Agoraphobia

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Agoraphobia
Agora of the Competaliasts 01 (cropped).jpg
An ancient agora in Delos, Greece. One of the public spaces after which the condition is named.
Specialty Psychiatry
Symptoms Anxiety in situations perceived to be unsafe, panic attacks [1] [2]
Complications Depression, substance use disorder [1]
Duration> 6 months [1]
Causes Genetic and environmental factors [1]
Risk factors Family history, stressful event [1]
Differential diagnosis Separation anxiety, post-traumatic stress disorder, major depressive disorder [1]
Treatment Cognitive behavioral therapy [3]
Prognosis Resolution in half with treatment [4]
Frequency1.7% of adults [1]

Agoraphobia is an anxiety disorder characterized by symptoms of anxiety in situations where the person perceives their environment to be unsafe with no easy way to escape. [1] These situations can include open spaces, public transit, shopping centers, or simply being outside their home. [1] Being in these situations may result in a panic attack. [2] The symptoms occur nearly every time the situation is encountered and last for more than six months. [1] Those affected will go to great lengths to avoid these situations. [1] In severe cases people may become completely unable to leave their homes. [2]

Contents

Agoraphobia is believed to be due to a combination of genetic and environmental factors. [1] The condition often runs in families, and stressful or traumatic events such as the death of a parent or being attacked may be a trigger. [1] In the DSM-5 agoraphobia is classified as a phobia along with specific phobias and social phobia. [1] [3] Other conditions that can produce similar symptoms include separation anxiety, post-traumatic stress disorder, and major depressive disorder. [1] Those affected are at higher risk of depression and substance use disorder. [1]

Without treatment it is uncommon for agoraphobia to resolve. [1] Treatment is typically with a type of counselling called cognitive behavioral therapy (CBT). [3] [5] CBT results in resolution for about half of people. [4] Agoraphobia affects about 1.7% of adults. [1] Women are affected about twice as often as men. [1] The condition often begins in early adulthood and becomes less common in old age. [1] It is rare in children. [1] The term "agoraphobia" is from Greek ἀγορά, agorā́, meaning a "place of assembly" or "market-place" and -φοβία, -phobía, meaning "fear." [6] [7]

Signs and symptoms

Agoraphobia is a condition where sufferers become anxious in unfamiliar environments or where they perceive that they have little control. Triggers for this anxiety may include wide-open spaces, crowds (social anxiety), or traveling (even short distances). Agoraphobia is often, but not always, compounded by a fear of social embarrassment, as the agoraphobic fears the onset of a panic attack and appearing distraught in public. Most of the time they avoid these areas and stay in the comfort of their safe haven, usually their home. [1]

Agoraphobia is also defined as "a fear, sometimes terrifying, by those who have experienced one or more panic attacks". [8] In these cases, the sufferer is fearful of a particular place because they have experienced a panic attack at the same location at a previous time. Fearing the onset of another panic attack, the sufferer is fearful or even avoids a location. Some refuse to leave their homes even in medical emergencies because the fear of being outside of their comfort areas is too great. [9]

The sufferers can sometimes go to great lengths to avoid the locations where they have experienced the onset of a panic attack. Agoraphobia, as described in this manner, is actually a symptom professionals check when making a diagnosis of panic disorder. Other syndromes like obsessive compulsive disorder or post-traumatic stress disorder can also cause agoraphobia. Essentially, any irrational fear that keeps one from going outside can cause the syndrome. [10]

Agoraphobics may suffer from temporary separation anxiety disorder when certain other individuals of the household depart from the residence temporarily, such as a parent or spouse, or when the agoraphobic is left home alone. Such temporary conditions can result in an increase in anxiety or a panic attack or feeling the need to separate themselves from family or maybe friends. [11] [12]

People with agoraphobia sometimes fear waiting outside for long periods of time; that symptom can be called "macrophobia." [13]

Panic attacks

Agoraphobia patients can experience sudden panic attacks when traveling to places where they fear they are out of control, help would be difficult to obtain, or they could be embarrassed. During a panic attack, epinephrine is released in large amounts, triggering the body's natural fight-or-flight response. A panic attack typically has an abrupt onset, building to maximum intensity within 10 to 15 minutes, and rarely lasts longer than 30 minutes. [14] Symptoms of a panic attack include palpitations, rapid heartbeat, sweating, trembling, nausea, vomiting, dizziness, tightness in the throat, and shortness of breath. Many patients report a fear of dying, fear of losing control of emotions or fear of losing control of behaviors. [14]

