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'''For patient information click [[Agoraphobia (patient information)|here]]'''
'''For patient information click [[Agoraphobia (patient information)|here]]'''


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{{SI}}
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{{CMG}}; {{AE}} {{KS}}, {{HW}}, {{I.D.}}


==Overview==
==Overview==
'''Agoraphobia''' is an [[anxiety disorder]] which primarily consists of the fear of experiencing a difficult or embarrassing situation from which the sufferer cannot escape. In more specific and analytical terms, it is actually a fear of [[panic attack]]s; literally, a fear of fear. As a result, severe sufferers of agoraphobia may become confined to their homes, experiencing difficulty traveling from this "safe place."
Agoraphobia is an [[Anxiety disorders|anxiety disorder]] characterized by intense terror and [[anxiety]] over any place or situation from which one might not easily be able to escape. This often leads sufferers to avoid leaving their homes, using public transportation or air travel, or being in crowded spaces. The average [[age of onset]] of agoraphobia is 20 years. Agoraphobia is closely associated with [[panic disorder]]; the two are commonly [[comorbid]]. Patients with agoraphobia often exhibit [[depressive]] symptoms, as well as social or specific [[phobias]], which can make the disorder difficult to diagnose. Patients with severe agoraphobia may become confined to their homes. The word "agoraphobia" is an English adoption of the [[Greek language|Greek]] words ''agora'' (αγορά) and ''phobos'' (φόβος), literally translated as "a fear of the marketplace."  This etymology is the reason for the common misconception that agoraphobia is a fear of open spaces.
 
==Historical Perspective==
*In 1871, Agoraphobia was first described by Karl Friedrich Otto Westphal, a German psychiatrist.
*Westphal coined the term after observing three of his patients, who exhibited severe [[anxiety]] and dread upon traveling to certain public areas of Berlin, in the city where he worked.
 
==Classification==
*The [[DSM|DSM-V]], released in 2013, classifies agoraphobia as a [[phobia]].<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*The ICD-10 places agoraphobia under the subcategory of "Phobic anxiety disorders," which falls under the category of "Neurotic, [[stress|stress-related]] and [[somatoform disorders]]."<ref name="#7">World Heart Organization (WHO). International Statistical Classification of Diseases and Related Health Problems 10 (ICD-10). Geneva, Switzerland. Retrieved 29 September 2016.</ref>
*Within the former subcategory, agoraphobia is grouped together with:<ref name="#7" />
**[[Social phobia|Social phobias]]
**Specific/isolated phobias
**Other [[phobic anxiety disorders]]
**[[Phobic anxiety disorder]], unspecified
 
*Though some experts have argued that agoraphobia can reasonably be thought of as a severe consequence of [[panic disorder]], a comparison of the multivariate comorbidity patterns of agoraphobia and [[panic disorder]] supports the independent classification of these disorders.<ref name="pmid26480214">{{cite journal| author=Greene AL, Eaton NR| title=Panic disorder and agoraphobia: A direct comparison of their multivariate comorbidity patterns. | journal=J Affect Disord | year= 2016 | volume= 190 | issue=  | pages= 75-83 | pmid=26480214 | doi=10.1016/j.jad.2015.09.060 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26480214  }} </ref>


==Definition==
==Pathophysiology==
The word "agoraphobia" is an English adoption of the [[Greek language|Greek]] words ''[[agora]]'' (αγορά) and ''[[phobos]]'' (φόβος), literally translated as "a fear of the marketplace."  This translation is the reason for the common misconception that agoraphobia is a fear of open spaces, and is not clinically accurate.


Agoraphobia describes a condition where the sufferer becomes uneasy is environments that are unfamiliar or where he/she perceives that he has little control.  Triggers may include crowds, wide open spaces or traveling alone even for short distances.  The anxiety is often compounded by a fear of social embarrassment in case of [[panic attacks]] or appearing distraught i,n public.<ref>http://psychcentral.com/disorders/sx29.htm</ref>
===Relationship to Balance Disorders===
*Agoraphobia may be related to defects in balance. Researchers who noticed a similarity between the situations commonly avoided by sufferers of agoraphobia and the types of environments that trigger disorientation in people with balance disorders administered a battery of audiovestibular tests, coupled with moving platform posturography, to 36 subjects with agoraphobic symptoms and 20 normal, healthy controls.
**Over 60% of the former group were destabilized by these disorienting conditions, compared to a mere 10% of the control group.
**Postural instability was found to be highly related to agoraphobic avoidance (r = 0.63, P < 0.01), event after the researchers controlled for [[symptoms]], [[anxiety]], and [[agoraphobic cognitions]].<ref name="pmid7755529">{{cite journal| author=Yardley L, Britton J, Lear S, Bird J, Luxon LM| title=Relationship between balance system function and agoraphobic avoidance. | journal=Behav Res Ther | year= 1995 | volume= 33 | issue= 4 | pages= 435-9 | pmid=7755529 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7755529  }} </ref>


