Agoraphobia

Not to be confused with Agraphobia.
Agoraphobia
Classification and external resources
ICD-10 F40
F40.00 unspecified, F40.01 With panic disorder, F40.02 Without panic disorder
ICD-9 300.22 Without panic disorder, 300.21 With panic disorder
Patient UK Agoraphobia
MeSH D000379

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.[1] In the DSM-5, however, agoraphobia is classified as being separate from panic disorder.[2] 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.[3] However, there is evidence that the implied one-way causal relationship between spontaneous panic attacks and agoraphobia in DSM-IV may be incorrect.[4] Onset is usually between ages 20 and 40 years and more common in women.[5] Approximately 3.2 million, or about 2.2%, of adults in the US between the ages of 18 and 54, suffer from agoraphobia.[6] Agoraphobia can account for approximately 60% of phobias.[7] Studies have shown two different age groups at first onset: early to mid twenties, and early thirties.[8]

In response to a traumatic event, anxiety may interrupt the formation of memories and disrupt the learning processes, resulting in dissociation. Depersonalization (a feeling of disconnection from one’s self) and derealisation (a feeling of disconnection from one's surroundings) are other dissociative methods of withdrawing from anxiety.[9]

Standardized tools, such as Panic and Agoraphobia Scale, can be used to measure the severity of agoraphobia and panic attacks and monitor treatment.[10][11]

The term agoraphobia comes from Greek ἀγορά, meaning "Large public square/Marketplace" and -φοβία, -phobia, meaning "fear".

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 (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 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.

Researchers have found similarities between symptoms of agoraphobia and the stereotypical female sex roles cast upon society. Researchers assert the socialization of stereotypic feminine behavior – helplessness, dependence, unassertiveness, accommodation – contributes to the development and maintenance of the characteristics of agoraphobia.[12]

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.[13]

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 thanatophobia, 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.[14] 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.[14]

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.[15][16] 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).[17] Likewise, they may be confused by sloping or irregular surfaces.[17] In a virtual reality study, agoraphobics showed impaired processing of changing audiovisual data in comparison with non-suffering subjects.[18]

Substance induced

Chronic use of tranquilizers and sleeping pills such as benzodiazepines has been linked to onset of agoraphobia.[19] In 10 patients who had developed agoraphobia during benzodiazepine dependence, symptoms abated within the first year of assisted withdrawal.[20] 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.[21] 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.[22]

Attachment theory

Main article: Attachment theory

Some scholars[23][24] have explained agoraphobia as an attachment deficit, i.e., the temporary loss of the ability to tolerate spatial separations from a secure base.[25] Recent empirical research has also linked attachment and spatial theories of agoraphobia.[26]

Spatial theory

In the social sciences there is a perceived clinical bias[27] 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.[28] 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.[29][30]

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.[31] Early treatment of panic disorder can often prevent agoraphobia.[32] Agoraphobia is typically determined when symptoms are worse than panic disorder but also do not mer the criteria for other anxiety disorders such as depression.[33] 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).

Treatments

Cognitive and 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.[34] 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.[8] 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.[8]

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 (SSRI). Benzodiazepines, MAO inhibitors and tricyclic antidepressants are also sometimes prescribed for treatment of agoraphobia. Antidepressants are important because some have antipanic effects.[8] Antidepressants should be used in conjunction with exposure as a form of self-help or with cognitive behaviour therapy.[8] Some evidence shows that a combination of medication and cognitive behaviour therapy is the most effective treatment for agoraphobia.[8]

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:

Alternative treatments

Eye movement desensitization and reprogramming (EMDR) has been studied as a possible treatment for agoraphobia, with poor results.[35] As such, EMDR is only recommended in cases where cognitive-behavioral approaches have proven ineffective or in cases where agoraphobia has developed following trauma.[36]

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.[37]

In popular culture

Epidemiology

Agoraphobia occurs about twice as commonly among women as it does in men.[40] 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 (including dependent and helpless behaviors); 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.[41] Research has not yet produced a single clear explanation for the gender difference in agoraphobia.[41]

