Agoraphobia

Leaving home can be a reason to panic for some. Agoraphobia refers to a fear of any place where escape may be difficult, including large open spaces or crowds, as well as various means of travel.

Definition

Translated from Greek as "fear of the marketplace," agoraphobia involves intense fear and anxiety of any place or situation where escape might be difficult. Agoraphobics may avoid situations such as being alone outside of the home; traveling in a car, bus, or airplane; being in a crowded area; or being on a bridge or in an elevator.

Endurance of such situations can put a person with agoraphobia under great stress, and a panic attack may result. Such high discomfort and stress may require another person's company in such situations.

Agoraphobia often accompanies another anxiety disorder, such as panic disorder or a specific phobia. If agoraphobia occurs with panic disorder, the onset is usually during the 20s; women are affected more often than men. Approximately 1.8 million American adults age 18 and over (about 0.8 percent of people in this age group in a given year) have agoraphobia without a history of panic disorder.

In panic disorder, panic attacks recur and the person develops an intense apprehension of having another attack. This fear—called anticipatory anxiety or fear of fear—can be present most of the time and seriously interfere with the person's life even when a panic attack is not in progress.

Agoraphobia affects about a third of all people with panic disorder. Typically, people with agoraphobia restrict themselves to a "zone of safety" that may include only the home or the immediate neighborhood. Any movement beyond the edges of this zone creates mounting anxiety. Even when they restrict themselves to "safe" situations, most people with agoraphobia continue to have panic attacks at least a few times a month.

People with agoraphobia can be seriously disabled by their condition. Some are unable to work, and they may need to rely heavily on other family members, who must do the shopping and household errands, as well as accompany the affected person on rare excursions outside the "safety zone." People with this disorder may become housebound for years, with resulting impairment of social and interpersonal relationships. Thus the person with agoraphobia typically leads a life of extreme dependency as well as great discomfort.

Symptoms

  • Fear of being alone
  • Fear of losing control in a public place
  • Fear of being in places where escape might be difficult
  • Becoming housebound for prolonged periods
  • Feelings of detachment or estrangement from others
  • Feelings of helplessness
  • Dependence upon others
  • Feeling that the body is unreal
  • Feeling that the environment is unreal
  • Anxiety or panic attack (acute severe anxiety)
  • Unusual temper or agitation with trembling or twitching

Additional symptoms that may occur:

  • Lightheadedness, near fainting
  • Dizziness
  • Excessive sweating
  • Skin flushing
  • Breathing difficulty
  • Chest pain
  • Heartbeat sensations
  • Nausea and vomiting
  • Numbness and tingling
  • Abdominal distress
  • Confused or disordered thoughts
  • Intense fear of going crazy
  • Intense fear of dying

There may be a history of phobias, or the health care provider may receive a description of typical behaviors from family, friends, or the affected person. The pulse (heart rate) is often rapid, sweating is present, and the patient may have high blood pressure. A person may be described as having agoraphobia if other mental disorders or medical conditions do not provide better explanation for the person's symptoms.

Causes

The etiology of most anxiety disorders, although not fully understood, has come into sharper focus in the last decade. In broad terms, the likelihood of developing anxiety involves a combination of life experiences, psychological traits, and/or genetic factors. The anxiety disorders are so heterogeneous that the relative roles of these factors are likely to differ. It is not clear why females have higher rates than males of most anxiety disorders, although some theories have suggested a role for the gonadal steroids. Other research on women's responses to stress also suggests that women experience a wider range of life events (such as those happening to friends) as stressful as compared with men who react to a more limited range of stressful events, specifically those affecting themselves or close family members.