People with agoraphobia may experience [[panic attack]]s in situations where they feel trapped, insecure, out of control, or too far from their personal [[comfort zone]]. In severe cases, an agoraphobic may be confined to their home. <ref name="NIH91">{{Citation | title=Treatment of Panic Disorder | journal=NIH Consens Statement | date=Sep 25-27, 1991 | volume=9 | issue=2 | pages=1-24 |url=http://consensus.nih.gov/1991/1991PanicDisorder085html.htm}}</ref> Some people with agoraphobia are comfortable seeing visitors, but only in a defined space they feel in control of. Such people may live for years without leaving their homes, while happily seeing visitors and working, as long as they can stay within their safety zones. The safety zones can vary, from not being able to leave home, or not being able to make eye contact. If the person leaves their 'safety zone' they can have an anxiety attack.
===Attachment Theory===
*Some scholars (e.g., Liotti  1996, Bowlby 1998) have explained agoraphobia as an [[attachment]] deficit, i.e., the temporary loss of the ability to tolerate spatial separations from a secure base.<ref>G. Liotti, (1996). ''Insecure attachment and agoraphobia'', in: C. Murray-Parkes, J. Stevenson-Hinde, & P. Marris (Eds.). Attachment Across the Life Cycle.</ref><ref>J. Bowlby, (1998). ''Attachment and Loss'' (Vol. 2: Separation).</ref>
 
===Spatial Theory===
*In the social sciences, there is a perceived clinical bias (e.g., Davidson 2003) in agoraphobia research. Branches of the social sciences, especially geography, have increasingly become interested in what may be thought of as a spatial phenomenon.<ref>J. Davidson, (2003). ''Phobic Geographies''</ref>
 
===Associated Conditions===
*Commonly comorbid conditions include:<ref name="pmid26487813">{{cite journal| author=Bandelow B, Michaelis S| title=Epidemiology of anxiety disorders in the 21st century. | journal=Dialogues Clin Neurosci | year= 2015 | volume= 17 | issue= 3 | pages= 327-35 | pmid=26487813 | doi= | pmc=4610617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26487813  }} </ref>
**[[Panic disorder]]
**[[SAD]]
**[[Specific phobia]]


==Differential Diagnosis==
==Differential Diagnosis==
 
*Agoraphobia must be differentiated from other disorders with similar [[symptomology]], including:<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
**[[Acute stress disorder]]
**[[Major depressive disorder]]
**Other medical conditions
***[[Parkinson's disease]]
***[[Multiple sclerosis]]
**[[Panic disorder]] without agoraphobia
**[[Post traumatic stress disorder]]
**[[Separation anxiety disorder]]
**[[Social anxiety disorder]] ([[social phobia]])
**Specific [[phobia]], situational type


==Epidemiology and Demographics==
==Epidemiology and Demographics==
===Prevalence===
===Prevalence===
The prevalence of agoraphobia is 1,700 per 100,000 (1.7%) of the overall population.<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*The prevalence of agoraphobia is 1,700 per 100,000 (1.7%) of the overall population.<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>


==Prevalence==
===Age===
The one-year prevalence of agoraphobia is about 5 percent. <ref> {{cite book | year=2006 | publisher=NIH Publication No. 06-3879 | title='''Anxiety Disorders''' | url=http://www.nimh.nih.gov/publicat/NIMHanxiety.pdf}} </ref> About one third of people with [[Panic Disorder]] progress to develop Agoraphobia. <ref> {{Citation | year=1991 | editor-last=Robins |editor-first=LN | editor2-last=Regier | editor2-first=DN | title='''Psychiatric Disorders in America: the Epidemiologic Catchment Area Study''' | publisher=The Free Press | location=New York, NY}} </ref> Agoraphobia occurs about twice as commonly among women as it does in men (Magee et al., 1996<ref>Magee, W. J., Eaton, W. W. , Wittchen, H. U., McGonagle, K. A., & Kessler, R. C. (1996). ''Agoraphobia, simple phobia, and social phobia in the National Comorbidity Survey'', Archives of General Psychiatry, 53, 159–168.</ref>).
*Among children, ages 13 to 18, there is a lifetime prevalence of 2,400 per 100,000 (2.4%) for agoraphobia.<ref name="pmid20855043">{{cite journal| author=Merikangas KR, He JP, Burstein M, Swanson SA, Avenevoli S, Cui L et al.| title=Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication--Adolescent Supplement (NCS-A). | journal=J Am Acad Child Adolesc Psychiatry | year= 2010 | volume= 49 | issue= 10 | pages= 980-9 | pmid=20855043 | doi=10.1016/j.jaac.2010.05.017 | pmc=2946114 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20855043  }} </ref>
*Among adults in the United States, agoraphobia has a 12-month prevalence of  800 per 100,000 (0.8%). 40.6% of these cases are classified as "severe."<ref name="pmid15939837">{{cite journal| author=Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE| title=Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. | journal=Arch Gen Psychiatry | year= 2005 | volume= 62 | issue= 6 | pages= 593-602 | pmid=15939837 | doi=10.1001/archpsyc.62.6.593 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15939837  }} </ref>