Causes

Agoraphobia is believed to be due to a combination of genetic and environmental factors. [1] The condition often runs in families, and stressful or traumatic events such as the death of a parent or being attacked may be a trigger. [1]

Research has uncovered a link between agoraphobia and difficulties with spatial orientation. [15] [16] Individuals without agoraphobia are able to maintain balance by combining information from their vestibular system, their visual system, and their proprioceptive sense. A disproportionate number of agoraphobics have weak vestibular function and consequently rely more on visual or tactile signals. They may become disoriented when visual cues are sparse (as in wide-open spaces) or overwhelming (as in crowds). [17] Likewise, they may be confused by sloping or irregular surfaces. [17] In a virtual reality study, agoraphobics showed impaired processing of changing audiovisual data in comparison with subjects without agoraphobia. [18]

Substance induced

Chronic use of tranquilizers and sleeping pills such as benzodiazepines has been linked to onset of agoraphobia. [19] In 10 patients who had developed agoraphobia during benzodiazepine dependence, symptoms abated within the first year of assisted withdrawal. [20] Similarly, alcohol use disorders are associated with panic with or without agoraphobia; this association may be due to the long-term effects of alcohol consumption causing a distortion in brain chemistry. [21] Tobacco smoking has also been associated with the development and emergence of agoraphobia, often with panic disorder; it is uncertain how tobacco smoking results in anxiety-panic with or without agoraphobia symptoms, but the direct effects of nicotine dependence or the effects of tobacco smoke on breathing have been suggested as possible causes. Self-medication or a combination of factors may also explain the association between tobacco smoking and agoraphobia and panic. [22]

Attachment theory

Some scholars [23] [24] have explained agoraphobia as an attachment deficit, i.e., the temporary loss of the ability to tolerate spatial separations from a secure base. [25] Recent empirical research has also linked attachment and spatial theories of agoraphobia. [26]

Spatial theory

In the social sciences, a perceived clinical bias [27] exists in agoraphobia research. Branches of the social sciences, especially geography, have increasingly become interested in what may be thought of as a spatial phenomenon. One such approach links the development of agoraphobia with modernity. [28] Factors considered contributing to agoraphobia within modernity are the ubiquity of cars and urbanization. These have helped develop the expansion of public space, on one hand, and the contraction of private space on the other, thus creating in the minds of agoraphobia-prone people a tense, unbridgeable gulf between the two.

Evolutionary psychology

An evolutionary psychology view is that the more unusual primary agoraphobia without panic attacks may be due to a different mechanism from agoraphobia with panic attacks. Primary agoraphobia without panic attacks may be a specific phobia explained by it once having been evolutionarily advantageous to avoid exposed, large, open spaces without cover or concealment. Agoraphobia with panic attacks may be an avoidance response secondary to the panic attacks, due to fear of the situations in which the panic attacks occurred. [29] [30]

Diagnosis

Most people who present to mental health specialists develop agoraphobia after the onset of panic disorder. [31] Agoraphobia is best understood as an adverse behavioral outcome of repeated panic attacks and subsequent anxiety and preoccupation with these attacks that leads to an avoidance of situations where a panic attack could occur. [32] Early treatment of panic disorder can often prevent agoraphobia. [33] Agoraphobia is typically determined when symptoms are worse than panic disorder, but also do not meet the criteria for other anxiety disorders such as depression. [34] In rare cases where agoraphobics do not meet the criteria used to diagnose panic disorder, the formal diagnosis of agoraphobia without history of panic disorder is used (primary agoraphobia).

