Agoraphobia is an anxiety disorder characterized by intense fear related to being in situations from which escape might be difficult or embarrassing (i.e., being on a bus or train), or in which help might not be available in the event of a panic attack or panic symptoms. Panic is defined as extreme and unreasonable fear and anxiety.
According to the handbook used by mental health professionals to diagnose mental disorders, the Diagnostic and Statistical Manual of Mental Disorders , fourth edition, text revision, also known as the DSM-IV-TR, patients with agoraphobia are typically afraid of such symptoms as feeling dizzy, having an attack of diarrhea, fainting, or "going crazy."
The word "agoraphobia" comes from two Greek words that mean "fear" and "marketplace." The anxiety associated with agoraphobia leads to avoidance of situations that involve being outside one's home alone, being in crowds, being on a bridge, or traveling by car or public transportation. Agoraphobia may intensify to the point that it interferes with a person's ability to take a job outside the home or to carry out such ordinary errands and activities as picking up groceries or going out to a movie.
The close association in agoraphobia between fear of being outside one's home and fear of having panic symptoms is reflected in DSM-IV-TR classification of two separate disorders: panic disorder (PD) with agoraphobia, and agoraphobia without PD. PD is essentially characterized by sudden attacks of fear and panic. There may be no known reason for the occurrence of panic attacks; they are frequently triggered by fear-producing events or thoughts, such as driving, or being in an elevator. PD is believed due to an abnormal activation of the body's hormonal system, causing a sudden "fight-or-flight" response.
The chief distinction between PD with agoraphobia and agoraphobia without PD is that patients who are diagnosed with PD with agoraphobia meet all criteria for PD; in agoraphobia without PD, patients are afraid of panic-like symptoms in public places, rather than full-blown panic attacks.
People with agoraphobia appear to suffer from two distinct types of anxiety— panic, and the anticipatory anxiety related to fear of future panic attacks. Patients with agoraphobia are sometimes able to endure being in the situations they fear by "gritting their teeth," or by having a friend or relative accompany them.
In the United States' diagnostic system, the symptoms of agoraphobia can be similar to those of specific phobia and social phobia . In agoraphobia and specific phobia, the focus is fear itself; with social phobia, the person's focus is on how others are perceiving him/her. Patients diagnosed with agoraphobia tend to be more afraid of their own internal physical sensations and similar cues than of the reactions of others per se. In cases of specific phobia, the person fears very specific situations, whereas in agoraphobia, the person generally fears a variety of situations (being outside of the home alone, or traveling on public transportation including a bus, train, or automobile, for example). An example of a patient diagnosed with a specific phobia rather than agoraphobia would be the person whose fear is triggered only by being in a bus, rather than a car or taxi. The fear of the bus is more specific than the agoraphobic's fear of traveling on public transportation in general. The DSM-IVTR remarks that the differential diagnosis of agoraphobia "can be difficult because all of these conditions are characterized by avoidance of specific situations."
Causes and symptoms
GENETIC. As of 2002, the causes of agoraphobia are complex and not completely understood. It has been known for some years that anxiety disorders tend to run in families. Recent research has confirmed earlier hypotheses that there is a genetic component to agoraphobia, and that it can be separated from susceptibility to PD. In 2001 a team of Yale geneticists reported the discovery of a genetic locus on human chomosome 3 that governs a person's risk of developing agoraphobia. PD was found to be associated with two loci: one on human chromosome 1 and the other on chromosome 11q. The researchers concluded that agoraphobia and PD are common; they are both inheritable anxiety disorders that share some, but not all, of their genetic loci for susceptibility.
