Agoraphobia

Agoraphobia (from Greek ἀγορά, "marketplace"; and φόβος/φοβία, -phobia) is an anxiety disorder. Agoraphobia may arise by the fear of having a panic attack in a setting from which there is no easy means of escape. Alternatively, social anxiety problems may also be an underlying cause. As a result, sufferers of agoraphobia avoid public and/or unfamiliar places, especially large, open, spaces such as shopping malls or airports where there are few places to hide. In severe cases, the sufferer may become confined to his or her home, experiencing difficulty traveling from this safe place. Although mostly thought to be a fear of public places, it is now believed that agoraphobia develops as a complication of panic attacks.^[1] However, there is evidence that the implied one-way causal relationship between spontaneous panic attacks and agoraphobia in DSM-IV may be incorrect.^[2]Approximately 3.2 million adults in the US between the ages of 18 and 54, or about 2.2%, suffer from agoraphobia.^[3]

Definition

Not to be confused with agraphobia, 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 (social anxiety), or traveling (even short distances). 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 a 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.

The sufferer is now considered to suffer from Agoraphobia. 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, basically any irrational fear that keeps one from going outside can cause the syndrome.^[4]

There are basically three levels of severity in agoraphobia as related to travel distance that are currently not covered in diagnostic statistical manuals of mental disorders.

Level I Agoraphobia consists of an ideational fear or actual panic attack as the result of traveling beyond the general perimeters of the region one resides in, such as a large city or county.

Level II Agoraphobia consists of an ideational fear or actual panic attack as the result of traveling beyond the general perimeters of one’s neighborhood or residential district.

Level III Agoraphobia consists of an ideational fear or actual panic attack as the result of stepping outside the boundaries or premises of one’s residence. Most sufferers of this category are able to walk outdoors onto a porch, balcony, roof, yard or patio, but a minority of Level III suffers are fearful of stepping outdoors at all.

It is not uncommon for Level II and Level III agoraphobics in particular 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.

Another common associative disorder of agoraphobia is thanatophobia—fear of death. The anxiety level of agoraphobics often increases when dwelling upon the idea of eventually dying, which they 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.

Gender differences

Agoraphobia occurs about twice as commonly among women as it does in men.^[5] The gender difference may be attributable to social-cultural factors that encourage, or permit, the greater expression of avoidant coping strategies by women. Other theories include the ideas that women are more likely to seek help and therefore be diagnosed, that men are more likely to abuse alcohol as a reaction to anxiety and be diagnosed as an alcoholic, and that traditional female sex roles encourage women to react to anxiety by engaging in dependent and helpless behaviors.^[6] Research results have not yet produced a single clear explanation as to the gender difference in agoraphobia.

Causes and contributing factors

The exact causes of agoraphobia are currently unknown, although some clinicians that have treated or attempted to treat agoraphobia offer valid theories. The condition has been linked to the presence of other anxiety disorders, a stressful environment or substance abuse. Chronic use of tranquilizers and sleeping pills such as benzodiazepines has been linked to causing agoraphobia.^[7] When benzodiazepine dependence has been treated and after a period of abstinence, agoraphobia symptoms gradually abate.^[8]

Research has uncovered a linkage between agoraphobia and difficulties with spatial orientation.^[9][10] 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 as in wide open spaces or overwhelming as in crowds. Likewise, they may be confused by sloping or irregular surfaces.^[11] Compared to controls, in virtual reality studies, agoraphobics on average show impaired processing of changing audiovisual data.^[12]

Alternate theories

Attachment theory

Some scholars ^[13][14] have explained agoraphobia as an attachment deficit, i.e., the temporary loss of the ability to tolerate spatial separations from a secure base.^[15] Recent empirical research has also linked attachment and spatial theories of agoraphobia.^[16]

Spatial theory

In the social sciences there is a perceived clinical bias ^[17] 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.^[18]

Diagnosis

Most people who present to mental health specialists develop agoraphobia after the onset of panic disorder (American Psychiatric Association, 1998). 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.^[19] 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 (Primary Agoraphobia).

Association with 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.^[20] Symptoms of a panic attack include palpitations, a rapid heartbeat, sweating, trembling, 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.^[20]

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.^[21] Similarly, Systematic desensitization may also be used.

Cognitive restructuring has also proved useful in treating agoraphobia. This treatment involves coaching a participant through a dianoetic discussion, with the intent of substituting 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.

Psychopharmaceutical treatments

Anti-depressant medications most commonly used to treat anxiety disorders are mainly in the SSRI (selective serotonin reuptake inhibitor) class and include sertraline, paroxetine and fluoxetine. Benzodiazepine tranquilizers, MAO inhibitors and tricyclic antidepressants are also commonly prescribed for treatment of agoraphobia.

Alternative treatments

Eye movement desensitization and reprogramming (EMDR) has been studied as a possible treatment for agoraphobia, with poor results.^[22] As such, EMDR is only recommended in cases where cognitive-behavioral approaches have proven ineffective or in cases where agoraphobia has developed following trauma.^[23]

Many people with anxiety disorders benefit from joining a self-help or support group (telephone conference call support groups or online support groups being of particular help for completely housebound individuals). 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.^[24]

Notable agoraphobes

See also

• List of films featuring mental illness#Agoraphobia
• Agyrophobia, fear of crossing roads
• Enochlophobia, fear of crowds
• Generalized anxiety disorder
• Hikikomori
• Obsessive compulsive disorder, can have a variety of specific fears that cause one to become homebound
• Post traumatic stress disorder
• Social anxiety
• Social phobia
• Xenophobia, fear of strangers

References

 This article incorporates public domain material from websites or documents of the National Institute of Mental Health.

Suggested Links

• Support Group Providers for / Agoraphobia at the Open Directory Project Includes Telephone Support Group Providers for Homebound Agoraphobics