What is agoraphobia?

A phobia is generally defined as the unrelenting fear of a situation, activity, or thing that causes one to want to avoid it. The definition of agoraphobia is a fear of being outside or otherwise being in a situation from which one either cannot escape or from which escaping would be difficult or humiliating.

Phobias are largely underreported, probably because many phobia sufferers find ways to avoid the situations to which they are phobic. The fact that agoraphobia often occurs in combination with panic disorder makes tracking how often it occurs all the more difficult. Other facts about agoraphobia include that researchers estimate it occurs in less than 1 percent to almost 7 percent of the population and that it is specifically thought to be grossly underdiagnosed.

What causes agoraphobia?

There are a number of theories about what can cause agoraphobia. One hypothesis is that agoraphobia develops in response to repeated exposure to anxiety-provoking events. Mental-health theory that focuses on how individuals react to internal emotional conflicts (psychoanalytic theory) describes agoraphobia as the result of a feeling of emptiness that comes from an unresolved Oedipal conflict, which is a struggle between the feelings the person has toward the opposite-sex parent and a sense of competition with the same-sex parent. Although agoraphobia, like other mental disorders, is caused by a number of factors, it also tends to run in families and for some people, may have a clear genetic factor contributing to its development.

What are the symptoms of agoraphobia?

The symptoms of agoraphobia include anxiety that one will have a panic attack when in a situation from which escape is not possible or is difficult or embarrassing. The panic attack associated with agoraphobia, like all panic attacks, may involve intense fear, disorientation, rapid heart beat, dizziness, or diarrhea. Agoraphobic individuals often begin to avoid the situations that provoke these reactions. Interestingly, the situations that are often avoided by people with agoraphobia and the environments which cause people with balance disorders to feel disoriented are quite similar. This leads some cases of agoraphobia to be considered as vestibular function agoraphobia.

What are the risk factors for agoraphobia?

Agoraphobia tends to begin by adolescence or early adulthood. Girls and women, Native Americans, middle-aged individuals, low-income populations, and individuals who are either widowed, separated, or divorced are at increased risk of developing agoraphobia. Individuals who are Asian, Hispanic, or of African/African-American descent tend to have a lower risk of developing this disorder.

While having a history of panic attacks is a risk factor for developing agoraphobia, agoraphobic individuals are at increased risk for developing panic attacks as well. Other anxiety disorders that tend to co-occur with agoraphobia include social anxiety disorder and generalized anxiety disorder. Even the use of alcohol can result in severe, temporary anxiety.

When should one seek medical care for agoraphobia?

Call your doctor when the signs and symptoms of anxiety are not easily, quickly, and clearly relieved. For example:

• if the symptoms are so severe that you believe medication may be needed



• If the symptoms are interfering with your personal, social, or professional life



• if you have chest pain, shortness of breath, headaches, palpitations, dizziness, fainting spells, or unexplained weakness



• if you are depressed and feel suicidal or homicidal

When the signs and symptoms suggest that anxiety may have been present for a prolonged period (more than a few days) and appear to be stable (not getting worse rapidly), you may be able to make an appointment with your doctor for evaluation. But when the signs and symptoms are severe and come on suddenly, they may indicate serious medical illness that needs immediate evaluation and treatment in a hospital's emergency department.

How is agoraphobia diagnosed?

Interestingly, agoraphobia, like other phobias, is often diagnosed and treated when patients seek treatment for other medical or emotional problems rather than as the primary reason that care is sought. As with other mental disorders, there is no single, specific test for agoraphobia. The primary-care doctor or psychiatrist will take a careful history, perform or refer to another doctor for a physical examination, and order laboratory tests as needed. If you have another medical condition that you know about, there may be an overlap of signs and symptoms between the old and the new conditions. Just determining that anxiety does not have a physical cause does not immediately identify the ultimate cause. Often, determining the cause requires the involvement of a psychiatrist, clinical psychologist, and/or other mental-health professional.

In order to diagnose agoraphobia, the professional will likely ask questions to ensure that the anxiety of the sufferer is truly the result of a fear of being in situations that make it impossible, difficult, or embarrassing to escape rather than in the context of another emotional problem (for example, fear of being near people that remind one of an abuser in the case of posttraumatic stress disorder or the fear of hearing voices that have no basis in reality as occurs in schizophrenia).

How is agoraphobia treated?

There are a variety of treatments available for agoraphobia, including specific kinds of psychotherapy as well as several effective medications. A specific form of psychotherapy that focuses on decreasing negative, anxiety-provoking, or other self-defeating thoughts and behaviors (called cognitive behavioral therapy) has been found to be highly effective in treating agoraphobia. In fact, when agoraphobia occurs along with panic disorder, cognitive behavioral therapy, with or without treatment with medications, is considered to be the most effective way to both relieve symptoms and prevent their return. In fact, sometimes patients respond equally as well when treated with group cognitive behavioral therapy or a brief course of cognitive behavioral therapy as they do when treated with traditional cognitive therapy. Psychotherapy for agoraphobia has even been found to be effective for many people when they receive it over the Internet, which is optimistic news for people who live in areas that are hundreds of miles from the nearest mental-health professional.