INNATE TEMPERAMENT. A number of researchers have pointed to inborn temperament as a broad vulnerability factor in the development of anxiety and mood disorders. In other words, a person's natural disposition or temperament may become a factor in developing a number of mood or anxiety disorders. Some people seem more sensitive throughout their lives to events, but upbringing and life history are also important factors in determining who will develop these disorders. Children who manifest what is known as "behavioral inhibition" in early infancy are at increased risk for developing more than one anxiety disorder in adult life—particularly if the inhibition remains over time. (Behavioral inhibition refers to a group of behaviors that are displayed when the child is confronted with a new situation or unfamiliar people.) These behaviors include moving around, crying, and general irritability, followed by withdrawing, seeking comfort from a familiar person, and stopping what one is doing when one notices the new person or situation. Children of depressed or anxious parents are more likely to develop behavioral inhibition.
PHYSIOLOGICAL REACTIONS TO ILLNESS. Another factor in the development of PD and agoraphobia appears to be a history of respiratory disease. Some researchers have hypothesized that repeated episodes of respiratory disease would predispose a child to PD by making breathing difficult and lowering the threshold for feeling suffocated. It is also possible that respiratory diseases could generate fearful beliefs in the child's mind that would lead him or her to exaggerate the significance of respiratory symptoms.
LIFE EVENTS. About 42% of patients diagnosed with agoraphobia report histories of real or feared separation from their parents or other caretakers in childhood. This statistic has been interpreted to mean that agoraphobia in adults is the aftermath of unresolved childhood separation anxiety. The fact that many patients diagnosed with agoraphobia report that their first episode occurred after the death of a loved one, and the observation that other agoraphobics feel safe in going out as long as someone is with them, have been taken as supportive evidence of the separation anxiety hypothesis.
LEARNED BEHAVIOR. There are also theories about human learning that explain agoraphobia. It is thought that a person's initial experience of panic-like symptoms in a specific situation— for example, being alone in a subway station— may lead the person to associate physical symptoms of panic with all subway stations. Avoiding all subway stations would then reduce the level of the person's discomfort. Unfortunately, the avoidance strengthens the phobia because the person is unlikely to have the opportunity to test whether subway stations actually cause uncomfortable physical sensations. One treatment modality—exposure therapy—is based on the premise that phobias can be "unlearned" by reversing the pattern of avoidance.
SOCIAL FACTORS RELATED TO GENDER. Gender role socialization has been suggested as an explanation for the fact that the majority of patients with agoraphobia are women. One form of this hypothesis maintains that some parents still teach girls to be fearful and timid about venturing out in public. Another version relates agoraphobia to the mother-daughter relationship, maintaining that mothers tend to give daughters mixed messages about becoming separate individuals. As a result, girls grow up with a more fragile sense of self, and may stay within the physical boundaries of their home because they lack a firm sense of their internal psychological boundaries.
The symptoms of an episode of agoraphobia may include any or all of the following:
- breaking out in a sweat
- heart palpitations
- paresthesias (tingling or "pins and needles" sensations in the hands or feet)
- rapid pulse or breathing rate
- a sense of impending doom
In most cases, the person with agoraphobia feels some relief from the symptoms after he or she has left the precipitating situation or returned home.
In general, phobias are the most common mental disorders in the general United States population, affecting about 7% of adults, or 6.4 million Americans. Agoraphobia is one of the most common phobias, affecting between 2.7% and 5.8% of American adults. The onset of symptoms is most likely to occur between age 15 and age 35.The lifetime prevalence of agoraphobia is estimated at 5%–12%. Like most phobias, agoraphobia is two to four times more common in women than in men.
The incidence of agoraphobia appears to be similar across races and ethnic groups in the U.S.
The differential diagnosis of agoraphobia is described differently in DSM-IV-TR and in ICD-10, the European diagnostic manual. The U.S. diagnostic manual specifies that agoraphobia must be defined in relation to PD, and that the diagnoses of specific phobias and social phobias are the next to consider. The DSM-IV-TR also specifies that the patient's symptoms must not be related to substance abuse; and if they are related to a general medical condition, they must have excessive symptoms usually associated with that condition. For example, a person with Crohn's disease has realistic concerns about an attack of diarrhea in a public place and should not be diagnosed with agoraphobia unless the fear of losing bowel control is clearly exaggerated. The DSMIV-TR does not require a person to experience agoraphobia within a set number of circumstances in order to meet the diagnostic criteria.
