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
Pronunciation
Specialty Psychiatry, clinical psychology
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]
Frequency1.9% of adults [1]

Agoraphobia [1] is a mental and behavioral disorder, [5] specifically 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 public transit, shopping centers, crowds and queues, or simply being outside their home on their own. [1] Being in these situations may result in a panic attack. [2] 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. 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] The diagnosis of agoraphobia has been shown to be comorbid with depression, substance abuse, and suicide ideation. [6] [7]

    Without treatment, it is uncommon for agoraphobia to resolve. [1] Treatment is typically with a type of counselling called cognitive behavioral therapy (CBT). [3] [8] CBT results in resolution for about half of people. [4] In some instances, those with a diagnosis of agoraphobia have reported taking benzodiazepines and antipsychotics. [6] Agoraphobia affects about 1.7% of adults. [1] Women are affected about twice as often as men. The condition is rare in children, often begins in adolescence or early adulthood, and becomes more common at age 65 or above. [1]

    Etymology

    The term agoraphobia was coined in German in 1871 by pioneering German psychologist Karl Friedrich Otto Westphal (1833–1890), in his article "Die Agoraphobie, eine neuropathische Erscheinung". Archiv für Psychiatrie und Nervenkrankheiten, Berlin, 1871–72; 3: 138–161. It is derived from Greek ἀγορά (agorā́), meaning ' place of assembly ' or 'market-place' and -φοβία (-phobía), meaning 'fear'. [9] [10]

    Signs and symptoms

    Agoraphobia is a condition where individuals 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 a person experiencing agoraphobia 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 a known, controllable space, usually their home. [1]

    Agoraphobia is also defined as "a fear, sometimes terrifying, by those who have experienced one or more panic attacks". [11] In these cases, the patient is fearful of a particular place because they have previously experienced a panic attack at the same location. Fearing the onset of another panic attack, the patient is fearful or avoids a location. Some refuse to leave their homes in medical emergencies because the fear of being outside of their comfort areas is too great. [12]

    The person with this condition 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 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. Any irrational fear that keeps one from going outside can cause the syndrome. [13]

    People with agoraphobia may experience temporary separation anxiety disorder when certain individuals of the household depart from the residence temporarily, such as a parent or spouse, or when they are left home alone. These situations can result in an increase in anxiety or a panic attack or feeling the need to separate themselves from family or friends. [14] [15]

    People with agoraphobia sometimes fear waiting outside for long periods of time; that symptom can be called "macrophobia". [16]

    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. [17] 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. [17]

    Causes

    Agoraphobia is believed to be due to a combination of genetic and environmental factors. 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. [18] [19] 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). [20] Likewise, they may be confused by sloping or irregular surfaces. [20]

    In a virtual reality study, agoraphobics showed impaired processing of changing audiovisual data in comparison with subjects without agoraphobia. [21]

    Substance-induced

    Chronic use of tranquilizers and sleeping pills such as benzodiazepines has been linked to onset of agoraphobia. [22] In 10 patients who had developed agoraphobia during benzodiazepine dependence, symptoms abated within the first year of assisted withdrawal. [23] 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. [24]

    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. [25]

    Attachment theory

    Some scholars [26] [27] have explained agoraphobia as an attachment deficit, i.e., the temporary loss of the ability to tolerate spatial separations from a secure base. [28] Recent empirical research has also linked attachment and spatial theories of agoraphobia. [29]

    Spatial theory

    In the social sciences, a perceived clinical bias [30] 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. [31] Factors considered contributing to agoraphobia within modernity are the ubiquity of cars and urbanization. These have helped develop the expansion of public space and the contraction of private space, thus creating a conflict in the mind of agoraphobic individuals.