Treatments

Therapy

Systematic desensitization can provide lasting relief to the majority of patients with panic disorder and agoraphobia. The disappearance of residual and sub-clinical agoraphobic avoidance, and not simply of panic attacks, should be the aim of exposure therapy. [35] Many patients can deal with exposure easier if they are in the company of a friend on whom they can rely. [36] [37] Patients must remain in the situation until anxiety has abated because if they leave the situation, the phobic response will not decrease and it may even rise. [37]

A related exposure treatment is in vivo exposure, a Cognitive Behavioral Therapy method, that gradually exposes patients to the feared situations or objects. [38] This treatment was largely effective with an effect size from d = 0.78 to d = 1.34, and these effects were shown to increase over time, proving that the treatment had long-term efficacy (up to 12 months after treatment). [38]

Psychological interventions in combination with pharmaceutical treatments were overall more effective than treatments simply involving either CBT or pharmaceuticals. [38] Further research showed there was no significant effect between using group CBT versus individual CBT. [38]

Cognitive restructuring has also proved useful in treating agoraphobia. This treatment involves coaching a participant through a dianoetic discussion, with the intent of replacing irrational, counterproductive beliefs with more factual and beneficial ones.

Relaxation techniques are often useful skills for the agoraphobic to develop, as they can be used to stop or prevent symptoms of anxiety and panic. [39]

Medications

Antidepressant medications most commonly used to treat anxiety disorders are mainly selective serotonin reuptake inhibitors. Benzodiazepines, monoamine oxidase inhibitor, and tricyclic antidepressants are also sometimes prescribed for treatment of agoraphobia. [40] Antidepressants are important because some have anxiolytic effects. [37] Antidepressants should be used in conjunction with exposure as a form of self-help or with cognitive behaviour therapy. [37] A combination of medication and cognitive behaviour therapy is sometimes the most effective treatment for agoraphobia. [37]

Benzodiazepines and other anxiolytic medications such as alprazolam and clonazepam are used to treat anxiety and can also help control the symptoms of a panic attack. If taken for too long, they can cause dependence. Treatment with benzodiazepines should not exceed 4 weeks. Side effects may include confusion, drowsiness, light-headedness, loss of balance, and memory loss.

Alternative medicine

Eye movement desensitization and reprocessing (EMDR) has been studied as a possible treatment for agoraphobia, with poor results. [41] As such, EMDR is only recommended in cases where cognitive-behavioral approaches have proven ineffective or in cases where agoraphobia has developed following trauma. [42]

Many people with anxiety disorders benefit from joining a self-help or support group (telephone conference-call support groups or online support groups being of particular help for completely housebound individuals). Sharing problems and achievements with others, as well as sharing various self-help tools, are common activities in these groups. In particular, stress management techniques and various kinds of meditation practices and visualization techniques can help people with anxiety disorders calm themselves and may enhance the effects of therapy, as can service to others, which can distract from the self-absorption that tends to go with anxiety problems. Also, preliminary evidence suggests 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. [43]

Epidemiology

Agoraphobia occurs about twice as commonly among women as it does in men. [44] The gender difference may be attributable to several factors: sociocultural traditions that encourage, or permit, the greater expression of avoidance coping strategies by women (including dependent and helpless behaviors), women perhaps being more likely to seek help and therefore be diagnosed, and men being more likely to abuse alcohol in reaction to anxiety and be diagnosed as an alcoholic. [45] Research has not yet produced a single clear explanation for the gender difference in agoraphobia. [45]

Panic disorder with or without agoraphobia affects roughly 5.1% of Americans, [38] and about 1/3 of this population with panic disorder have co-morbid agoraphobia. It is uncommon to have agoraphobia without panic attacks, with only 0.17% of people with agoraphobia not presenting panic disorders as well. [38]

Society and culture

Notable cases

See also

Related Research Articles

Anxiety is an emotion characterized by an unpleasant state of inner turmoil, often accompanied by nervous behavior such as pacing back and forth, somatic complaints, and rumination. It includes subjectively unpleasant feelings of dread over anticipated events.

Benzodiazepine Class of psychoactive drugs with a core chemical structure of benzene and diazepine rings

Benzodiazepines, sometimes called "benzos", are a class of psychoactive drugs whose core chemical structure is the fusion of a benzene ring and a diazepine ring. The first such drug, chlordiazepoxide (Librium), was discovered accidentally by Leo Sternbach in 1955, and made available in 1960 by Hoffmann–La Roche, which, since 1963, has also marketed the benzodiazepine diazepam (Valium). In 1977 benzodiazepines were globally the most prescribed medications. They are in the family of drugs commonly known as minor tranquilizers.