In contrast, the European diagnostic manual primarily distinguishes between agoraphobia and delusional or obsessive disorders, and depressive episodes. In addition, ICD-10 specifies that the patient's anxiety must be restricted to or occur primarily within two out of four specific situations: crowds; public places; traveling alone; or traveling away from home. The primary area of agreement between the American and European diagnostic manuals is that both specify avoidance of the feared situation as a diagnostic criterion.
Diagnosis of agoraphobia is usually made by a physician after careful exclusion of other mental disorders and physical conditions or diseases that might be related to the patient's fears. Head injury, pneumonia, and withdrawal from certain medications can produce some of the symptoms of a panic attack. In addition, the physician may ask about caffeine intake as a possible dietary factor. As of 2002, there are no laboratory tests or diagnostic imaging studies that can be used to diagnose agoraphobia.
Furthermore, there are no widely used diagnostic interviews or screening instruments specifically for agoraphobia. One self-report questionnaire, however, is under development by Dutch researchers who recently reported on its validity. The test is called the Agoraphobic Self-Statements Questionnaire, or ASQ, and is intended to evaluate thinking processes in patients with agoraphobia, as distinct from their emotional responses.
Treatment of agoraphobia usually consists of medication plus cognitive-behavioral therapy (CBT). The physician may also recommend an alternative form of treatment for the anxiety symptoms associated with agoraphobia. Some patients may be advised to cut down on or give up coffee or tea, as the caffeine in these beverages can be contribute to their panic symptoms.
Medications that have been used with patients diagnosed with agoraphobia include the benzodiazepine tranquilizers, the MAO inhibitors (MAOIs), tricyclic antidepressants (TCAs), and the selective serotonin uptake inhibitors, or SSRIs. In the past few years, the SSRIs have come to be regarded as the first-choice medication treatment because they have fewer side effects. The benzodiazepines have the disadvantage of increasing the symptoms of agoraphobia when they are withdrawn, as well as interfering with CBT. (Benzodiazepines can decrease mental sharpness, making it difficult for patients taking these medications to focus in therapy sessions.) The MAO inhibitors require patients to follow certain dietary guidelines. For example, they must exclude aged cheeses, red wine, and certain types of beans. TCAs may produce such side effects as blurred vision, constipation, dry mouth, and drowsiness.
CBT is regarded as the most effective psychotherapeutic treatment for agoraphobia. The specific CBT approach that seems to work best with agoraphobia is exposure therapy. Exposure therapy is based on undoing the association that the patient originally formed between the panic symptoms and the feared situation. By being repeatedly exposed to the feared location or situation, the patient gradually learns that he or she is not in danger, and the anxiety symptoms fade away. The therapist typically explains the procedure of exposure therapy to the patient and reassures him or her that the exposure can be stopped at any time that his or her limits of toleration have been reached. The patient is then exposed in the course of a number of treatment sessions to the feared situation, usually for a slightly longer period each time. A typical course of exposure therapy takes about 12 weeks.
On the other hand, one group of German researchers reported good results in treating patients with agoraphobia with individual high-density exposure therapy. The patients were exposed to their respective feared situations for an entire day for two–three weeks. One year later, the patients had maintained their improvement.
Exposure treatment for agoraphobia may be combined with cognitive restructuring. This form of cognitive behavioral therapy teaches patients to observe the thoughts that they have in the feared situation, such as, "I'll die if I have to go into that railroad station," and replace these thoughts with positive statements. In this example, the patient with agoraphobia might say to him- or herself, "I'll be just fine when I go in there to buy my ticket."
