Agoraphobia
Encyclopedia
Agoraphobia is an anxiety disorder
defined as a morbid fear of having a panic attack
or panic-like symptoms in a situation from which it is perceived to be difficult (or embarrassing) to escape. These situations can include, but are not limited to, wide-open spaces, crowds, or uncontrolled social conditions. 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 from which they cannot easily escape if they have a panic attack. In severe cases, the sufferer may become confined to his or her home, unable to leave their 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. Agoraphobia, as studies have shown, has two age groups at which the first onset generally occurs — early to mid twenties and in the early thirties — thus helping to distinguish between simple phobias in child and adolescent years.
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 Panic and Agoraphobia Scale
can be used to measure agoraphobia and panic attacks severity and monitoring treatment.
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. 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, basically 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.
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 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.
, symptoms abated within the first year of assisted withdrawal.
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 (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 healthy subjects.
, have increasingly become interested in what may be thought of as a spatial phenomenon. One such approach links the development of agoraphobia with modernity.
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 being evolutionary 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.
(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.
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).
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.
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 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.
) class and include sertraline
, paroxetine
and fluoxetine
. Benzodiazepine
tranquilizers, MAO inhibitors and tricyclic antidepressants are also commonly prescribed for treatment of agoraphobia. Antidespressants 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.
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 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.
Anxiety disorder
Anxiety disorder is a blanket term covering several different forms of abnormal and pathological fear and anxiety. Conditions now considered anxiety disorders only came under the aegis of psychiatry at the end of the 19th century. Gelder, Mayou & Geddes explains that anxiety disorders are...
defined as a morbid fear of having a panic attack
Panic attack
Panic attacks are periods of intense fear or apprehension that are of sudden onset and of relatively brief duration. Panic attacks usually begin abruptly, reach a peak within 10 minutes, and subside over the next several hours...
or panic-like symptoms in a situation from which it is perceived to be difficult (or embarrassing) to escape. These situations can include, but are not limited to, wide-open spaces, crowds, or uncontrolled social conditions. Alternatively, social anxiety
Social anxiety
Social anxiety is anxiety about social situations, interactions with others, and being evaluated or scrutinized by other people...
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 from which they cannot easily escape if they have a panic attack. In severe cases, the sufferer may become confined to his or her home, unable to leave their 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. Agoraphobia, as studies have shown, has two age groups at which the first onset generally occurs — early to mid twenties and in the early thirties — thus helping to distinguish between simple phobias in child and adolescent years.
In response to a traumatic event, anxiety may interrupt the formation of memories and disrupt the learning processes, resulting in dissociation
Dissociation
Dissociation is an altered state of consciousness characterized by partial or complete disruption of the normal integration of a person’s normal conscious or psychological functioning. Dissociation is most commonly experienced as a subjective perception of one's consciousness being detached from...
. Depersonalization
Depersonalization
Depersonalization is an anomaly of the mechanism by which an individual has self-awareness. It is a feeling of watching oneself act, while having no control over a situation. Sufferers feel they have changed, and the world has become less real, vague, dreamlike, or lacking in significance...
(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 Panic and Agoraphobia Scale
Panic and Agoraphobia Scale
The Panic and Agoraphobia Scale is a rating scale developed for measuring severity of agoraphobia with or without panic attacks. The PAS scale contains 13 questions based on a five point Litkert scale...
can be used to measure agoraphobia and panic attacks severity and monitoring treatment.
Definition
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 disorderSocial anxiety disorder
Social anxiety disorder , also known as social phobia, is an anxiety disorder characterized by intense fear in social situations causing considerable distress and impaired ability to function in at least some parts of daily life...
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. 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
Panic disorder
Panic disorder is an anxiety disorder characterized by recurring severe panic attacks. It may also include significant behavioral change lasting at least a month and of ongoing worry about the implications or concern about having other attacks. The latter are called anticipatory attacks...
. 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.
It is not uncommon for agoraphobics to also suffer from temporary separation anxiety disorder
Separation anxiety disorder
Separation anxiety disorder is a psychological condition in which an individual experiences excessive anxiety regarding separation from home or from people to whom the individual has a strong emotional attachment...
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 necrophobia
Necrophobia
Necrophobia is the abnormal fear of dead things as well as things associated with death . Necrophobia is derived from Greek nekros for "corpse" and -phob- from the Greek phobos for "fear".With all types of emotions, obsession with death becomes evident in both fascination and...
, the 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. 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. Research has not yet produced a single clear explanation for the gender difference in agoraphobia.Causes and contributing factors
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. 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 dependenceBenzodiazepine dependence
Benzodiazepine dependence or benzodiazepine addiction is a condition during which a person is dependent on benzodiazepine drugs. Dependence can be either a psychological dependence, physical dependence, or a combination of the two...
, symptoms abated within the first year of assisted withdrawal.
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
Vestibular system
The vestibular system, which contributes to balance in most mammals and to the sense of spatial orientation, is the sensory system that provides the leading contribution about movement and sense of balance. Together with the cochlea, a part of the auditory system, it constitutes the labyrinth of...
, their visual system
Visual system
The visual system is the part of the central nervous system which enables organisms to process visual detail, as well as enabling several non-image forming photoresponse functions. It interprets information from visible light to build a representation of the surrounding world...