Phobia Anxiety disorder defined by a persistent and excessive fear of an object or situation

A phobia is a type of anxiety disorder defined by a persistent and excessive fear of an object or situation. Phobias typically result in a rapid onset of fear and are present for more than six months. Those affected will go to great lengths to avoid the situation or object, to a degree greater than the actual danger posed. If the object or situation cannot be avoided, they experience significant distress. Other symptoms can include fainting, which may occur in blood or injury phobia, and panic attacks, which are often found in agoraphobia. Around 75% of those with phobias have multiple phobias.

Anxiety disorder Cognitive disorder with an excessive, irrational dread of everyday situations

Anxiety disorders are a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal function are significantly impaired. Anxiety is a worry about future events, while fear is a reaction to current events. Anxiety may cause physical and cognitive symptoms such as restlessness, irritability, easy fatigability, difficulty concentrating, increased heart rate, chest pain, abdominal pain, and many others. In casual discourse the words "anxiety" and "fear" are often used interchangeably; in clinical usage, they have distinct meanings: "anxiety" is defined as an unpleasant emotional state for which the cause is either not readily identified or perceived to be uncontrollable or unavoidable, whereas "fear" is an emotional and physiological response to a recognized external threat. The umbrella term "anxiety disorder" refers to a number of specific disorders that include fears (phobias) or anxiety symptoms.

Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling of impending doom. The maximum degree of symptoms occurs within minutes. Typically they last for about 30 minutes but the duration can vary from seconds to hours. There may be a fear of losing control or chest pain. Panic attacks themselves are not dangerous physically.

Specific phobia is an anxiety disorder, characterized by an unreasonable fear associated with a specific object or situation. Specific phobia can lead to avoidance of the object or situation, persistence of the fear, and significant distress or problems functioning associated with the fear.

Alprazolam Benzodiazepine medication

Alprazolam, sold under the brand name Xanax, among others, is a short-acting tranquilizer of the triazolobenzodiazepine (TBZD) class, which are benzodiazepines (BZDs) fused with a triazole ring. It is most commonly used in short-term management of anxiety disorders, specifically panic disorder or generalized anxiety disorder (GAD). Other uses include the treatment of chemotherapy-induced nausea, together with other treatments. GAD improvement occurs generally within a week. Alprazolam is generally taken by mouth.

Claustrophobia Medical condition

Claustrophobia is the fear of confined spaces. It can be triggered by many situations or stimuli, including elevators, especially when crowded to capacity, windowless rooms, and hotel rooms with closed doors and sealed windows. Even bedrooms with a lock on the outside, small cars, and tight-necked clothing can induce a response in those with claustrophobia. It is typically classified as an anxiety disorder, which often results in panic attacks. The onset of claustrophobia has been attributed to many factors, including a reduction in the size of the amygdala, classical conditioning, or a genetic predisposition to fear small spaces.

Avoidant personality disorder (AvPD) is a Cluster C personality disorder in which the main coping mechanism of those affected is avoidance of feared stimuli.

Generalized anxiety disorder Long-lasting anxiety not focused on any one object or situation

Generalized anxiety disorder (GAD) is an anxiety disorder characterized by excessive, uncontrollable and often irrational worry about events or activities. Worry often interferes with daily functioning, and sufferers are overly concerned about everyday matters such as health, finances, death, family, relationship concerns, or work difficulties. Symptoms may include excessive worry, restlessness, trouble sleeping, exhaustion, irritability, sweating, and trembling.

Exposure therapy is a technique in behavior therapy to treat anxiety disorders. Exposure therapy involves exposing the target patient to the anxiety source or its context without the intention to cause any danger. Doing so is thought to help them overcome their anxiety or distress. Procedurally, it is similar to the fear extinction paradigm developed studying laboratory rodents. Numerous studies have demonstrated its effectiveness in the treatment of disorders such as generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, PTSD, and specific phobias.

Mental health professionals often distinguish between generalized social phobia and specific social phobia. People with generalized social phobia have great distress in a wide range of social situations. Those with specific social phobia may experience anxiety only in a few situations. The term "specific social phobia" may also refer to specific forms of non-clinical social anxiety.