Notable cases

See also

References

  1. ↑ Behavenet. DSM-IV & DSM-IV TR: Agorophobia.
  2. ↑ Highlights of Changes from DSM-IV-TR to DSM-5 (PDF). American Psychiatric Association. May 17, 2013. Retrieved May 23, 2013.
  3. ↑ "Panic Attacks and Panic Disorder: Symptoms, Causes, and Treatment". Helpguide.org. Retrieved 2013-05-08.
  4. ↑ Bienvenu OJ, Onyike CU, Stein MB, Chen LS, Samuels J, Nestadt G, Eaton WW (2006). "Agoraphobia in adults: incidence and longitudinal relationship with panic". Br J Psychiatry 188: 432–8. doi:10.1192/bjp.bp.105.010827. PMID 16648529.
  5. ↑ Goldberg RJ (2007). Practical guide to the care of the psychiatric patient (3rd ed.). Philadelphia: Mosby/Elsevier. p. 171. ISBN 032303683X.
  6. ↑ Phobia Fear Release. "Percentage Of Americans With Phobias". Retrieved 2010-04-07.
  7. ↑ p212
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Gelder, Michael G.; Mayou, Richard.; Geddes, John (2005). Psychiatr. New York: Oxford University Press. ISBN 0-19-852863-9.
  9. ↑ Nettina, M,S. 2006. Manual of Nursing Practice. 8th Ed. US:Lippincott Company.
  10. ↑ Bandelow B, Broocks A, Pekrun G, George A, Meyer T, Pralle L, Bartmann U, Hillmer-Vogel U, Rüther E (2000). "The use of the Panic and Agoraphobia Scale (P & A) in a controlled clinical trial". Pharmacopsychiatry 33 (5): 174–81. doi:10.1055/s-2000-12982. PMID 11071019.
  11. ↑ Tural U, Fidane H, Alkin T, Bandelow B (2002). "Assessing the severity of panic disorder and agoraphobia: validity, reliability and objectivity of the Turkish translation of the Panic and Agoraphobia Scale (P&A)". J Anxiety Disord 16 (3): 331–40. doi:10.1016/s0887-6185(02)00104-4. PMID 12214818.
  12. ↑ Capps Lisa and Ochs Elinor. Constructing Panic: the Discourse of Agoraphobia. Cambridge: Harvard University Press, 1995. Print.
  13. ↑ Psych Central: Agoraphobia Symptoms
  14. ↑ 14.0 14.1 David Satcher et al. (1999). "Chapter 4.2". Mental Health: A Report of the Surgeon General.
  15. ↑ Yardley L, Britton J, Lear S, Bird J, Luxon LM (May 1995). "Relationship between balance system function and agoraphobic avoidance". Behav Res Ther 33 (4): 435–9. doi:10.1016/0005-7967(94)00060-W. PMID 7755529.
  16. ↑ Jacob RG, Furman JM, Durrant JD, Turner SM (1996). "Panic, agoraphobia, and vestibular dysfunction". Am J Psychiatry 153 (4): 503–512. PMID 8599398.
  17. ↑ 17.0 17.1 Jacob RG, Furman JM, Durrant JD, Turner SM (1997). "Surface dependence: a balance control strategy in panic disorder with agoraphobia". Psychosom Med 59 (3): 323–30. doi:10.1097/00006842-199705000-00016. PMID 9178344.
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  19. ↑ Hammersley D, Beeley L (1996). "The effects of medication on counselling". In Palmer S, Dainow S, Milner P (eds.). Counselling: The BACP Counselling Reader 1. Sage. pp. 211–4. ISBN 978-0-8039-7477-7.
  20. ↑ Ashton H (June 1987). "Benzodiazepine withdrawal: outcome in 50 patients". Br J Addict 82 (6): 665–71. doi:10.1111/j.1360-0443.1987.tb01529.x. PMID 2886145.
  21. ↑ Cosci F, Schruers KR, Abrams K, Griez EJ (June 2007). "Alcohol use disorders and panic disorder: a review of the evidence of a direct relationship". J Clin Psychiatry 68 (6): 874–80. doi:10.4088/JCP.v68n0608. PMID 17592911.
  22. ↑ Cosci F, Knuts IJ, Abrams K, Griez EJ, Schruers KR (May 2010). "Cigarette smoking and panic: a critical review of the literature". J Clin Psychiatry 71 (5): 606–15. doi:10.4088/JCP.08r04523blu. PMID 19961810.
  23. ↑ G. Liotti, (1996). Insecure attachment and agoraphobia, in: C. Murray-Parkes, J. Stevenson-Hinde, & P. Marris (Eds.). Attachment Across the Life Cycle.
  24. ↑ J. Bowlby, (1998). Attachment and Loss (Vol. 2: Separation).
  25. ↑ Jacobson K (2004). "Agoraphobia and Hypochondria as Disorders of Dwelling". International Studies in Philosophy 36: 31–44. doi:10.5840/intstudphil2004362165.
  26. ↑ Holmes J (2008). "Space and the secure base in agoraphobia: a qualitative survey". Area 40 (3): 357–382.
  27. ↑ J. Davidson, (2003). Phobic Geographies
  28. ↑ Holmes J (2006). "Building Bridges and Breaking Boundaries: Modernity and Agoraphobia". Opticon1826 1: 1. doi:10.5334/opt.010606.