    Evolutionary Perspectives

    Some evolutionary models propose that agoraphobia—like other specific phobias—may be rooted in adaptive mechanisms that helped early humans avoid threats in open or unfamiliar environments. From this viewpoint, fear and avoidance behaviors could have been selectively favored if they aided survival—for instance, by prompting individuals to steer clear of potentially dangerous surroundings or minimize exposure to predators and pathogens. According to preparedness models, human defensive systems are especially sensitive to cues linked to ancestral threats and can rapidly form strong, lasting fear associations with them. In modern life, such defenses might become mismatched to relatively low-risk environments, producing disproportionate anxiety responses. [32]

    An additional 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. [33] [34]

    Diagnosis

    Most people who present to mental health specialists develop agoraphobia after the onset of panic disorder. [35] 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. [36] Early treatment of panic disorder can often prevent agoraphobia. [37] Agoraphobia is typically determined when symptoms are worse than panic disorder, but also do not meet the criteria for other mental disorders such as depression. [38]

    Agoraphobia without history of panic disorder

    Agoraphobia without a history of panic disorder (also called primary agoraphobia) is an anxiety disorder where the individual with the diagnosis does not meet the DSM-5 criteria for panic disorder. Agoraphobia typically develops as a result of having panic disorder. In a small minority of cases, however, agoraphobia can develop by itself without being triggered by the onset of panic attacks. Agoraphobia can be caused by traumatic experiences, such as bullying or abuse. Historically, there has been debate over whether agoraphobia without panic genuinely existed, or whether it was simply a manifestation of other disorders such as panic disorder, generalized anxiety disorder, avoidant personality disorder and social phobia. One researcher said: "out of 41 agoraphobics seen (at a clinic) during a period of 1 year, only 1 fit the diagnosis of agoraphobia without panic attacks, and even this particular classification was questionable...Do not expect to see too many agoraphobics without panic". [39] In spite of this earlier skepticism, current thinking is that agoraphobia without panic disorder is indeed a valid, unique illness which has gone largely unnoticed, since those with the condition are far less likely to seek clinical treatment.[ citation needed ]

    According to the DSM-IV-TR, a widely-used manual for diagnosing mental disorders, the condition is diagnosed when agoraphobia is present without panic disorder where symptoms are not caused by or are unreasonable to an underlying medical problem or pharmacological influence. [40] The DSM-5 decoupled agoraphobia and panic disorder, making them separate disorders that can be diagnosed together. [41]

    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. [42] Many patients can deal with exposure easier if they are in the company of a friend on whom they can rely. [43] [44] In this approach, it is suggested that people being treated remain in the situation that provokes anxiety until the symptoms anxiety have subsided because if they leave the situation, the phobic response will not decrease and it may even rise. [44]

    A related exposure treatment is in vivo exposure, a cognitive behavioral therapy method, that gradually exposes patients to the feared situations or objects. [45] 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). [45]

    Psychological interventions in combination with pharmaceutical treatments were overall more effective than treatments simply involving either CBT or pharmaceuticals. Further research showed there was no significant effect between using group CBT versus individual CBT. [45]

    Cognitive restructuring has also proved useful in treating agoraphobia. [46] This treatment involves coaching a participant through a dianoetic discussion, with the intent of replacing irrational, counterproductive beliefs with more factual and beneficial ones. [46]

    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. [47]

    Videoconferencing psychotherapy (VCP) is an emerging modality used to treat various disorders in a remote method. [48] Similar to traditional face-to-face interventions, VCP can be used to administer CBT. [49]

    Virtual reality computer stimulated therapy has been suggested to help people with psychosis and agoraphobia manage their avoidance of outside environments. In the therapy, the user wears a headset and a virtual character provides psychological advice and guides them as they explore simulated environments (such as a cafe or a busy street). [50]

    Medications

    Antidepressant medications most commonly used to treat anxiety disorders are mainly selective serotonin reuptake inhibitors. benzodiazepines, monoamine oxidase inhibitors, and tricyclic antidepressants are also sometimes prescribed for treatment of agoraphobia. [51] Antidepressants are important because some have anxiolytic effects. Antidepressants should be used in conjunction with exposure as a form of self-help or with cognitive behaviour therapy. [44] A combination of medication and cognitive behaviour therapy is sometimes the most effective treatment for agoraphobia. [44]

    Alternative medicine

    Eye movement desensitization and reprocessing (EMDR) has been studied as a possible treatment for agoraphobia, with poor results. [52] As such, EMDR is only recommended in cases where cognitive-behavioral approaches have proven ineffective or in cases where agoraphobia has developed following trauma. [53]