Treatments

The goal of treatment is to help the phobic person function effectively. The success of treatment usually depends upon the severity of the phobia. Systematic desensitization called "exposure therapy," is a behavioral technique used to treat phobias. It is based on having the person relax, then imagine the components of the phobia, working from the least fearful to the most fearful. Graded real-life exposure has also been used with success to help people overcome their fears. This technique involves exposure to actual situations progressing from small scale to more normal situations. For example, a person might be in contact with a few people then progressively spend time with more people in order to overcome fear of crowds. The individual will work with a therapist to develop coping strategies such as relaxation and breathing techniques. While "in vivo" or real-life exposure is ideal, imagined exposure is also an acceptable alternative in desensitization exercises. Treating agoraphobia with exposure therapy reduced anxiety, improved morale and quality of life within 75 percent of cases.

Other types of therapy, such as cognitive therapy, assertiveness training, biofeedback, hypnosis, meditation, relaxation, or couples therapy were found to be helpful for some patients. Cognitive behavioral therapy is a combination of cognitive therapy, which can modify or eliminate thought patterns contributing to the patient's symptoms, and behavioral therapy, which aims to help the patient change his or her behavior.

Treatment is complicated by the fact that patients have difficulty getting to appointments because of their fears. To address this issue, some therapists will go to an agoraphobic patient's home to conduct the initial sessions. Often therapists take their patients on excursions to shopping malls and other places the patients have been avoiding. Or they may accompany their patients who are trying to overcome fear of driving a car, for example.

The patient approaches a feared situation gradually, attempting to stay in spite of rising levels of anxiety. In this way the patient sees that as frightening as the feelings are, they are not dangerous, and they do pass. On each attempt, the patient faces as much fear as he or she can stand. Patients find that with this step-by-step approach, aided by encouragement and skilled advice from the therapist, they can gradually master their fears and enter situations that had seemed unapproachable.

Many therapists assign the patient "homework" to do between sessions. Sometimes patients spend only a few sessions in one-on-one contact with a therapist and continue to work on their own with the aid of a printed manual.

Often the patient will join a therapy group with others striving to overcome panic disorder or phobias, meeting with them weekly to discuss progress, exchange encouragement, and receive guidance from the therapist.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) is very useful in treating anxiety disorders. The cognitive part helps people change the thinking patterns that support their fears, and the behavioral part helps people change the way they react to anxiety-provoking situations. For example, CBT can help people with panic disorder learn that their panic attacks are not really heart attacks and help people with social phobia learn how to overcome the belief that others are always watching and judging them. When people are ready to confront their fears, they are shown how to use exposure techniques to desensitize themselves to situations that trigger their anxieties.

CBT is undertaken when people decide they are ready for it and with their permission and cooperation. To be effective, the therapy must be directed at the person's specific anxieties and must be tailored to his or her needs. There are no side effects other than the discomfort of temporarily increased anxiety.

Cognitive behavioral therapy generally requires at least 8 to 12 weeks. Some people may need a longer time in treatment to learn and implement the skills. This kind of therapy, which is reported to have a low relapse rate, is effective in eliminating panic attacks or reducing their frequency. It also reduces anticipatory anxiety and the avoidance of feared situations.

Treatment with Medications

In this treatment approach, which is also called pharmacotherapy, a prescription medication is used both to prevent panic attacks or reduce their frequency and severity, and to decrease the associated anticipatory anxiety. When patients find that their panic attacks are less frequent and severe, they are increasingly able to venture into situations that had been off-limits to them. In this way, they benefit from exposure to previously feared situations as well as from the medication.

The three groups of medications most commonly used are the tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), the high-potency benzodiazepines, and the monoamine oxidase inhibitors (MAOIs). Determination of which drug to use is based on considerations of safety, efficacy, and the personal needs of the patient. Some information about each of the classes of drugs follows:

Tricyclics are older than SSRIs and work as well as SSRIs for anxiety disorders other than OCD. Imipramine is the tricyclic most commonly used for this condition. When Imipramine is prescribed, the patient usually starts with small daily doses that are increased every few days until an effective dosage is reached. The slow introduction of Imipramine helps minimize side effects such as dry mouth, constipation, and blurred vision.

Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. SSRIs alter the levels of the neurotransmitter serotonin in the brain, which, like other neurotransmitters, helps brain cells communicate with one another.

Fluoxetine (Prozac®), sertraline (Zoloft®), escitalopram (Lexapro®), paroxetine (Paxil®), and citalopram (Celexa®) are some of the SSRIs commonly prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs in combination with OCD, social phobia, or depression. These medications are started at low doses and gradually increased until they have a beneficial effect.

SSRIs have fewer side effects than older antidepressants (tricyclics), but they sometimes produce slight nausea or jitters when people first start to take them. These symptoms fade with time. Some people also experience sexual dysfunction with SSRIs, which may be helped by adjusting the dosage or switching to another SSRI.

The high-potency benzodiazepines are a class of medications that effectively reduce anxiety. Alprazolam, clonazepam, and lorazepam are medications that belong to this class. They take effect rapidly, have few bothersome side effects, and are well-tolerated by the majority of patients. However, some patients, especially those who have had problems with alcohol or drug dependency, may become dependent on benzodiazepines.

Generally, the physician prescribing one of these drugs starts the patient on a low dose and gradually increases it until panic attacks cease. This procedure minimizes side effects.

Treatment with high-potency benzodiazepines is usually continued for six months to a year. One drawback of these medications is that patients may experience withdrawal symptoms—malaise, weakness, and other unpleasant effects—when the treatment is discontinued. Reducing the dose gradually generally minimizes these problems. There may also be a recurrence of panic attacks after the medication is withdrawn.

Of the MAOIs, a class of antidepressants that have been shown to be effective against panic disorder, phenelzine is the most commonly used. Treatment with phenelzine usually starts with a relatively low daily dosage that is increased gradually until panic attacks cease or the patient reaches a maximum dosage of about 100 milligrams a day.

Use of phenelzine or any other MAOI requires the patient to observe exacting dietary restrictions, because there are foods and prescription drugs and certain substances of abuse that can interact with the MAOI to cause a sudden, dangerous rise in blood pressure. All patients who are taking MAOIs should obtain their physician's guidance concerning dietary restrictions and should consult with their physician before using any over-the-counter or prescription medications.

Treatment with any of the previous medications such as high-potency benzodiazepines, imipramine, phenelzine or another MAOI generally lasts six months to a year. At the conclusion of the treatment period, the medication is gradually tapered.

Combination Treatments

Some patients with anxiety disorders may benefit from psychotherapy and pharmacotherapy treatment modalities, either combined or used in sequence. The combined approach is said to offer rapid relief, high effectiveness, and a low relapse rate.

Drawing from the experiences of depression researchers, it seems likely that such combinations are not uniformly necessary and are probably more cost-effective when reserved for patients with more complex, complicated, severe, or comorbid disorders. The benefits of multimodal therapies for anxiety need further study. Comparing medications and psychological treatments and determining how well they work in combination is the goal of several studies. One study is designed to determine how treatment with imipramine compares with a cognitive-behavioral approach, and whether combining the two yields benefits over either method alone.

Ways to Make Treatment More Effective

Many people with anxiety disorders benefit from joining a self-help or support group and sharing their problems and achievements with others. Talking with a trusted friend or member of the clergy can also provide support, but it is not a substitute for care from a mental-health professional.

Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy. There is 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. Check with your physician or pharmacist before taking any additional medications.

The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive and not help perpetuate their loved one's symptoms. Family members should not trivialize the disorder or demand improvement without treatment. If your family is doing either of these things, you may want to show them this information so they can become educated allies and help you succeed in therapy.

Sources

  • National Institute of Mental Health
  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised
  • Archives of General Psychiatry
  • Psychological Medicine
  • National Institutes of Health - National Library of Medicine
  • Public Health Service (1999). Mental Health: A Report of the Surgeon General
Last reviewed 11/24/2014