  29. ↑ Bracha HS (2006). "Human brain evolution and the "Neuroevolutionary Time-depth Principle:" Implications for the Reclassification of fear-circuitry-related traits in DSM-V and for studying resilience to warzone-related posttraumatic stress disorder". Progress in Neuro-Psychopharmacology and Biological Psychiatry 30 (5): 827–853. doi:10.1016/j.pnpbp.2006.01.008. PMID 16563589.
  30. ↑ Raffaello S, Alessandra SM, Alessandra S (2011). "[Primary agoraphobia specific symptoms: from natural information to mental representations]" (PDF). Italian Journal of Psychopathology (in Italian) 17 (3): 265–276.
  31. ↑ Barlow DH (1988). Anxiety and its disorders: The nature and treatment of anxiety and panic. Guilford Press.
  32. ↑ http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001921/
  33. ↑ Kenny, Tim; Lawson, Euan. "Agoraphobia". Patient.co.uk. Retrieved 8 December 2014.
  34. ↑ Fava GA, Rafanelli C, Grandi S, Conti S, Ruini C, Mangelli L, Belluardo P (2001). "Long-term outcome of panic disorder with agoraphobia treated by exposure". Psychological Medicine (Cambridge University Press) 31 (5): 891–898. doi:10.1017/S0033291701003592. PMID 11459386.
  35. ↑ Goldstein, Alan J., de Beurs, Edwin, Chambless, Dianne L., Wilson, Kimberly A. (2000). "EMDR for Panic Disorder With Agoraphobia : Comparison With Waiting List and Credible Attention-Placebo Control Conditions". Journal of Consulting & Clinical Psychology 68 (6): 947–957. doi:10.1037/0022-006X.68.6.947.
  36. ↑ Agoraphobia Resource Center. "Agoraphobia treatments—Eye movement desensitization and reprogramming". Archived from the original on 5 April 2008. Retrieved 2008-04-18.
  37. ↑ National Institute of Mental Health. "How to get help for anxiety disorders". Retrieved 2008-04-18.
  38. ↑ Van Dover, J. Kenneth, At Wolfe's Door: The Nero Wolfe Novels of Rex Stout. Rockville, Maryland: James A. Rock & Company, 2003 (second edition) ISBN 0-918736-52-8 p. 2
  39. ↑ Dave Trumbore (October 10, 2013). "Bella Thorne and Kyra Sedgwick Tackle BIG SKY". Collider. Retrieved January 6, 2015.
  40. ↑ Magee WJ, Eaton WW, Wittchen HU, McGonagle KA, Kessler RC (Feb 1996). "Agoraphobia, simple phobia, and social phobia in the National Comorbidity Survey.". Arch Gen Psychiatry 53 (2): 159–68. doi:10.1001/archpsyc.1996.01830020077009. PMID 8629891.
  41. ↑ 41.0 41.1 Agoraphobia Research Center. "Is agoraphobia more common in men or women?". Archived from the original on 2 December 2007. Retrieved 2007-11-15.
  42. ↑ "Reconstructing Woody"
  43. ↑ "Kim Basinger". Nndb.com. Retrieved 2009-08-19.
  44. ↑ "Campbell Breaks Free Again" Los Angeles Times. Retrieved 2011-05-01
  45. ↑ "CNN.com – Transcripts". CNN. 2004-05-27. Retrieved 2009-08-07.
  46. ↑ Julia Moskin (February 28, 2007). "From Phobia To Fame: A Southern Cook's Memoir". The New York Times.
  47. ↑ Biography for Daryl Hannah. Internet Movie Database. Retrieved 28 November 2007.
  48. ↑ Hart, Miranda (December 4, 2010). "This Life: Miranda Hart on Finding Joy in Being Alone". The Daily Mail. Retrieved 4 December 2012.
  49. ↑ Psychological Autopsy can help understand controversial deaths—The Crime Library on truTV.com
  50. ↑ Olivia Hussey—People Magazine—March 16, 1992
  51. ↑ Olivia Hussey Biography—Internet Movie Database
  52. ↑ NYT Review by Joyce Carol Oates
  53. ↑ essay by Jonathan Lethem
  54. ↑ Mike Conklin. (2004-12-10). "Where is Elfriede Jelinek?". Chicago Tribune. Retrieved 2013-05-08.
  55. ↑ 'There’s a lot to be said for saying NO': Alison Moyet talks about her self-imposed exile from music. Daily Mail. Retrieved 2 October 2009 .
  56. ↑ Stanisław Fita, ed., Wspomnienia o Bolesławie Prusie (Reminiscences about Bolesław Prus), Warsaw, Państwowy Instytut Wydawniczy (State Publishing Institute), 1962, p. 113.
  57. ↑ Whatever Happened to the Gender Benders?, Channel 4 documentary, United Kingdom.
  58. ↑ Profile of Brian Wilson. The Independent. Retrieved 3 September 2007.

Further reading

External links

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