==Risk Factors==
===Gender===
*No gender disparity in the incidence of agoraphobia has been widely established.<ref name="pmid15939837">{{cite journal| author=Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE| title=Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. | journal=Arch Gen Psychiatry | year= 2005 | volume= 62 | issue= 6 | pages= 593-602 | pmid=15939837 | doi=10.1001/archpsyc.62.6.593 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15939837  }} </ref>
*Some studies have suggested that [[panic disorder]] patients with agoraphobia are more likely to be female than patients who have [[panic disorder]] but not agoraphobia. Female patients were also found to have a higher prevalence of [[comorbidities]].<ref name="pmid27423353">{{cite journal| author=Inoue K, Kaiya H, Hara N, Okazaki Y| title=A discussion of various aspects of panic disorder depending on presence or absence of agoraphobia. | journal=Compr Psychiatry | year= 2016 | volume= 69 | issue=  | pages= 132-5 | pmid=27423353 | doi=10.1016/j.comppsych.2016.05.014 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27423353  }} </ref>


===Race===
*No racial predilection has been established for agoraphobia.<ref name="pmid15939837">{{cite journal| author=Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE| title=Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. | journal=Arch Gen Psychiatry | year= 2005 | volume= 62 | issue= 6 | pages= 593-602 | pmid=15939837 | doi=10.1001/archpsyc.62.6.593 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15939837  }} </ref>


==Risk Factors==
*The exact cause of agoraphobia is unknown. In some instances, someone who has a panic attack may begin to exhibit signs of agoraphobia out of fear that another panic attack will occur.<ref name="#8">NIH: U.S. National Library of Medicine. (2016). Agoraphobia. https://medlineplus.gov/ency/article/000923.htm Retrieved 29 September 2016.</ref>
*Risk factors for agoraphobia include:<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
**[[Anxiety]] sensitivity
**Behavioral inhibition
**[[Genetic predisposition]]
**Neurotic disposition ([[neuroticism]])
**Negative events in childhood
***Separation/divorce of parents
***Death of parent
***Bullying
**Stressful or traumatic events (e.g., being attacked or mugged)


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==


===Natural History===
*People with agoraphobia may experience [[panic attack]]s in situations in which they feel trapped, insecure, out of control, or too far from their personal comfort zone. In severe cases, an agoraphobic person may be completely confined to his or her home.<ref name="NIH91">{{Citation | title=Treatment of Panic Disorder | journal=NIH Consens Statement | date=Sep 25-27, 1991 | volume=9 | issue=2 | pages=1-24 |url=http://consensus.nih.gov/1991/1991PanicDisorder085html.htm}}</ref>
**Some people with agoraphobia are comfortable seeing visitors, but only in a defined space in which they feel in control.
***Such people may live for years without leaving their homes, while happily seeing visitors and working, as long as they can stay within their safety zones.
***If someone suffering from agoraphobia leaves his or her "safety zone," an [[anxiety]] attack may occur.
**Agoraphobia patients can experience sudden panic attacks when traveling to places where they fear, where help would be difficult to obtain. During a panic attack, [[adrenaline]] is released in large amounts for several minutes causing the classical "fight or flight" condition.
***The attack typically has an abrupt onset, building to maximum intensity within 10 to 15 minutes, and rarely lasts longer than 30 minutes. <ref name="NIH4.2">{{cite book | year=1999 | chapter=Chapter 4.2| author=David Satcher etal.| title='''Mental Health: A Report of the Surgeon General'''| url=http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec2.html}}</ref>
***These symptoms include palpitations, sweating, trembling, and shortness of breath. Many patients report a fear of dying, or losing control of emotions or behavior. <ref name="NIH4.2" />


===Complications===
*Complications associated with agoraphobia may encompass physical, behavioral, or lifestyle changes.
**The avoidance behaviors associated with agoraphobia are established correlates of treatment discontinuation.<ref name="pmid27385412">{{cite journal| author=Bélanger C, Courchesne C, Leduc AG, Dugal C, El-Baalbaki G, Marchand A et al.| title=Predictors of Dropout From Cognitive-Behavioral Group Treatment for Panic Disorder With Agoraphobia: An Exploratory Study. | journal=Behav Modif | year= 2016 | volume=  | issue=  | pages=  | pmid=27385412 | doi=10.1177/0145445516656614 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27385412  }} </ref>
**Individuals with agoraphobia are more likely to show signs of decreased assertiveness, perhaps because their illness cultivates feelings of helplessness and insecurity.<ref name="pmid26915016">{{cite journal| author=Levitan MN, Simoes P, Sardinha AG, Nardi AE| title=Agoraphobia Related to Unassertiveness in Panic Disorder. | journal=J Nerv Ment Dis | year= 2016 | volume= 204 | issue= 5 | pages= 396-9 | pmid=26915016 | doi=10.1097/NMD.0000000000000486 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26915016  }} </ref>
**The avoidance of places or structures in which panic attacks have occurred may limit a patient’s job prospects or proximity to desirable facilities or services.<ref name="#9">NIH: U.S. National Library of Medicine. (2016). About Panic and Agoraphobia. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0024921/ Retrieved 29 September 2016.</ref>


