What is Agoraphobia? (Sadock, et al., 2017)
Agoraphobia is defined as intense fear or anxiety triggered by the real or anticipated exposure to multiple public situations, such as open or enclosed spaces. It is a type of anxiety disorder. Agoraphobia literally means fear of the marketplace, symbolizing a fear of open spaces. Patients with agoraphobia specifically fear the panic or shame that can develop in public situations which they cannot escape or where they cannot get help (e.g., traveling in a bus or train, being in a crowd, being on a bridge). Agoraphobia is now a separate diagnosis in DSM-5, recognizing that it can exist without panic attacks.
The fear or anxiety is “out of proportion” to the real threat. Patients with agoraphobia may develop “panic-like” symptoms, and other psychosomatic symptoms, often gastrointestinal or autonomic, associated with fear or anxiety. This can lead to major life dysfunction. Eventually, patients may avoid all employment and in-person social interactions.
Around 0.8% of adults in America have agoraphobia. More women than men have agoraphobia and the age of onset peaks in the late teens to early twenties. It is, in part, heritable, with certain personality factors predicting the onset, as well. Agoraphobia, if left untreated, is both chronic and persistent, with complete remission rates of about 10% (American Psychiatric Association, 2013).
Symptoms of Agoraphobia (NHS UK, 2018)
Symptoms of agoraphobia include fear of:
- Leaving home alone
- Being in a crowd
- Enclosed spaces – elevators, theaters, restaurants, stores, etc.
- Open spaces – parking lots, malls, bridges, etc.
- Using public transportation
People with agoraphobia experience anxiety in these situations because they fear they will not be able to escape or find help if they start to have embarrassing symptoms. Hence, they indulge in avoidance behaviors, such as ordering groceries online to avoid a visit to the grocery store, not leaving home or leaving home in the company of someone, etc.
Symptoms similar to those of a panic attack can occur if they find themselves in a public situation that triggers them, including:
- Increased heart rate
- Rapid breathing
- Excessive sweating
- Chest discomfort or pain
- Trembling and shaking
- Dizziness and lightheadedness
- Feeling faint
In addition, you could have fears that in the places that trigger your agoraphobia:
- You cannot escape the situation or get help for your symptoms
- You will look stupid or feel embarrassed in front of other people
- Your heart might stop
- You may be unable to breathe
- You may vomit or faint
- You might fall (in older people)
- You might be incontinent (in older people)
Causes of Agoraphobia (Harrison, et al., 2018)
The exact cause of agoraphobia is unknown. Several theories have been put forward to explain both the initial anxiety attack and its spread and maintenance.
Agoraphobia begins with anxiety in a public place—generally, but not always, as a panic attack. There are three explanations given for the initial anxiety:
The cognitive hypothesis proposes that the anxiety attack develops because the person is unreasonably afraid of the situation or of certain symptoms that are experienced in the situation.
The biological theory says that it results from certain environmental stimuli acting on an individual who is constitutionally predisposed to over-respond with anxiety. There is some evidence for a genetic component to this predisposition, in that relatives of people with agoraphobia are at increased risk of experiencing an anxiety disorder themselves.
The psychoanalytic theory proposes that it is caused by unconscious mental conflicts related to unacceptable sexual or aggressive impulses triggered indirectly by the original situation. Evidence is lacking for this theory.
Theories of the spread and maintenance of agoraphobia symptoms are:
Learning theories. Conditioning could account for the association of anxiety with increasing numbers of situations, and avoidance learning could account for the subsequent avoidance of these situations. There is no direct evidence to support it.
Personality. Agoraphobic patients are often described as dependent, and prone to avoiding rather than confronting problems. This dependency could be a result of overprotection in childhood, which is seen more often in agoraphobic individuals than in controls.
Family influences. In some cases, family problems and overprotective attitudes of other family members could be contributory factors.