    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. [54]

    Epidemiology

    Agoraphobia occurs about twice as commonly among women as it does in men. It can develop at any age but is much more common in adolescence and early adulthood and occurs more often in people of above average intelligence. [55]

    Panic disorder with or without agoraphobia affects roughly 5.1% of Americans, [45] 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. [45]

    Society and culture

    Notable cases

    See also

    Related Research Articles

    <span class="mw-page-title-main">Cognitive behavioral therapy</span> Type of therapy to improve mental health

    Cognitive behavioral therapy (CBT) is a form of psychotherapy that aims to reduce symptoms of various mental health conditions, primarily depression, PTSD and anxiety disorders. Cognitive behavioral therapy focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed as an approach to treat depression, CBT is often prescribed for the evidence-informed treatment of many mental health and other conditions, including anxiety, substance use disorders, marital problems, ADHD, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.

    <span class="mw-page-title-main">Phobia</span> Anxiety disorder classified by a persistent and excessive fear of an object or situation

    A phobia is an anxiety disorder, defined by an irrational, unrealistic, persistent and excessive fear of an object or situation. Phobias typically result in a rapid onset of fear and are usually present for more than six months. Those affected 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, often found in agoraphobia and emetophobia. Around 75% of those with phobias have multiple phobias.

    <span class="mw-page-title-main">Anxiety disorder</span> Cognitive disorder with an excessive, irrational dread of everyday situations

    Anxiety disorders are a group of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired. Anxiety may cause physical and cognitive symptoms, such as restlessness, irritability, easy fatigue, difficulty concentrating, increased heart rate, chest pain, abdominal pain, and a variety of other symptoms that may vary based on the individual.

    <span class="mw-page-title-main">Panic attack</span> Sudden periods of intense fear

    Panic attacks are sudden periods of intense fear and discomfort that may include palpitations, otherwise defined as a rapid, irregular heartbeat, sweating, chest pain or discomfort, shortness of breath, trembling, dizziness, numbness, confusion, or a sense of impending doom or loss of control. Typically, these symptoms are the worst within ten minutes of onset and can last for roughly 30 minutes, though they can vary anywhere from seconds to hours. While they can be extremely distressing, panic attacks themselves are not physically dangerous.

    Specific phobia is an anxiety disorder, characterized by an extreme, unreasonable, and irrational fear associated with a specific object, situation, or concept which poses little or no actual danger. 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. A phobia can be the fear of anything.

    <span class="mw-page-title-main">Hypochondriasis</span> Medical condition

    Hypochondriasis or hypochondria is a condition in which a person is excessively and unduly worried about having a serious illness. Hypochondria is an old concept whose meaning has repeatedly changed over its lifespan. It has been claimed that this debilitating condition results from an inaccurate perception of the condition of body or mind despite the absence of an actual medical diagnosis. An individual with hypochondriasis is known as a hypochondriac. Hypochondriacs become unduly alarmed about any physical or psychological symptoms they detect, no matter how minor the symptom may be, and are convinced that they have, or are about to be diagnosed with, a serious illness.

    <span class="mw-page-title-main">Claustrophobia</span> Fear of small spaces

    Claustrophobia is a fear of confined spaces. It is 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.

    <span class="mw-page-title-main">Avoidant personality disorder</span> Personality disorder

    Avoidant personality disorder (AvPD), or anxious personality disorder, is a cluster C personality disorder characterized by excessive social anxiety and inhibition, fear of intimacy, severe feelings of inadequacy and inferiority, and an overreliance on avoidance of feared stimuli as a maladaptive coping method. Those affected typically display a pattern of extreme sensitivity to negative evaluation and rejection, a belief that one is socially inept or personally unappealing to others, and avoidance of social interaction despite a strong desire for it. It appears to affect an approximately equal number of men and women.

    Generalized anxiety disorder (GAD) is a mental and behavioral disorder, specifically an anxiety disorder characterized by excessive, uncontrollable and often irrational worry about events or activities. Worry often interferes with daily functioning, and individuals with GAD are often 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.