===Prognosis===
*The prognosis of agoraphobia depends upon the severity of the disease.
*The prognosis is generally good with early medical intervention; if left untreated, the disorder may become more difficult for healthcare providers to effectively manage.<ref name="#8" />


==Diagnosis==
==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 the subsequent worry, preoccupation, and avoidance.<ref>{{cite book | year=1988| author=Barlow, D. H.| title='''Anxiety and its disorders: The nature and treatment of anxiety and panic'''| publisher=Guilford Press}}</ref> Thus, the formal diagnosis of panic disorder with agoraphobia was established. However, for those people in communities or clinical settings who do not meet full criteria for [[panic disorder]], the formal diagnosis of [[Agoraphobia Without History of Panic Disorder]] is used ([[DSM-IV]]).
===Diagnostic Criteria===


==Diagnostic Criteria==
====DSM-V Diagnostic Criteria for Agoraphobia====


 
The fifth version of the DSM, released in 2013, sets forth the following as diagnostic criteria for agoraphobia:<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
===DSM-V Diagnostic Criteria for Intellectual Disability<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>===
{{cquote|
{{cquote|


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'''''AND'''''
'''''AND'''''


*H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease) is present, the fear, anxiety, or avoidance is clearly excessive.
*H. If another medical condition (e.g., [[inflammatory bowel disease]], [[Parkinson’s disease]]) is present, the fear, anxiety, or avoidance is clearly excessive.


'''''AND'''''
'''''AND'''''


*I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder—for example, the symptoms are not confined to specific phobia, situational
*I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder—for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in [[social anxiety disorder]]): and are not related exclusively to obsessions (as in [[obsessive-compulsive disorder]]),perceived defects or flaws in physical appearance (as in body dysmorhic disorder), reminders of traumatic events (as in [[post traumatic stress disorder]]), or fear of separation (as in [[separation anxiety disorder]]).  
type; do not involve only social situations (as in social anxiety disorder): and are not related exclusively to obsessions (as in obsessive-compulsive disorder), perceived defects or flaws in physical appearance (as in [[body dysmorhic disorder]]), reminders of traumatic events (as in [[post traumatic stress disorder]]), or fear of separation (as in separation anxiety disorder).  
 
<SMALL>''Note:Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned .''</SMALL>


<SMALL>''Note: Agoraphobia is diagnosed irrespective of the presence of [[panic disorder]]. If an individual’s presentation meets criteria for [[panic disorder]] and agoraphobia, both diagnoses should be assigned.''</SMALL>
}}
}}


==Association with panic attacks==
===History and Symptoms===
{{main|Panic attack}}
Symptoms of agoraphobia may include the following:<ref name="#8" />
Agoraphobia patients can experience sudden panic attacks when traveling to places where they fear, where help would be difficult to obtain. During a panic attack, adrenaline is released in large amounts for several minutes causing the classical "fight or flight" condition. The attack typically has an abrupt onset, building to maximum intensity within 10 to 15 minutes, and rarely lasts longer than 30 minutes. <ref name="NIH4.2">{{cite book | year=1999 | chapter=Chapter 4.2| author=David Satcher etal.| title='''Mental Health: A Report of the Surgeon General'''| url=http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec2.html}}</ref> These symptoms include palpitations, sweating, trembling, and shortness of breath. Many patients report a fear of dying, or losing control of emotions or behavior. <ref name="NIH4.2"/>
*Fear of crowds, bridges, and/or being outside alone
*Fear of losing control of oneself in a public place
*Feeling dependent upon others
*Feeling [[helpless]]
*Feeling that one’s body or surroundings are not real
*Being easily agitated or angered
*Staying in one’s house for long periods of time
*[[Self-medication]] with drugs or alcohol
*Inability to function at work or other inherently social settings
*[[Depression]] or suicidal ideation


