Agoraphobia

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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]

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 attacks; 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. "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 translation is the reason for the common misconception that agoraphobia is a fear of open spaces, and is not clinically accurate.

Pathophysiology

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.

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.

Differential Diagnosis

• Acute stress disorder
• Major depressive disorder
• Other medical conditions

• Parkinson's disease
• Multiple sclerosis

• Panic disorder
• Post traumatic stress disorder
• Separation anxiety disorder
• Social anxiety disorder (social phobia)
• Specific phobia, situational type

Epidemiology and Demographics

Prevalence

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

Risk Factors

• Anxiety sensitivity
• Behavioral inhibition
• Genetic predisposition
• Neurotic disposition (neuroticism)
• Negative events in childhood

• Separation
• Death of parent

• Stressful events (for example being attacked or mugged)

Natural History, Complications, and Prognosis

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.

People with agoraphobia may experience panic attacks 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. 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.

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. These symptoms include palpitations, sweating, trembling, and shortness of breath. Many patients report a fear of dying, or losing control of emotions or behavior.

Diagnostic Criteria

DSM-V Diagnostic Criteria for Agoraphobia

“

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

”

Treatment

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.

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.

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.

References

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