    Taijin kyofusho is a Japanese culture-specific syndrome. The term taijin kyofusho translates into the disorder (sho) of fear (kyofu) of interpersonal relations (taijin). Those who have taijin kyofusho are likely to be extremely embarrassed about themselves or fearful of displeasing others when it comes to the functions of their bodies or their appearances. These bodily functions and appearances include their faces, odor, actions, or looks. They do not want to embarrass other people with their presence. This culture-bound syndrome is a social phobia based on fear and anxiety.

    Mysophobia, also known as verminophobia, germophobia, germaphobia, bacillophobia and bacteriophobia, is a pathological fear of contamination and germs. It is classified as a type of specific phobia, meaning it is evaluated and diagnosed based on the experience of high levels of fear and anxiety beyond what is reasonable when exposed to or in anticipation of exposure to stimuli related to the particular concept. William A. Hammond first coined the term in 1879 when describing a case of obsessive–compulsive disorder (OCD) exhibited in repeatedly washing one's hands.

    <span class="mw-page-title-main">Cynophobia</span> Fear of dogs and canines

    Cynophobia is the fear of dogs and canines in general. Cynophobia is classified as a specific phobia, under the subtype "animal phobias". According to Timothy O. Rentz of the Laboratory for the Study of Anxiety Disorders at the University of Texas, animal phobias are among the most common of the specific phobias and 36% of patients who seek treatment report being afraid of dogs or afraid of cats. Although ophidiophobia or arachnophobia are more common animal phobias, cynophobia is especially debilitating because of the high prevalence of dogs and the general ignorance of dog owners to the phobia. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) reports that only 12% to 30% of those with a specific phobia will seek treatment.

    Exposure therapy is a technique in behavior therapy to treat anxiety disorders. Exposure therapy involves exposing the patient to the anxiety source or its context. Doing so is thought to help them overcome their anxiety or distress. Numerous studies have demonstrated its effectiveness in the treatment of disorders such as generalized anxiety disorder (GAD), social anxiety disorder (SAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and specific phobias.

    Social anxiety is the anxiety and fear specifically linked to being in social settings. Some categories of disorders associated with social anxiety include anxiety disorders, mood disorders, autism spectrum disorders, eating disorders, and substance use disorders. Individuals with higher levels of social anxiety often avert their gazes, show fewer facial expressions, and show difficulty with initiating and maintaining a conversation. Social anxiety commonly manifests itself in the teenage years and can be persistent throughout life; however, people who experience problems in their daily functioning for an extended period of time can develop social anxiety disorder. Trait social anxiety, the stable tendency to experience this anxiety, can be distinguished from state anxiety, the momentary response to a particular social stimulus. 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.

    <span class="mw-page-title-main">Thalassophobia</span> Fear of the sea or large open water

    Thalassophobia is the persistent and intense fear of deep bodies of water, such as the ocean, seas, or lakes. Though related, thalassophobia should not be confused with aquaphobia, which is classified as the fear of water itself. Thalassophobia can include fears of being in deep bodies of water, the vastness of the sea, sea waves, aquatic animals, and great distance from land.

    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.

    <span class="mw-page-title-main">Social anxiety disorder</span> Anxiety disorder associated with social situations

    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 impairing 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 evaluations from other people.

    <span class="mw-page-title-main">Panic disorder</span> Anxiety disorder characterized by reoccurring unexpected panic attacks

    Panic disorder is a mental and behavioral disorder, specifically 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.

    <span class="mw-page-title-main">Fear of flying</span> Fear of being in a flying vehicle whilst in flight

    Fear of flying is the fear of being on a flying vehicle, such as an airplane or helicopter, while it is in flight. It is also referred to as flying anxiety, flying phobia, flight phobia, aviophobia, aerophobia, or pteromerhanophobia.

    Autophobia, also called monophobia, isolophobia, or eremophobia, is the specific phobia or a morbid fear or dread of oneself or of being alone, isolated, abandoned, and ignored. This specific phobia is associated with the idea of being alone, often causing severe anxiety.

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