Although insight-oriented therapies have generally been considered relatively ineffective in treating agoraphobia, a recent trial of brief psychodynamic psychotherapy in patients with PD with agoraphobia indicates that this form of treatment may also be beneficial. Of the 21 patients who participated in the 24-session course of treatment (twice weekly for 12 weeks), 16 experienced remission of their agoraphobia. There were no relapses at six-month follow-up.
Alternative and complementary treatments
Patients diagnosed with agoraphobia have reported that alternative therapies, such as hypnotherapy and music therapy, were helpful in relieving symptoms of anxiety and panic. Ayurvedic medicine, yoga , religious practice, and guided imagery meditation have also been helpful.
The prognosis for untreated agoraphobia is considered poor by most European as well as most American physicians. The DSM-IV-TR remarks that little is known about the course of agoraphobia without PD, but that anecdotal evidence indicates that it may persist for years with patients becoming increasingly impaired. The ICD-10 refers to agoraphobia as "the most incapacitating of the phobic disorders," to the point that some patients become completely housebound. With proper treatment, however, 90% of patients diagnosed with agoraphobia can recover and resume a normal life.
As of this writing in 2002, the genetic factors that appear to be implicated in the development of agoraphobia cannot be prevented. On the other hand, recent recognition of the link between anxiety and mood disorders in parents and vulnerability to phobic disorders in their children may help to identify children at risk and to develop appropriate preventive strategies for them.
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Anxiety Disorders Association of America. 11900 Parklawn Drive, Suite 100, Rockville, MD 20852-2624. (301) 231-9350. <www.adaa.org>.
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Rebecca J. Frey, Ph.D.
"Agoraphobia." Gale Encyclopedia of Mental Disorders. . Encyclopedia.com. (August 17, 2017). http://www.encyclopedia.com/psychology/encyclopedias-almanacs-transcripts-and-maps/agoraphobia
"Agoraphobia." Gale Encyclopedia of Mental Disorders. . Retrieved August 17, 2017 from Encyclopedia.com: http://www.encyclopedia.com/psychology/encyclopedias-almanacs-transcripts-and-maps/agoraphobia
The word agoraphobia is derived from Greek words literally meaning "fear of the marketplace." The term is used to describe an irrational and often disabling fear of being out in public.
Agoraphobia is just one type of phobia, or irrational fear. People with phobias feel dread or panic when they face certain objects, situations, or activities. People with agoraphobia frequently also experience panic attacks, but panic attacks, or panic disorder, are not a requirement for a diagnosis of agoraphobia. The defining feature of agoraphobia is anxiety about being in places from which escape might be embarrasing or difficult, or in which help might be unavailable. The person suffering from agoraphobia usually avoids the anxiety-provoking situation and may become totally housebound.
Causes and symptoms
Agoraphobia is the most common type of phobia, and it is estimated to affect between 5-12% of Americans within their lifetime. Agoraphobia is twice as common in women as in men and usually strikes between the ages of 15-35.
The symptoms of the panic attacks which may accompany agoraphobia vary from person to person, and may include trembling, sweating, heart palpitations (a feeling of the heart pounding against the chest), jitters, fatigue, tingling in the hands and feet, nausea, a rapid pulse or breathing rate, and a sense of impending doom.
Benzodiazepines— A group of tranquilizers often used to treat anxiety.
Desensitization— A treatment for phobias which involves exposing the phobic person to the feared situation. It is often used in conjunction with relaxation techniques.
Phobia— An intense and irrational fear of a specific object, activity, or situation.
Agoraphobia and other phobias are thought to be the result of a number of physical and environmental factors. For instance, they have been associated with biochemical imbalances, especially related to certain neurotransmitters (chemical nerve messengers) in the brain. People who have a panic attack in a given situation (e.g., a shopping mall) may begin to associate the panic with that situation and learn to avoid it. According to some theories, irrational anxiety results from unresolved emotional conflicts. All of these factors may play a role to varying extents in different cases of agoraphobia.