==Treatments==
If agoraphobic patients find themselves in a situation that triggers their anxiety, symptoms may include the following:<ref name="#8" />
Agoraphobia can be successfully treated in many cases through a very gradual process of [[graduated exposure therapy]] combined with [[cognitive therapy]] and sometimes [[anti-anxiety]] or [[antidepressant]] medications.  Treatment options for agoraphobia and [[panic disorder]] are similar.
*Powerful sensations of [[panic]] and [[distress]]
*[[Tachycardia]]
*[[Chest pain]] or discomfort
*[[Choking]]
*[[Dizziness]] or [[syncope]]
*[[Dyspnea]]
*[[Sweating]]
*[[Tremors]]


[[Graduated exposure therapy|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. <ref> {{cite journal | last1=Fava | first1=G.A. | last2=Rafanelli | first2=C. | last3=Grandi | first3=S. | last4=Cinto | first4=S. | last5=Ruini | first5=C. | title=Long-term outcome of panic disorder with agoraphobia treated by exposure | journal=Psychological Medicine | volume=31 | pages=891-898 | publisher=Cambridge University Press}}</ref>
===Physical Examination===
*Healthcare providers will examine a patient who is exhibiting signs of agoraphobia for a history of panic disorders.
*The clinician will also get a description of the relevant symptoms and behaviors of the patient and, if possible, from any family members or friends who might have knowledge of relevant behaviors.<ref name="#8" />


Anti-anxiety medications include [[benzodiazepines]] such as [[alprazolam]]. Anti-depressant medications which are used to treat anxiety disorders are mainly in the SSRI ([[selective serotonin reuptake inhibitor]]) class such as [[sertraline]], [[paroxetine]] and [[fluoxetine]]. [[Hypnosis]] is a possible alternative treatment. {{fact|date=July 2007}}
==Treatment==


==Alternate theories==
===Medical Therapy===
===Attachment theory===
*The mainstay of therapy for agoraphobia is a combination of [[CBT]], [[talk therapy]], and [[medicine]]. Certain drugs that are regularly used to treat [[depression]], such as [[SSRI|SSRIs]] and [[SNRI|SNRIs]], may also be helpful in the treatment of agoraphobia.<ref name="#8" />
Some scholars (e.g., Liotti  1996,<ref>G. Liotti, (1996). ''Insecure attachment and agoraphobia'', in: C. Murray-Parkes, J. Stevenson-Hinde, & P. Marris (Eds.). Attachment Across the Life Cycle.</ref> [[Bowlby]] 1998<ref>J. Bowlby, (1998). ''Attachment and Loss'' (Vol. 2: Separation).</ref>) have explained agoraphobia as an [[attachment]] deficit, i.e., the temporary loss of the ability to tolerate spatial separations from a secure base.
**Treatment delivery factors, particularly therapist adherence, are important indicators of the potential for successful [[CBT]].<ref name="pmid27235836">{{cite journal| author=Weck F, Grikscheit F, Höfling V, Kordt A, Hamm AO, Gerlach AL et al.| title=The role of treatment delivery factors in exposure-based cognitive behavioral therapy for panic disorder with agoraphobia. | journal=J Anxiety Disord | year= 2016 | volume= 42 | issue=  | pages= 10-8 | pmid=27235836 | doi=10.1016/j.janxdis.2016.05.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27235836  }} </ref>
**Studies have shown that therapist-directed [[CBT]] has a more significant impact on agoraphobic [[psychopathology]] in the short-term than do [[SSRIs]]/[[SNRIs]].<ref name="pmid26837851">{{cite journal| author=Liebscher C, Wittmann A, Gechter J, Schlagenhauf F, Lueken U, Plag J et al.| title=Facing the fear--clinical and neural effects of cognitive behavioural and pharmacotherapy in panic disorder with agoraphobia. | journal=Eur Neuropsychopharmacol | year= 2016 | volume= 26 | issue= 3 | pages= 431-44 | pmid=26837851 | doi=10.1016/j.euroneuro.2016.01.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26837851  }} </ref>
**At a physician’s discretion, [[sedatives]] or [[hypnotics]] may also be prescribed. A physician may advise an agoraphobic patient to take such drugs when the symptoms of agoraphobia are particularly severe or as a preventive measure, when one expects to be exposed to a triggering situation.<ref name="#8" />


===Spatial theory===
===Surgery===
In the social sciences there is a perceived clinical bias (e.g., Davidson 2003<ref>J. Davidson, (2003). ''Phobic Geographies''</ref>) in agoraphobia research. Branches of the social sciences, especially [[geography]], have increasingly become interested in what may be thought of as a [[spatial]] phenomenon.
*Surgical intervention is not recommended for the management of agoraphobia.