Risk factors for agoraphobia include:
- Having panic disorder or other phobias
- Excessive fear and avoidance of panic attacks
- Stress, such as physical or sexual abuse, the death of a loved one or being attacked
- Anxious or nervous temperament
- Family history of agoraphobia
Diagnosis of Agoraphobia
DSM-5 gives the following diagnostic criteria for agoraphobia (American Psychiatric Association, 2013):
- Marked fear or anxiety about two (or more) of the following five situations:
- Using public transportation.
- Being in open spaces (e.g., parking lots, marketplaces, bridges).
- Being in enclosed places (e.g., shops, elevators, cinemas).
- Standing in line or being in a crowd.
- Being alone outside the home.
- They fear and avoid these situations because escape may be difficult or help may not be available should panic-like symptoms or other incapacitating or embarrassing symptoms develop (e.g., fear of falling in the elderly; fear of incontinence).
- These situations provoke fear or anxiety.
- These situations are avoided, or require the company of another person, or are endured with intense fear or anxiety.
- The fear or anxiety is out of proportion to the actual danger and to the sociocultural context.
- These symptoms last for 6 months or more.
- The symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning.
- The fear or anxiety is not better explained by another medical condition or another mental disorder—for example, specific phobia; social anxiety disorder; obsessive-compulsive disorder; body dysmorphic disorder; posttraumatic stress disorder; separation anxiety disorder.
Treatment of Agoraphobia (NHS UK, 2018)
Lifestyle Changes and Self-help Techniques
Lifestyle changes may help, including:
- Regular exercise – relieves stress and tension, and improves mood
- Eating healthy food – a poor diet can worsen the symptoms
- Avoiding alcohol and drugs – alcohol and drugs worsen the symptoms
- Avoiding caffeinated drinks, such as tea, coffee, and cola – these drinks worsen symptoms
Self-help techniques that can help during a panic attack include:
- Staying where you are – do not give in to the urge to run to a place of safety; if you are driving, pull over and park where it’s safe to do so.
- Focusing on something that’s non-threatening and visible, such as looking at your watch, or items in a supermarket; remind yourself the symptoms will eventually pass.
- Breathing slowly and deeply – quick and shallow breathing can worsen the symptoms.
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) tries to correct unhelpful and unrealistic thinking that leads to negative behavior. The therapist will do this by teaching you new ways of thinking that can lead to more positivity in your thinking and behavior. For example, he will correct your unrealistic thought that a panic attack will kill you, by encouraging a more positive way of thinking – for example, by making you realize that although having a panic attack may be unpleasant, it isn’t fatal and will pass. This can make the person more willing to confront situations that previously scared them.
CBT is usually combined with exposure therapy, wherein initially you will be made to go to the local corner shop. As your confidence increases, you will be made to tackle more challenging goals, such as going to a large supermarket or having a meal in a busy restaurant.
A course of CBT usually consists of 12 to 15 weekly sessions, with each session lasting about an hour.
Medication can also be used in combination with CBT. The medications found effective are antidepressants, and on a short-term basis, benzodiazepines. It may take trial-and-error to find the right medication. Even then it may take a few weeks for symptoms to improve with the medication.
Antidepressants. SSRIs, such as fluoxetine (Prozac) and sertraline (Zoloft), and other types of antidepressants can be effective in the treatment of agoraphobia.
Benzodiazepines. Anti-anxiety drugs called benzodiazepines are sedatives. They should be used only on a short-term basis to relieve anxiety because they can be habit-forming.
American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Publishing.
Harrison, P., Cowen, P., Burns, T. & Fazel, M., 2018. Shorter Oxford Textbook of Psychiatry. 7 ed. Oxford: Oxford University Press.
NHS UK, 2018. Symptoms: Agoraphobia. [Online]
Available at: https://www.nhs.uk/conditions/agoraphobia/
[Accessed 29 Nov 2019].
Sadock, B. J., Sadock, V. A. & Ruiz, P., 2017. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 10th ed. Philadelphia: Wolters Kluwer.