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 to a real or anticipated place or situation where escape might be difficult. People with agoraphobia may avoid situations such as being alone outside of the home, traveling in a car, bus, or airplane, being in a crowded area, being in enclosed spaces such as shops and cinemas, or being on a bridge or in an elevator.

An individual with agoraphobia fears these situations because of thoughts that escape might be difficult in the event of an emergency, or that help might not be available if the person develops panic-like symptoms or other embarrassing symptoms. Such high discomfort and stress may require another person's company in such situations. For agoraphobia to be considered as a diagnosis, the agoraphobic situations must almost always create fear and anxiety that are out of proportion to the actual danger posed, and these signs of distress typically last for a minimum of six months. In its most severe form, people with agoraphobia are completely unable to leave their home.

Approximately 1.7 percent of adolescents and adults are diagnosed with agoraphobia. Women are twice as likely as men to experience agoraphobia. Initial onset is typically in late adolescence or early adulthood, although agoraphobia can occur in childhood as well. The thoughts that usually cause fear and anxiety tend to change with age: Children often fear becoming lost, adults may fear experiencing panic-like symptoms, and older adults may fear falling. Agoraphobia often accompanies another anxiety disorder (such as panic disorder or a specific phobia) and depressive disorders.

In panic disorder, panic attacks recur and the person develops an intense fear 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. The majority of people with panic disorder show signs of agoraphobia and anxiety before developing 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.

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 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 relationships. It has been estimated that more than one-third of people with agoraphobia do not leave their home and are unable to work.

Symptoms

  • Fear or anxiety about:
    • being outside of the home alone
    • using public transportation
    • being in enclosed places (stores, movie theaters)
    • standing in line or being in a crowd
    • being in open spaces (markets, parking lots)
    • being in places where escape might be difficult
  • Active avoidance of all situations that provoke fear and anxiety
  • Becoming housebound for prolonged periods
  • Feelings of detachment or estrangement from others
  • Feelings of helplessness
  • Dependence upon others
  • Anxiety or panic attack (acute severe anxiety)

A person may be described as having agoraphobia if other mental disorders or medical conditions do not provide a better explanation for the person's symptoms. Additionally, it is common for people with agoraphobia to also abuse alcohol and sedative medication as a way of coping with their distress.

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. Heritability for agoraphobia is reported to be 61 percent, making it the phobia most strongly linked to the genetic factor that represents predisposition to phobias. Some of the environmental factors that are known to be associated with the development of agoraphobia are experiencing stressful events (the death of a parent, being attacked or mugged) and being raised in a household characterized by little warmth and high levels of overprotection.

Treatments

The goal of treatment is to help the agoraphobic person function effectively. The success of treatment usually depends upon the severity of the phobia. Systematic desensitization, also 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 real aversive situations, progressing from less to more extreme situations. For example, a person might be in contact with a few people before they progressively spend time with large groups of people in order to overcome a 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 an acceptable alternative in desensitization exercises. Treating agoraphobia with exposure therapy reduces anxiety and improves 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 (CBT) 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. 

CBT generally requires at least 8 to 12 weeks. Some people may need more time in treatment to learn and implement their newly acquired 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 may be 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, in order to provide support and help the patient cope with their fear.

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. In 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 the encouragement and skilled advice of therapist, they can gradually master their fears and enter situations that had previously seemed unapproachable.

Many therapists assign their patients "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 agoraphobia, meeting with them weekly to discuss progress, exchange encouragement, and receive guidance from the therapist.

Treatment with Medications

Patients who experience panic attacks as part of their agoraphobia may benefit from a prescription medication 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 previously been anxiety-provoking.

The groups of medications most commonly used are 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.

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.

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.

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.

Combination Treatments

Some patients with anxiety disorders may benefit from the combination or sequential use of psychotherapy and pharmacotherapy treatment modalities. The combined approach is said to offer rapid relief, high effectiveness, and a low relapse rate.

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 confidante 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. Aerobic exercise can also 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.

References

  • National Institute of Mental Health
  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised
  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
  • Archives of General Psychiatry
  • National Institutes of Health - National Library of Medicine

Last reviewed 03/05/2018