Another form of therapy that has been found effective in managing agoraphobia includes self-exposure. In that intervention, the person either imagines or puts him or herself into situations that cause increasing levels of agoraphobic anxiety, using relaxation techniques in each situation in order to master their anxiety. As people gain access to the Internet, there is increasing evidence that exposure therapy can also be done effectively through that medium.

Regarding medical therapy, agoraphobia is usually treated in connection with panic disorder. Commonly, members of the serotonin selective reuptake inhibitor (SSRI) and the minor tranquilizer (benzodiazepine) groups of medications are used in treatment. Examples of SSRI medications include sertraline (Zoloft), paroxetine (Paxil), and fluoxetine (Prozac). The possible side effects of SSRI medications can vary greatly from person to person and depend on which medication is being used. Common side effects of this group of medications include dry mouth, sexual dysfunction, nausea, tremors, trouble sleeping, blurred vision, constipation or soft stools, and dizziness. In very rare cases, some people have been thought to become acutely more anxious or depressed once on the medication, even trying to or completing suicide or homicide. Children and teens are thought to be particularly vulnerable to this rare possibility.

Phobias are also sometimes treated using beta-blocker medications, which block the effects of adrenaline on the body. An example of a beta-blocker medication is propranolol.

Panic disorder and phobias are less commonly treated with drugs in a medication class known as benzodiazepines. This class of medications causes relaxation but is used much less often these days to treat anxiety due to the possibility of addiction, increasing need for higher doses, and overdose. The risk of overdose is especially heightened if taken when alcohol is also being consumed. Examples of medications from that group include diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan), and clonazepam (Klonopin).

As anything that is ingested carries the risk of possible side effects, it is important to work closely with your doctor to decide whether medication is appropriate, and if so, which medication would be best for you. Further, the treating doctor will likely closely monitor for the possibility of side effects that can vary from the minor to the severe and in rare cases may even be life-threatening.

What are the complications of agoraphobia?

Agoraphobia increases the likelihood that the person will also suffer from another anxiety disorder and that both conditions will be more severe and difficult to treat. Also, agoraphobia tends to occur more often in individuals who have a number of different physical conditions, including irritable bowel syndrome (IBS) and asthma. If left untreated, agoraphobia may worsen to the point at which the person's life is seriously affected by the disease itself and/or by attempts to avoid or conceal it. In fact, some people have had problems with friends and family, failed in school, and/or lost jobs while struggling to cope with severe agoraphobia or another severe phobia. There may be periods of spontaneous improvement, but the condition does not usually go away unless the person receives treatments designed specifically to help phobia sufferers. Further, alcoholics can be up to 10 times more likely to suffer from a phobia than those who are not alcoholics, and phobic individuals can be twice as likely to be addicted to alcohol as are people who have never been phobic.

goraphobia At A Glance

• Agoraphobia is defined as a fear of being outside or otherwise being in a situation from which one either cannot escape or from which escaping would be difficult or humiliating.
• Like other phobias, agoraphobia is largely underreported, probably because many phobia sufferers find ways to avoid the situations to which they are phobic.
• Agoraphobia often occurs in combination with panic disorder.
• Agoraphobia occurs alone in less than 1 percent to almost 7 percent of the population.
• There are a number of theories about what can cause agoraphobia, including a response to repeated exposure to anxiety-provoking events or a reaction to internal emotional conflicts.
• As with other mental disorders, agoraphobia is usually caused by a number of factors, tends to run in families, and for some people, may have a clear genetic factor involved in its development.
• Symptoms of agoraphobia include anxiety and subsequent avoidance of being in a situation in which one will have a panic attack, when in a situation from which escape is not possible, or is difficult or embarrassing.
• The panic attacks associated with agoraphobia, like all panic attacks, may involve intense fear, disorientation, rapid heart beat, dizziness, or diarrhea.
• The situations that are often avoided by people with agoraphobia and the environments which cause people with balance disorders to feel disoriented are sometimes quite similar, leading some cases of agoraphobia to be classified as vestibular function agoraphobia.
• Agoraphobia tends to begin by adolescence or early adulthood.
• Girls and women, Native Americans, middle-aged individuals, low-income populations, and individuals who are either widowed, separated, or divorced are at increased risk of developing agoraphobia.
• Suffering from virtually any other anxiety disorder increases the risk of developing agoraphobia.
• Symptoms of agoraphobia should be treated when the signs and symptoms of the associated anxiety are not easily, quickly, and clearly relieved.
• Agoraphobia is often diagnosed and treated when patients seek treatment for other medical or emotional problems rather than as the primary reason that care is sought.
• To diagnose agoraphobia, the treating psychiatrist or other physician will usually take a careful history, perform or refer to another doctor for a physical examination, and order laboratory tests as needed. Any medical condition or other emotional problem will be considered.
• Cognitive behavioral therapy and exposure therapy are the most effective psychotherapies used to treat agoraphobia.
• Medications like SSRIs, beta blockers, and benzodiazepines are most commonly used to treat agoraphobia. The risk of overdose, addiction, or need for increasingly higher doses make benzodiazepines a less desirable treatment for agoraphobia.
• Agoraphobia increases the likelihood that the person will also suffer from another anxiety disorder and that both conditions will be more severe and difficult to treat.
• Agoraphobia tends to occur more often in individuals who have a number of different physical conditions.
• If left untreated, agoraphobia may worsen to the point where the person's life is seriously affected by the disease itself and/or by attempts to avoid or conceal it.

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