People who suffer from panic attacks should discuss the problem with a physician. The doctor can diagnose the underlying panic or anxiety disorder and make sure the symptoms aren't related to some other underlying medical condition.
The doctor makes the diagnosis of agoraphobia based primarily on the patient's description of his or her symptoms. The person with agoraphobia experiences anxiety in situations where escape is difficult or help is unavailable-or in certain situations, such as being alone. While many people are somewhat apprehensive in these situations, the hallmark of agoraphobia is that a person's active avoidance of the feared situation impairs his or her ability to work, socialize, or otherwise function.
Treatment for agoraphobia usually consists of both medication and psychotherapy. Usually, patients can benefit from certain antidepressants, such as amitriptyline (Elavil), or selective serotonin reuptake inhibitors, such as paroxetine (Paxil), fluoxetine (Prozac), or sertraline (Zoloft). In addition, patients may manage panic attacks in progress with certain tranquilizers called benzodiazepines, such as alprazolam (Xanax) or clonazepam (Klonipin).
The mainstay of treatment for agoraphobia and other phobias is cognitive behavioral therapy. A specific technique that is often employed is called desensitization. The patient is gradually exposed to the situation that usually triggers fear and avoidance, and, with the help of breathing or relaxation techniques, learns to cope with the situation. This helps break the mental connection between the situation and the fear, anxiety, or panic. Patients may also benefit from psychodynamically oriented psychotherapy, discussing underlying emotional conflicts with a therapist or support group.
With proper medication and psychotherapy, 90% of patients will find significant improvement in their symptoms.
Forsyth, Sondra. "I Panic When I'm Alone." Mademoiselle April 1998: 119-24.
American Psychiatric Association. 1400 K Street NW, Washington DC 20005. (888) 357-7924. 〈http://www.psych.org〉.
Anxiety Disorders Association of America. 11900 Park Lawn Drive, Ste. 100, Rockville, MD 20852. (800) 545-7367. 〈http://www.adaa.org〉.
National Institute of Mental Health. Mental Health Public Inquiries, 5600 Fishers Lane, Room 15C-05, Rockville, MD 20857. (888) 826-9438. 〈http://www.nimh.nih.gov〉.
"Agoraphobia." Gale Encyclopedia of Medicine, 3rd ed.. . Encyclopedia.com. (August 17, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/agoraphobia
"Agoraphobia." Gale Encyclopedia of Medicine, 3rd ed.. . Retrieved August 17, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/agoraphobia
Agoraphobia (a-go-ra-FO-bee-a) is an anxiety disorder that involves intense fear of having a panic (PA-nik) attack and avoidance of situations that a person fears may trigger a panic attack, such as leaving the home or being in a crowd. The effort to avoid such situations may greatly limit a person’s life.
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In Greek, the word agoraphobia means “fear of the marketplace.” In English, the term is used to describe a disabling disorder that often leads people to fear being in crowds, standing in lines, going to shopping malls, or riding in cars, buses, or subways. In its most extreme form, the disorder can make people afraid of traveling beyond their neighborhoods or even stepping outside their homes. Put simply, agoraphobia is a fear of fear.
Agoraphobia refers to an intense, unreasonable, and long-lasting fear (a phobia) of panic attacks and avoidance of situations in which a panic attack might arise. A panic attack is a sudden surge of overwhelming terror that occurs unexpectedly and without good reason. The person is actually in no real danger. Although it is harmless, a panic attack can cause upsetting psychological symptoms, such as a feeling of unrealness and a fear of losing control, as well as unpleasant physical symptoms, such as a racing heart, sweating, trembling, shortness of breath, chest pain, upset stomach, and dizziness. People with agoraphobia have experienced panic attacks and are fearful about experiencing more attacks.