==Agoraphobics==
===Primary Prevention===
*[[Philip K. Dick]], American science fiction writer
*There is no established method for the primary prevention of agoraphobia.
*[[Emily Dickinson]], American Poet
*Robert Alan, A citizen of Oregon
*[[Woody Allen]], American film director
*[[Kim Basinger]], American actress
*[[Roy Castle]], British TV presenter
*[[Ronald Jones (musician)]], American musician, guitarist for Flaming Lips
*[[Elfriede Jelinek]], [[Nobel prize|Nobel]] laureate for Literature, 2004
*[[Paula Deen]], American cook, restaurateur, writer, and TV personality, (after her parents died, recovered, while working at a bank was robbed at gun point, the disorder came back, but recovered again.)
*[[Rose McGowan]], American actress
*[[Ben Weasel]], American musician, frontman of Screeching Weasel
*[[Edvard Munch]], Norwegian Symbolist painter, printmaker, and an important forerunner of Expressionistic art.
*[[Alessandro Manzoni]], Italian novelist and poet
*[[Marilyn (musician)|Peter Robinson]], British musician known simply as Marilyn.<ref>''Whatever Happened to the Gender Benders?'', Channel 4 documentary, United Kingdom.</ref>
*Edna Turnblad, a [[fictional character]] created by [[John Waters (filmmaker)|John Waters]] who refuses to leave her apartment.
*Maureen Leahy, Citizen of California
*[[Sentry (Robert Reynolds)|Robert Reynolds]], a fictional character in the [[Marvel Comics|Marvel]] Universe


==See also==
===Secondary Prevention===
* [[Agoraphobia Without History of Panic Disorder]]
*Maintenance of a healthy lifestyle may be helpful in the secondary prevention of agoraphobia. This includes:<ref name="#8" />
**Eating a balanced diet
**Exercising regularly
**Getting a sufficient amount of sleep


==References==
==References==
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[[Category:Disease]]
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[[Category:Overview complete]]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2], Haleigh Williams, B.S., Irfan Dotani

Overview

Agoraphobia is an anxiety disorder characterized by intense terror and anxiety over any place or situation from which one might not easily be able to escape. This often leads sufferers to avoid leaving their homes, using public transportation or air travel, or being in crowded spaces. The average age of onset of agoraphobia is 20 years. Agoraphobia is closely associated with panic disorder; the two are commonly comorbid. Patients with agoraphobia often exhibit depressive symptoms, as well as social or specific phobias, which can make the disorder difficult to diagnose. Patients with severe agoraphobia may become confined to their homes. The word "agoraphobia" is an English adoption of the Greek words agora (αγορά) and phobos (φόβος), literally translated as "a fear of the marketplace." This etymology is the reason for the common misconception that agoraphobia is a fear of open spaces.

Historical Perspective

  • In 1871, Agoraphobia was first described by Karl Friedrich Otto Westphal, a German psychiatrist.
  • Westphal coined the term after observing three of his patients, who exhibited severe anxiety and dread upon traveling to certain public areas of Berlin, in the city where he worked.

Classification

  • Though some experts have argued that agoraphobia can reasonably be thought of as a severe consequence of panic disorder, a comparison of the multivariate comorbidity patterns of agoraphobia and panic disorder supports the independent classification of these disorders.[3]

Pathophysiology

Relationship to Balance Disorders

  • Agoraphobia may be related to defects in balance. Researchers who noticed a similarity between the situations commonly avoided by sufferers of agoraphobia and the types of environments that trigger disorientation in people with balance disorders administered a battery of audiovestibular tests, coupled with moving platform posturography, to 36 subjects with agoraphobic symptoms and 20 normal, healthy controls.
    • Over 60% of the former group were destabilized by these disorienting conditions, compared to a mere 10% of the control group.
    • Postural instability was found to be highly related to agoraphobic avoidance (r = 0.63, P < 0.01), event after the researchers controlled for symptoms, anxiety, and agoraphobic cognitions.[4]

Attachment Theory

  • Some scholars (e.g., Liotti 1996, Bowlby 1998) have explained agoraphobia as an attachment deficit, i.e., the temporary loss of the ability to tolerate spatial separations from a secure base.[5][6]

Spatial Theory

  • In the social sciences, there is a perceived clinical bias (e.g., Davidson 2003) in agoraphobia research. Branches of the social sciences, especially geography, have increasingly become interested in what may be thought of as a spatial phenomenon.[7]

Associated Conditions

Differential Diagnosis

Epidemiology and Demographics

Prevalence

  • The prevalence of agoraphobia is 1,700 per 100,000 (1.7%) of the overall population.[1]

Age

  • Among children, ages 13 to 18, there is a lifetime prevalence of 2,400 per 100,000 (2.4%) for agoraphobia.[9]
  • Among adults in the United States, agoraphobia has a 12-month prevalence of 800 per 100,000 (0.8%). 40.6% of these cases are classified as "severe."[10]

Gender

  • No gender disparity in the incidence of agoraphobia has been widely established.[10]
  • Some studies have suggested that panic disorder patients with agoraphobia are more likely to be female than patients who have panic disorder but not agoraphobia. Female patients were also found to have a higher prevalence of comorbidities.[11]