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
Virtual reality
Virtual reality , also known as virtuality, is a term that applies to computer-simulated environments that can simulate physical presence in places in the real world, as well as in imaginary worlds...
study, agoraphobics showed impaired processing of changing audiovisual data in comparison with healthy subjects.
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 geographyGeography
Geography is the science that studies the lands, features, inhabitants, and phenomena of Earth. A literal translation would be "to describe or write about the Earth". The first person to use the word "geography" was Eratosthenes...
, have increasingly become interested in what may be thought of as a spatial phenomenon. One such approach links the development of agoraphobia with modernity.
Evolutionary psychology
An evolutionary psychologyEvolutionary psychology
Evolutionary psychology is an approach in the social and natural sciences that examines psychological traits such as memory, perception, and language from a modern evolutionary perspective. It seeks to identify which human psychological traits are evolved adaptations, that is, the functional...
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
Specific phobia
A specific phobia is a generic term for any kind of anxiety disorder that amounts to an unreasonable or irrational fear related to exposure to specific objects or situations...
explained by it once having being evolutionary 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 disorderPanic disorder
Panic disorder is an anxiety disorder characterized by recurring severe panic attacks. It may also include significant behavioral change lasting at least a month and of ongoing worry about the implications or concern about having other attacks. The latter are called anticipatory attacks...
(American Psychiatric Association
American Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
, 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.
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
Agoraphobia Without History of Panic Disorder
Agoraphobia Without a History of Panic Disorder is an anxiety disorder characterized by extreme fear of experiencing panic symptoms, of panic attacks....
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, epinephrineEpinephrine
Epinephrine is a hormone and a neurotransmitter. It increases heart rate, constricts blood vessels, dilates air passages and participates in the fight-or-flight response of the sympathetic nervous system. In chemical terms, adrenaline is one of a group of monoamines called the catecholamines...
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.
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 desensitizationSystematic desensitization
Systematic desensitization is a type of behavioral therapy used in the field of psychology to help effectively overcome phobias and other anxiety disorders. More specifically, it is a type of Pavlovian therapy / classical conditioning therapy developed by a South African psychiatrist, Joseph Wolpe...
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
Cognitive restructuring
Cognitive restructuring, sometimes used synonymously with Debating, is the process of learning to identify irrational or maladaptive thoughts and challenge their veracity using strategies such as logical disputation....
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 inhibitorSelective serotonin reuptake inhibitor
Selective serotonin re-uptake inhibitors or serotonin-specific reuptake inhibitor are a class of compounds typically used as antidepressants in the treatment of depression, anxiety disorders, and some personality disorders. The efficacy of SSRIs is disputed...
) class and include sertraline
Sertraline
Sertraline hydrochloride is an antidepressant of the selective serotonin reuptake inhibitor class. It was introduced to the market by Pfizer in 1991. Sertraline is primarily used to treat major depression in adult outpatients as well as obsessive–compulsive, panic, and social anxiety disorders in...
, paroxetine
Paroxetine
Paroxetine is an SSRI antidepressant. Marketing of the drug began in 1992 by the pharmaceutical company SmithKline Beecham, now GlaxoSmithKline...
and fluoxetine
Fluoxetine
Fluoxetine is an antidepressant of the selective serotonin reuptake inhibitor class. It is manufactured and marketed by Eli Lilly and Company...
. Benzodiazepine
Benzodiazepine
A benzodiazepine is a psychoactive drug whose core chemical structure is the fusion of a benzene ring and a diazepine ring...
tranquilizers, MAO inhibitors and tricyclic antidepressants are also commonly prescribed for treatment of agoraphobia. Antidespressants 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.
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
Self-help
Self-help, or self-improvement, is a self-guided improvement—economically, intellectually, or emotionally—often with a substantial psychological basis. There are many different self-help movements and each has its own focus, techniques, associated beliefs, proponents and in some cases, leaders...
or support group
Support group
In a support group, members provide each other with various types of help, usually nonprofessional and nonmaterial, for a particular shared, usually burdensome, characteristic...
(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.
See also
- List of films featuring mental illness#Agoraphobia
- AgyrophobiaAgyrophobiaAgyrophobia is a case of specific phobia, the irrational fear that crossing roads will cause bodily harm to oneself, even if no actual threat is posed....
, fear of crossing roads - Enochlophobia, fear of crowds
- Generalized anxiety disorder
- HikikomoriHikikomoriis a Japanese term to refer to the phenomenon of reclusive people who have chosen to withdraw from social life, often seeking extreme degrees of isolation and confinement because of various personal and social factors in their lives...
- Obsessive compulsive disorder, which can feature specific fears that cause one to become homebound
- Post traumatic stress disorder
- Social anxietySocial anxietySocial anxiety is anxiety about social situations, interactions with others, and being evaluated or scrutinized by other people...
- Social phobiaSocial phobiaSocial phobia may refer to any of the following conditions:* Social anxiety disorder – a diagnosis referring to clinically excessive social anxiety...
- XenophobiaXenophobiaXenophobia is defined as "an unreasonable fear of foreigners or strangers or of that which is foreign or strange". It comes from the Greek words ξένος , meaning "stranger," "foreigner" and φόβος , meaning "fear."...
, fear of strangers