Charles Darwin, Agoraphobic
Charles Darwin (1809-1882), father of the theory of evolution, is one of the best-known figures in the history of science. Many people do not know, however, that Darwin suffered for much of his adult life from a strange illness that greatly limited his activities. Two modern scientists, writing in the Journal of the American Medical Association, suggested that this illness might have been agoraphobia. This would partly explain Darwin’s lonely lifestyle and his trouble meeting with other people and speaking before groups.
People with agoraphobia may limit themselves to being in places they think of as safe. Any movement beyond this safety zone leads to mounting worry and nervousness. They may worry about whether they could quickly escape from a certain place if they should begin to have a panic attack there. People with agoraphobia often avoid being on busy streets or in crowded classes or stores for fear that they might feel trapped if they start to have a panic attack. Gradually, the places that feel “safe” become fewer and fewer. Some people reach the point where they are too frightened even to leave their homes. Others still go out, but it causes great distress, and they may insist that family members or friends go with them. Such self-imposed limits can make it difficult for people to get on with their lives at school and work.
Most people with agoraphobia experience the disorder after first having one or more panic attacks. Panic attacks usually strike unexpectedly, which makes it difficult for people to predict which situations will trigger them. This lack of predictability prompts people to worry about when the next attack will occur. It also teaches them to fear situations where attacks have happened in the past, even if this fear is unreasonable. As a result, people may begin avoiding such situations. Over time, avoidance actually can reinforce the person’s phobia, making the condition worse.
Agoraphobia typically starts between the ages of 18 and 35. Two-thirds of those affected are women. Most people with agoraphobia also have panic disorder, which means that they have repeated, unexpected panic attacks. A few do not have full-blown attacks, but they have similar symptoms of panic. Someone with agoraphobia may catastrophize (imagine the worst) about what could happen to them if they left home. For example, they may be afraid to leave home because they fear becoming dizzy, fainting, and then being left helpless on the ground. Without treatment, agoraphobia can cause misery for years.
About one-third of people with panic disorder eventually go on to have agoraphobia, too. Treatment of panic disorder can help prevent agoraphobia. Once agoraphobia has set in, people still may be helped by the same kinds of medications and therapy used to treat panic disorder. People with agoraphobia may be helped by exposure therapy (a type of behavior therapy), in which they gradually are put in situations that frighten them until the fear begins to fade. Some therapists go to people’s homes for the first few sessions, because someone with agoraphobia may not feel able to get to the therapist’s office. Therapists who do exposure therapy also teach coping skills to help with anxiety. Exposure therapy may involve taking patients on short trips to shopping malls or other places that the patients have been avoiding. As people begin to spend more and more time in feared situations, using coping skills instead of avoidance, they may learn that they can handle their feelings after all.
Anxiety and Anxiety Disorders
Anxiety Disorders Association of America, 11900 Parklawn Drive, Suite 100, Rockville, MD 20852. This nonprofit group promotes public awareness of agoraphobia and related disorders. Telephone 301-231-9350 http://www.adaa.org
Anxiety Disorders Education Program, National Institute of Mental Health, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. This government program provides reliable information about agoraphobia and related disorders. Telephone 888-8ANXIETY http://www.nimh.nih.gov/anxiety
KidsHealth.org is a website sponsored by the Nemours Foundation, created and maintained by the medical experts at A. I. duPont Hospital for Children, Wilmington, DE. It posts articles and information for kids, teens, and parents on a range of emotional concerns. http://www.KidsHealth.org
"Agoraphobia." Complete Human Diseases and Conditions. . Encyclopedia.com. (August 17, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/agoraphobia-0
"Agoraphobia." Complete Human Diseases and Conditions. . Retrieved August 17, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/agoraphobia-0
ag·o·ra·pho·bi·a / ˌagərəˈfōbēə/ • n. extreme or irrational fear of crowded spaces or enclosed public places. DERIVATIVES: ag·o·ra·pho·bic / -ˈfōbik/ adj. & n. ag·o·ra·phobe / ˈagərəˌfōb/ n.
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