Agoraphobia

Not to be confused with Agraphobia.

Agoraphobia
Classification and external resources
Specialty	Psychiatry
ICD-10	F40.0
ICD-9-CM	300.22 Without panic disorder, 300.21 With panic disorder
MedlinePlus	000923
Patient UK	Agoraphobia
MeSH	D000379

Agoraphobia is an anxiety disorder characterized by anxiety in situations where the sufferer perceives the environment to be dangerous, uncomfortable, or unsafe. These situations can include wide-open spaces, uncontrollable social situations, unfamiliar places, shopping malls, airports, and 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 sufferers may go to great lengths to avoid those situations, in severe cases becoming unable to leave their homes or safe havens.

Although mostly thought to be a fear of public places, it is now believed that agoraphobia develops as a complication of panic attacks. However, evidence indicates 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. About 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 about 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 (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.

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

The term "agoraphobia" was coined by the German psychiatrist Carl Friedrich Otto Westphal, from Greek ἀγορά, meaning "large public square/marketplace" and -φοβία, -phobia, meaning "fear".

Signs and symptoms

Agoraphobia is a condition where sufferers become anxious in unfamiliar environments or where they perceive 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. Most of the time they avoid these areas and stay in the comfort of their safe haven. This is also sometimes called "social agoraphobia", which may be a subtype of social anxiety disorder.

Not all agoraphobia is social in nature, however. Some agoraphobics have an exclusive 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 at a previous time. Fearing the onset of another panic attack, the sufferer is fearful or even avoids location. Some refuse to leave their homes even in medical emergencies because the fear of being outside of their comfort areas 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.

The sufferers 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 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.

Agoraphobics not uncommonly 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 feeling 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 emotional comfort and safety zones and loved ones, even for those who may otherwise believe in some form of afterlife.

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, 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 behaviors.

Causes

Although the exact causes of agoraphobia are 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 link 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 (as in wide-open spaces) or overwhelming (as in crowds). 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 nonsuffering 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

Main article: 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, a perceived clinical bias exists 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 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. Agoraphobia with panic attack, though, 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. Early treatment of panic disorder can often prevent agoraphobia. Agoraphobia is typically determined when symptoms are worse than panic disorder, but also do not meet the criteria for other anxiety disorders such as depression. 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. Similarly, systematic desensitization may also be used. Many patients can deal with exposure easier if they are in the company of a friend on whom they can rely. Patients must 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

Antidepressant medications most commonly used to treat anxiety disorders are mainly selective serotonin reuptake inhibitors. 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. A combination of medication and cognitive behaviour therapy is sometimes the most effective treatment for agoraphobia.

Benzodiazepines, antianxiety medications such as alprazolam and clonazepam, 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, and memory loss.

Alternative treatments

Eye movement desensitization and reprogramming (EMDR) 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 (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 and visualization techniques can help people with anxiety disorders calm themselves and may enhance the effects of therapy, as can service to others, which can distract from the self-absorption that tends to go with anxiety problems. Also, preliminary evidence suggests 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: sociocultural traditions that encourage, or permit, the greater expression of avoidance coping strategies by women (including dependent and helpless behaviors), women perhaps being more likely to seek help and therefore be diagnosed, and 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

• Will Friedle (b. 1976) American actor, known for role of Eric in Boy Meets World
• Woody Allen (b. 1935), American actor, director, musician
• Kim Basinger (b. 1953), American actress
• Earl Campbell (b. 1955), American pro football player
• Macaulay Culkin (b. 1980), American actor, known for his portrayal of Kevin McCallister in Home Alone and Home Alone 2: Lost in New York, said he had "self-diagnosed" agoraphobia.
• Paula Deen (b. 1947), American chef, author, and television personality
• H.L. Gold (1914–1996), science fiction editor - as a result of trauma during his wartime experiences, his agoraphobia became so severe that for more than two decades he was unable to leave his apartment. Towards the end of his life, he acquired some control over the condition.
• Daryl Hannah (b. 1960), American actress
• Miranda Hart, English comedienne and actor, known for her portrayal of Miranda in her self-titled sitcom
• Howard Hughes (1905–1976), American aviator, industrialist, film producer and philanthropist
• Olivia Hussey (b. 1951), Anglo-Argentine actress
• Shirley Jackson (1916–1965), American writer - her agoraphobia is considered to be a primary inspiration for the novel, We Have Always Lived in the Castle.
• Elfriede Jelinek (b. 1946), Austrian writer, Nobel Prize laureate in Literature in 2004
• Alison Moyet (b. 1961), English singer
• Bolesław Prus (1847–1912), Polish journalist and novelist
• Peter Robinson (1962–), British musician known as Marilyn
• Brian Wilson (b. 1942), American singer and songwriter, primary songwriter of the Beach Boys, a former recluse and agoraphobic who has schizophrenia

See also

• Ochlophobia: a fear of crowds but not of open-spaces.
• Enochlophobia: a fear of large crowds.
• 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
• Specific social phobia
• Xenophobia, fear of strangers

Further reading

• David (pseud.) (1946) The Autobiography of David, Edited by Ernest Raymond, Ed.V. Gollancz Ltd., London OCLC 1135847 – The memoir of an agoraphobiac

External links

• Support Group Providers for Agoraphobia at DMOZ This article incorporates public domain material from websites or documents of the National Institute of Mental Health.