Race

  • No racial predilection has been established for agoraphobia.[10]

Risk Factors

  • The exact cause of agoraphobia is unknown. In some instances, someone who has a panic attack may begin to exhibit signs of agoraphobia out of fear that another panic attack will occur.[12]
  • Risk factors for agoraphobia include:[1]
    • Anxiety sensitivity
    • Behavioral inhibition
    • Genetic predisposition
    • Neurotic disposition (neuroticism)
    • Negative events in childhood
      • Separation/divorce of parents
      • Death of parent
      • Bullying
    • Stressful or traumatic events (e.g., being attacked or mugged)

Natural History, Complications, and Prognosis

Natural History

  • People with agoraphobia may experience panic attacks in situations in which they feel trapped, insecure, out of control, or too far from their personal comfort zone. In severe cases, an agoraphobic person may be completely confined to his or her home.[13]
    • Some people with agoraphobia are comfortable seeing visitors, but only in a defined space in which they feel in control.
      • Such people may live for years without leaving their homes, while happily seeing visitors and working, as long as they can stay within their safety zones.
      • If someone suffering from agoraphobia leaves his or her "safety zone," an anxiety attack may occur.
    • Agoraphobia patients can experience sudden panic attacks when traveling to places where they fear, where help would be difficult to obtain. During a panic attack, adrenaline is released in large amounts for several minutes causing the classical "fight or flight" condition.
      • The attack typically has an abrupt onset, building to maximum intensity within 10 to 15 minutes, and rarely lasts longer than 30 minutes. [14]
      • These symptoms include palpitations, sweating, trembling, and shortness of breath. Many patients report a fear of dying, or losing control of emotions or behavior. [14]

Complications

  • Complications associated with agoraphobia may encompass physical, behavioral, or lifestyle changes.
    • The avoidance behaviors associated with agoraphobia are established correlates of treatment discontinuation.[15]
    • Individuals with agoraphobia are more likely to show signs of decreased assertiveness, perhaps because their illness cultivates feelings of helplessness and insecurity.[16]
    • The avoidance of places or structures in which panic attacks have occurred may limit a patient’s job prospects or proximity to desirable facilities or services.[17]

Prognosis

  • The prognosis of agoraphobia depends upon the severity of the disease.
  • The prognosis is generally good with early medical intervention; if left untreated, the disorder may become more difficult for healthcare providers to effectively manage.[12]

Diagnosis

Diagnostic Criteria

DSM-V Diagnostic Criteria for Agoraphobia

The fifth version of the DSM, released in 2013, sets forth the following as diagnostic criteria for agoraphobia:[1]

“
  • A. Marked fear or anxiety about two (or more) of the following five situations:
  • 1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).
  • 2. Being in open spaces (e.g., parking lots, marketplaces, bridges).
  • 3. Being in enclosed places (e.g., shops, theaters, cinemas).
  • 4. Standing in line or being in a crowd.
  • 5. Being outside of the home alone.

AND

  • B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence).

AND

  • C. The agoraphobic situations almost always provoke fear or anxiety.

AND

  • D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.

AND

  • E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the socio cultural context.

AND

  • F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

AND

  • G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

AND

AND

  • I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder—for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in social anxiety disorder): and are not related exclusively to obsessions (as in obsessive-compulsive disorder),perceived defects or flaws in physical appearance (as in body dysmorhic disorder), reminders of traumatic events (as in post traumatic stress disorder), or fear of separation (as in separation anxiety disorder).

Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned.

”

History and Symptoms

Symptoms of agoraphobia may include the following:[12]

  • Fear of crowds, bridges, and/or being outside alone
  • Fear of losing control of oneself in a public place
  • Feeling dependent upon others
  • Feeling helpless
  • Feeling that one’s body or surroundings are not real
  • Being easily agitated or angered
  • Staying in one’s house for long periods of time
  • Self-medication with drugs or alcohol
  • Inability to function at work or other inherently social settings
  • Depression or suicidal ideation

If agoraphobic patients find themselves in a situation that triggers their anxiety, symptoms may include the following:[12]

Physical Examination

  • Healthcare providers will examine a patient who is exhibiting signs of agoraphobia for a history of panic disorders.
  • The clinician will also get a description of the relevant symptoms and behaviors of the patient and, if possible, from any family members or friends who might have knowledge of relevant behaviors.[12]

Treatment

Medical Therapy

  • The mainstay of therapy for agoraphobia is a combination of CBT, talk therapy, and medicine. Certain drugs that are regularly used to treat depression, such as SSRIs and SNRIs, may also be helpful in the treatment of agoraphobia.[12]
    • Treatment delivery factors, particularly therapist adherence, are important indicators of the potential for successful CBT.[18]
    • Studies have shown that therapist-directed CBT has a more significant impact on agoraphobic psychopathology in the short-term than do SSRIs/SNRIs.[19]
    • At a physician’s discretion, sedatives or hypnotics may also be prescribed. A physician may advise an agoraphobic patient to take such drugs when the symptoms of agoraphobia are particularly severe or as a preventive measure, when one expects to be exposed to a triggering situation.[12]

Surgery

  • Surgical intervention is not recommended for the management of agoraphobia.

