residual
and subclinical agoraphobic avoidance, and not simply of panic attacks, should be the
aim of exposure therapy. Similarly, systematic desensitization may also be used. Many patients
can deal with exposure easier if they are in the company of a friend they can rely on.
It is vital that patients remain in the situation until anxiety has abated because if they leave
the situation the phobic response will not decrease and it may even rise.
Cognitive restructuring has also proved useful in treating agoraphobia. This treatment involves
coaching a participant through a dianoetic discussion, with the intent of replacing irrational,
counterproductive beliefs with more factual and beneficial ones.
Relaxation techniques are often useful skills for the agoraphobic to develop, as they can
be used to stop or prevent symptoms of anxiety and panic.
Medications Anti-depressant medications most commonly
used to treat anxiety disorders are mainly in the selective serotonin reuptake inhibitor.
Benzodiazepines, MAO inhibitors and tricyclic antidepressants are also sometimes prescribed
for treatment of agoraphobia. Antidepressants are important because some have antipanic
effects. Antidepressants should be used in conjunction with exposure as a form of self-help
or with cognitive behaviour therapy. Some evidence shows that a combination of medication
and cognitive behaviour therapy is the most effective treatment for agoraphobia.
Benzodiazepines - anti-anxiety medications Examples are alprazolam and clonazepam. They
are used to treat anxiety and can also help control the symptoms of a panic attack. If
taken in doses larger than those prescribed, or for too long, they can cause dependence.
Side effects may include: Confusion
Drowsiness Light-headedness
Loss of balance Memory loss
Alternative treatments Eye movement desensitization and reprogramming
has been studied as a possible treatment for agoraphobia, with poor results. As such, EMDR
is only recommended in cases where cognitive-behavioral approaches have proven ineffective or in cases
where agoraphobia has developed following trauma.
Many people with anxiety disorders benefit from joining a self-help or support group.
Sharing problems and achievements with others as well as sharing various self-help tools
are common activities in these groups. In particular stress management techniques and
various kinds of meditation practices as well as visualization techniques can help people
with anxiety disorders calm themselves and may enhance the effects of therapy. So can
service to others which can distract from the self-absorption that tends to go with
anxiety problems. There is also preliminary evidence that aerobic exercise may have a
calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold
medications can aggravate the symptoms of anxiety disorders, they should be avoided.
Epidemiology Agoraphobia occurs about twice as commonly
among women as it does in men. The gender difference may be attributable to several
factors: social-cultural traditions that encourage, or permit, the greater expression of avoidant
coping strategies by women; women perhaps being more likely to seek help and therefore
be diagnosed; men being more likely to abuse alcohol in reaction to anxiety and be diagnosed
as an alcoholic. Research has not yet produced a single clear explanation for the gender
difference in agoraphobia. Notable cases
See also List of films featuring mental illness: Agoraphobia
Agyrophobia, fear of crossing roads Generalized anxiety disorder
Hikikomori Obsessive compulsive disorder, which can feature
specific fears that cause one to become homebound Post traumatic stress disorder
Social anxiety Specific social phobia
Xenophobia, fear of strangers References
External links Support Group Providers for Agoraphobia at
DMOZ Agoraphobia
This article incorporates public domain material from websites or documents of the
National Institute of Mental Health.