Social anxiety is nervousness in social situations. Some disorders associated with the social anxiety spectrum include anxiety disorders, mood disorders, autistic spectrum disorders, eating disorders, and substance use disorders. Individuals higher in social anxiety avert their gazes, show fewer facial expressions, and show difficulty with initiating and maintaining a conversation. They may exhibit irrational anxiety and fear in social interactions. This differs from shyness because it is a persistent disorder that could influence one’s capability to interact with peers and family throughout a long period of time. This disorder is commonly found in teenagers and can be persistent throughout life. Trait social anxiety, the stable tendency to experience this nervousness, can be distinguished from state anxiety, the momentary response to a particular social stimulus. Nearly 90% of individuals, more of whom are women, report feeling symptoms of social anxiety at some point in their lives. Half of the individuals with any social fears meet the criteria for social anxiety disorder. Age, culture, and gender impact the severity of this disorder. The function of social anxiety is to increase arousal and attention to social interactions, inhibit unwanted social behavior, and motivate preparation for future social situations.

Thalassophobia is the persistent and intense fear of deep bodies of water such as the sea, oceans, pools or lakes. Though very closely related, thalassophobia should not be mistaken with aquaphobia which is classified as the fear of water itself. Thalassophobia can include fear of being in deep bodies of water, fear of the vast emptiness of the sea, of sea waves, sea creatures, and fear of distance from land. The causes of thalassophobia are not clear and are a subject of research by medical professionals as they can vary greatly between individuals. Researchers have proposed that the fear of large bodies of water is partly a human evolutionary response, and may also related to popular culture influences which induce fright and distress. The severity of thalassophobia and the signs and symptoms associated with it are quite fluid and complex. Those who suffer from thalassophobia go through numerous episodes of emotional and physical anguish caused by a variety of triggers. Treatment may comprise a combination of therapy and anxiolytics, and is most effective when administered to patients during childhood, when thalassophobia is generally at its peak.

Interoceptive exposure is a cognitive behavioral therapy technique used in the treatment of panic disorder. It refers to carrying out exercises that bring about the physical sensations of a panic attack, such as hyperventilation and high muscle tension, and in the process removing the patient's conditioned response that the physical sensations will cause an attack to happen.

Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by sentiments of fear and anxiety in social situations, causing considerable distress and impaired ability to function in at least some aspects of daily life. These fears can be triggered by perceived or actual scrutiny from others. Individuals with social anxiety disorder fear negative evaluation from other people.

Panic disorder Anxiety disorder characterized by reoccurring unexpected panic attacks

Panic disorder is an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something terrible is going to happen. The maximum degree of symptoms occurs within minutes. There may be ongoing worries about having further attacks and avoidance of places where attacks have occurred in the past.

Autophobia, also called monophobia, isolophobia, or eremophobia, is the specific phobia of isolation; a morbid fear of being egotistical, or a dread of being alone or isolated. Sufferers need not be physically alone, but just to believe that they are ignored or unloved. Contrary to what would be inferred by a literal reading of the term, autophobia does not describe a "fear of oneself" nor is it the fear of cars. It typically develops from and is associated with other anxiety disorders.

A driving phobia is a pathological fear of driving. It is also referred to as amaxophobia or vehophobia. Amaxophobia is an intense, persistent fear of participating in car traffic that interferes with the patient’s lifestyle and quality of life, including aspects such as inability to participate in the workforce due to the pathological and self-defeating avoidance of driving. The fear of driving may be triggered by specific driving situations, such as expressway driving or dense traffic. Driving anxiety can range from a mild cautious concern to an irrational phobia.

Safety behaviors are coping behaviors used to reduce anxiety and fear when the user feels threatened. An example of a safety behavior in social anxiety is to think of excuses to escape a potentially uncomfortable situation. These safety behaviors, although useful for reducing anxiety in the short term, might become maladaptive over the long term by prolonging anxiety and fear of nonthreatening situations. This problem is commonly experienced in anxiety disorders. Treatments such as exposure and response prevention focus on eliminating safety behaviors due to the detrimental role safety behaviors have in mental disorders. There is a disputed claim that safety behaviors can be beneficial to use during the early stages of treatment.

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Classification
D
External resources