Primary Prevention

  • There is no established method for the primary prevention of agoraphobia.

Secondary Prevention

  • Maintenance of a healthy lifestyle may be helpful in the secondary prevention of agoraphobia. This includes:[12]
    • Eating a balanced diet
    • Exercising regularly
    • Getting a sufficient amount of sleep

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  2. ↑ 2.0 2.1 World Heart Organization (WHO). International Statistical Classification of Diseases and Related Health Problems 10 (ICD-10). Geneva, Switzerland. Retrieved 29 September 2016.
  3. ↑ Greene AL, Eaton NR (2016). "Panic disorder and agoraphobia: A direct comparison of their multivariate comorbidity patterns". J Affect Disord. 190: 75–83. doi:10.1016/j.jad.2015.09.060. PMID 26480214.
  4. ↑ Yardley L, Britton J, Lear S, Bird J, Luxon LM (1995). "Relationship between balance system function and agoraphobic avoidance". Behav Res Ther. 33 (4): 435–9. PMID 7755529.
  5. ↑ G. Liotti, (1996). Insecure attachment and agoraphobia, in: C. Murray-Parkes, J. Stevenson-Hinde, & P. Marris (Eds.). Attachment Across the Life Cycle.
  6. ↑ J. Bowlby, (1998). Attachment and Loss (Vol. 2: Separation).
  7. ↑ J. Davidson, (2003). Phobic Geographies
  8. ↑ Bandelow B, Michaelis S (2015). "Epidemiology of anxiety disorders in the 21st century". Dialogues Clin Neurosci. 17 (3): 327–35. PMC 4610617. PMID 26487813.
  9. ↑ Merikangas KR, He JP, Burstein M, Swanson SA, Avenevoli S, Cui L; et al. (2010). "Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication--Adolescent Supplement (NCS-A)". J Am Acad Child Adolesc Psychiatry. 49 (10): 980–9. doi:10.1016/j.jaac.2010.05.017. PMC 2946114. PMID 20855043.
  10. ↑ 10.0 10.1 10.2 Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE (2005). "Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication". Arch Gen Psychiatry. 62 (6): 593–602. doi:10.1001/archpsyc.62.6.593. PMID 15939837.
  11. ↑ Inoue K, Kaiya H, Hara N, Okazaki Y (2016). "A discussion of various aspects of panic disorder depending on presence or absence of agoraphobia". Compr Psychiatry. 69: 132–5. doi:10.1016/j.comppsych.2016.05.014. PMID 27423353.
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 NIH: U.S. National Library of Medicine. (2016). Agoraphobia. https://medlineplus.gov/ency/article/000923.htm Retrieved 29 September 2016.
  13. ↑ "Treatment of Panic Disorder", NIH Consens Statement, 9 (2): 1–24, Sep 25–27, 1991
  14. ↑ 14.0 14.1 David Satcher; et al. (1999). "Chapter 4.2". Mental Health: A Report of the Surgeon General.
  15. ↑ Bélanger C, Courchesne C, Leduc AG, Dugal C, El-Baalbaki G, Marchand A; et al. (2016). "Predictors of Dropout From Cognitive-Behavioral Group Treatment for Panic Disorder With Agoraphobia: An Exploratory Study". Behav Modif. doi:10.1177/0145445516656614. PMID 27385412.
  16. ↑ Levitan MN, Simoes P, Sardinha AG, Nardi AE (2016). "Agoraphobia Related to Unassertiveness in Panic Disorder". J Nerv Ment Dis. 204 (5): 396–9. doi:10.1097/NMD.0000000000000486. PMID 26915016.
  17. ↑ NIH: U.S. National Library of Medicine. (2016). About Panic and Agoraphobia. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0024921/ Retrieved 29 September 2016.
  18. ↑ Weck F, Grikscheit F, Höfling V, Kordt A, Hamm AO, Gerlach AL; et al. (2016). "The role of treatment delivery factors in exposure-based cognitive behavioral therapy for panic disorder with agoraphobia". J Anxiety Disord. 42: 10–8. doi:10.1016/j.janxdis.2016.05.007. PMID 27235836.
  19. ↑ Liebscher C, Wittmann A, Gechter J, Schlagenhauf F, Lueken U, Plag J; et al. (2016). "Facing the fear--clinical and neural effects of cognitive behavioural and pharmacotherapy in panic disorder with agoraphobia". Eur Neuropsychopharmacol. 26 (3): 431–44. doi:10.1016/j.euroneuro.2016.01.004. PMID 26837851.


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